Steiner, Beat D. MD, MPH; Carlough, Martha MD, MPH; Dent, Georgette MD; Peña, Rodolfo MD, DrPH; Morgan, Douglas R. MD, MPH
Dr. Steiner is associate professor, Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
Dr. Carlough is associate professor, Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
Dr. Dent is associate dean of student affairs, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
Dr. Peña is dean, School of Medicine of the National Autonomous University of Nicaragua, León, Nicaragua.
Dr. Morgan is associate professor, Department of Internal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
Correspondence should be addressed to Dr. Steiner, Department of Family Medicine CB# 7595, University of North Carolina, Chapel Hill, NC 27516-7595; telephone: (919) 966-3106; fax: (919) 966-6125; e-mail: firstname.lastname@example.org.
Health sciences faculty promote global health opportunities as a means for physicians-in-training to learn important lessons about health disparities and cultural diversity and to encourage them to commit to lifelong service. Participation in global health electives is associated with favorable outcomes, including increased likelihood of community service, increased interest in primary health care fields, and improved skills in problem solving and clinical examination.1 Medical students' interest in global health has increased exponentially in the past decade. Approximately 30% of U.S. and Canadian students participate in an international health elective during medical school.2 The University of North Carolina (UNC) School of Medicine (SOM), like many schools, has a tradition of global electives. In the graduating class of 2008–2009, 53 out of 157 (34%) students received credit for international experiences at sites in over 20 countries. This growing interest among students has been accompanied by an increased commitment by the school to provide support, mentoring, and accountability for these endeavors. The school recently created the UNC Office of International Activities (OIA), the primary function of which is to provide programmatic structure and support for UNC-SOM medical students doing international electives.
UNC-SOM has a rich history in international health initiatives, including research and teaching partnerships with other universities, but until recently there was not an organizational entity that directly addressed the needs of students interested in global health. This resulted in students obtaining conflicting advice from various sources about opportunities, funding, and regulations. It also increased the likelihood of inadequate local supervision, poor educational experiences, and lack of preparation for health and safety emergencies while traveling. Student leaders became thoughtful and persistent lobbyists for better support for activities related to global health. The OIA was created within the Office of Student Affairs of the UNC-SOM to manage both incoming visiting international medical students and UNC medical student global health initiatives. The tuition for electives from the international medical students financially supports the office. It is staffed by a program manager who handles day-to-day activities (e.g., assisting students to identify elective opportunities, processing registration for courses and travel health insurance, supporting incoming medical students). These activities are conducted under the direction of UNC medical faculty who, on a part-time basis, provide overall leadership, develop educational initiatives (e.g., global health curricula, advising of student global health groups), and coordinate with other campus entities (communicate with the provost's office about travel health and safety, participate in the Global Health Advisory Committee for the university, etc.). In the recent past, with increased funding for global health, many academic institutions have formed global health institutes or departments. Although it is important to coordinate and share resources with these entities, the needs and perspectives of students are distinct and need more direct support.
The medical literature discusses the risks of international travel on the personal health of students, but the effects of larger geopolitical events remain largely unexamined.3 During a one-year period, UNC-SOM and the OIA were challenged by unexpected crises in countries with active UNC-SOM global health electives and student service projects. The evolution of these events necessitated deliberate responses from affected students, faculty, and administrators. In this article, we present three case studies that touch on three areas of potential crises: health epidemics, political events, and natural disasters. The case studies and lessons learned provide ideas for institutional structures and faculty development to prepare for disruptive events while maintaining favorable outcomes associated with global community service.
Case Study 1: Proyecto Puentes de Salud and the H1N1 Pandemic in Mexico
Proyecto Puentes de Salud4 (PPS) is a student-led service and research project founded in 2006 with the vision of understanding and reducing health care inequalities by serving as a “health bridge” to rural communities in Guanajuato, Mexico. Medical students, supervised by UNC-SOM faculty, provide screening and educational presentations focused on cardiovascular health and HIV. The group emphasizes the establishment of local community connections and close ties with the leadership of the Catholic Church in the region. The majority of students participating in the experience receive elective credit.
In the spring of 2009, as the students prepared for their summer elective, the H1N1 pandemic emerged in Mexico. The Centers for Disease Control and Prevention (CDC) recommended avoidance of nonessential travel to Mexico for U.S. citizens. UNC-SOM, like many institutions, follows both the CDC's and the U.S. State Department's travel warnings and requires students and faculty traveling on UNC-SOM programs to comply with travel restrictions. As the epidemic continued to spread, it became clear that limiting global travel was an ineffective strategy to contain the epidemic. When the CDC travel warning was lifted in mid-May, the majority of students and faculty had committed to other programs because of the uncertainty. The students and faculty who were able to participate in the summer PPS project were only able to partially implement planned projects. After nearly a year of planning, many students were appropriately frustrated and disappointed.
Case Study 2: The Honduran Health Alliance and Political Change in Honduras
The Honduran Health Alliance5 is a student-led service project founded in 2002 that provides sustainable health service and education to small rural communities in southern Honduras near the Nicaragua border. Students from UNC-SOM and the School of Public Health, supported by faculty advisors, work closely with community leaders to develop service projects to educate and empower residents, with a focus on women's health. The students design a health education curriculum with input from Honduran community leaders. During the monthlong summer project, students deliver small-group educational sessions and, with faculty supervision, perform screening PAP smears. Many students choose to receive elective credit.
In the summer of 2009, just as the students arrived on-site, Honduras entered a political crisis with the change in government. The country remained largely peaceful, albeit with military checkpoints and curfews. The students remained committed to their project. Cell phones facilitated consistent communication with UNC-SOM faculty. UNC-SOM leadership and UNC-SOM faculty advisors deemed that the southern rural communities remained safe, based on information provided by the U.S. embassy in Honduras and local community contacts. However, events continued to evolve rapidly. Tensions rose as the exiled president announced plans to reenter the country, the national airports were closed, and the U.S. State Department advised against nonessential travel. Although the students wanted to continue their program, there was a general consensus among student leaders, faculty advisors, and UNC-SOM administration that evacuation was prudent. Because of the potential continued instability in the capital, the student group was evacuated through Nicaragua in conjunction with the University of Nicaragua, León (UNAN), where UNC-SOM had close contacts (see below). Again, after an academic year of planning, students and faculty were appropriately frustrated and disappointed.
Case Study 3: The Collaborative Sahsa Health Initiative and Climate Disruption in Nicaragua
The Collaborative Sahsa Health Initiative (CSHI)6 is a global health elective and collaboration between UNC-SOM and UNAN. UNAN was one of the first responders in September 2007 in the relief efforts following Hurricane Felix, a Category 5 storm that struck the isolated Mosquitia region of northeastern Nicaragua. UNAN subsequently established a permanent presence in the underserved Tasba-Pri region, a network of about 50 villages centered around the village of Sahsa, located 100 kilometers from the Caribbean coast. The lack of roads to many of the villages limits the mode of travel to hiking, horseback, or canoe. Communication is limited to radio. The staffing of the permanent UNAN presence consists of rotating medical students, interns, and faculty who provide clinical care and public health efforts. The CHSI initiative partners UNC-SOM and UNAN students, residents, and faculty in July of each year for a field epidemiology and clinical experience. At the core is a field epidemiology project with household interviews for health promotion, patient education, and research initiatives.
In July 2008, a series of tropical depressions caused extensive flooding in the area. The flooding periodically precluded travel to and from the Tasha-Pri region, further isolating it from the rest of Nicaragua. These events directly affected planned travel to selected villages, limited the food supply, and could have impeded emergency evacuation of individuals. The proactive communication between UNC-SOM and UNAN faculty and students, albeit without cell phone technology, monitored the events; ultimately, the CSHI group was not evacuated. The majority of students returned from the challenging circumstances having had positive, but sobering experiences.
Discussion and Implications
The need to respond to the three crises in brief time periods helped distill important lessons that can help our institution and other institutions better prepare for future unpredictable events associated with international service experiences. These lessons are discussed in detail below and summarized in List 1.
Institutional travel policy
A well-designed travel policy makes it possible to respond decisively to crises that affect global health electives. The UNC-SOM travel policy is generally adequate, but the crises revealed some areas for improvement. All students receiving medical school credit or involved in research are required to sign a travel waiver and purchase evacuation insurance in addition to their usual health insurance. This policy helped improve student safety and facilitated a central database to track and communicate with students. When students register for travel health insurance, which is required by UNC, they also receive information about emergency and evacuation planning specific to their country of travel via a Web-based interface. A further strength of the UNC-SOM travel policy is its link to the U.S. State Department's and CDC's travel policies, which define what actions need to be taken by students and faculty in response to warnings. As a result of this linkage, decisions can be made based on well-defined guidelines, and consensus is facilitated among faculty, administration, and students. One aspect of the UNC-SOM policy that warrants improvement is the creation of an emergency contact list to proactively communicate with family members. Although there were reliable ways to contact the students involved in the electives, the school received many calls from concerned families during the Honduran crisis. The UNC-SOM database has now been expanded to include emergency contacts in the event of a crisis in order to facilitate communication. The crises raised additional questions that institutions should consider: Should travel to countries be limited during scheduled political events such as elections? How should electives in Mexico, Central America, and the Caribbean plan for the hurricane season?
Clear and frequent communication is crucial to making well-informed decisions. Although processes for responding to an emergency can be mapped out institutionally, improvised methods to integrate information from different sources with collaborative decision making with the students are important. In the case of the political events in Honduras, UNC-SOM administration, the OIA, faculty advisors, and student leaders remained in continuous contact through cell phone, e-mail, and meetings. As the weather experience in Nicaragua illustrates, cell phone service has increased dramatically but is not yet universal. Institutions should define expectations for communication in advance of international experiences. The following are questions to consider: Should student groups be required to have satellite phones in areas where cell phones are not available? Are certain areas of the world too remote to host student electives safely?
Responsible administrative entity
The existence of an administrative entity to coordinate the response to global events can contribute substantially to the success of international experiences. UNC-SOM was able to help finance the OIA with tuition from electives designed for visiting international students. This office has a specific role in collecting current climate, political, and health information in the countries with UNC-SOM-sponsored global health electives and student-led initiatives. The office also helps coordinate communication and, in the Honduras events, played a key role in developing an evacuation plan for the students. As the OIA is not open nights and on weekends, contact protocols through the UNC Department of Safety and the dean's office were established to enhance availability to communicate in emergencies. Not all institutions have a separate office of international activities, but an entity with such responsibility should be identified at each institution and used in collaboration with other resources to create a seamless system of response to an emergency.
Support and expectations for faculty advisors
Faculty advisors for global health experiences provide institutional memory and, in the event of crises, can serve as the university's point people. At most institutions, faculty who advise student-led global health initiatives remain volunteers, yet their role is vital in mentoring students and focusing creative energy. Their role becomes even more important during a crisis. Advisors serve as mediators between student leaders and institutional leadership and help ensure that students understand and follow policies, that decision making is collaborative and appropriate, and that students' interests and safety are balanced. Institutions must find mechanisms to support the time and responsibility required of faculty advisors for global health initiatives. Such support would also give institutions the leverage to develop clear expectations for faculty advisors.
A final important component of responding to an international crisis is ensuring that students are adequately prepared for the unpredictable nature of international experiences. Student groups involved in global health electives and service projects may need to suddenly change elective plans, return prematurely from their sites, or incur additional expenses. The travel waivers signed by students are generally insufficient preparation. Faculty advisors should lead students in gaining an understanding of the political, health, environmental, and socioeconomic realities in the countries of service through specific exercises, readings, and discussions. Examples of specific recommendations include avoiding demonstrations and travel on election days.7 Faculty advisors should explain to students how decisions are made in the event of a crisis and what role students have in making these decisions. Even with good preparation, students will be disappointed if a crisis changes the desired goals of the experience. Faculty and institutions should schedule formal debriefings of the experience through reflective exercises or other educational activities to help students appropriately process their disappointments and prepare them for future service.
Engagement in programs that promote understanding of global health appears to offer powerful benefits to future health care professionals. But these international health electives and global service projects carry unpredictability and inherent health and safety risks. Adequate preparation by institutions and faculty can lessen the potentially negative impact of such events on student learning.
The authors wish to acknowledge the Office of International Activities and the Institute of Global Health and Infectious Diseases at the University of North Carolina, Chapel Hill for their support of global service experiences for students. The authors also thank Dr. Bonzo Reddick, faculty advisor for the Honduran Health Alliance at the University of North Carolina, for his support and mentorship of students engaged in international service work.