International electives have become increasingly popular among medical students and residents. Their educational value and supporting motivations, however, have been questioned,1,2 and ethical considerations have arisen. For participants in these electives, perhaps the most relevant of the ethical challenges relate to working with limited resources. Junior doctors may find themselves in situations beyond their competency level, often with minimal supervision. Not only is this unacceptable from educational and safety perspectives, but institutions partnering with programs in low-income countries (LICs) must take care not to challenge the limited resources of the host institution by requiring the few available consultants to spend additional time teaching or supervising visiting trainees.3 The cost of international academic collaborations should certainly not drain from the limited resources of the host institutions. Trainees themselves can begin to address ethical considerations by assessing and minimizing personal risk, including accidents and bloodborne or airborne diseases, before traveling to the host country.4 Approaches to these challenges have been successfully developed as outlined below.
Studies proving the educational value of international electives have supported—in many cases successfully—the request that trainees' home institutions pay the salaries of trainees abroad as a sign of recognition of the importance of these electives and to mitigate the financial strain on host institutions. Formal agreements between the partner institutions, at the administrative and academic levels, ensure that roles and expectations on both sides are clear and have led to more sustained and productive initiatives. Pretraveling preparation for trainees, including lectures on the culture of the host country, language training, and immunization planning, has been shown to significantly improve the success of the rotations, when consistently implemented. Systematic postrotation evaluation ensures the achievement of academic objectives.5
Although most international rotations occur during medical school or residency, delaying this experience to the time of fellowship may address some of these ethical and logistical challenges, as the subspecialty fellow is expected to be competent and knowledgeable in general practice, reducing the risk of facing situations beyond his or her scope of expertise. Also, fellows may more easily appreciate the peculiarities of practice in underdeveloped situations and have a more critical appraisal of their experience. A “late” international elective may have a very different effect on career planning than one early in training. During medical school, international electives may help students decide which specialty they want to pursue. Subspecialty fellows, however, have already oriented their career to a specific field. As the role of subspecialties is becoming increasingly relevant in LICs, international electives can allow fellows to explore global health as a possible career niche.
One Author's Experience
One of the authors (P.A.) completed a rotation in an LIC during her second year of fellowship. In this section, she shares her experience as an example of a delayed international elective.
I began to explore opportunities to work in an LIC as a pediatric oncologist through existing resources at the University of Toronto, which boasts a robust selection of research and education initiatives in global health. In my second year of fellowship, after establishing contact with a senior staff member from Tata Memorial Hospital (TMH), Mumbai, India, I arranged a six-week elective rotation in India as an observer, with the formal objective of having a firsthand experience in an LIC, preliminary to my future involvement in twinning projects and cooperation efforts.
My experience at TMH was extremely educational. I was working in an urban setting in one of the most developed institutions in India. I saw a huge number of patients with unique features related to delayed presentation, comorbidities, complications, and genetic background. The financial constraints at TMH led the physicians to practice strictly evidence-based medicine. The treatment protocols were tailored to local epidemiology and financial and social background, and I was challenged to critically appreciate the literature, the Western protocols, and their applicability or relevance to the Indian reality. When I completed my rotation, I summarized these discussions and presented an overview of my experience to my division at University of Toronto.
Despite my short time in India and the language and cultural barriers, I had the opportunity to appreciate some of the problems that affect practice in an LIC, such as financial constraints, lack of education, and lack of manpower. I ended my elective with a commitment to return to conduct a research project based on the suggestions of colleagues at TMH. The project developed during a second elective experience in my third year of fellowship. My experience also triggered the development of a curriculum in global health within the pediatric hematology and oncology fellowship at University of Toronto, including guest speakers and forum discussions on the social determinants of health affecting our local and international patient populations.
Fellows in LICs
From the above individual experience, we see that visiting fellows have a unique role to play in clinical activities, education, and research in LICs.
Their direct involvement in clinical activities may be limited by language barriers and incomplete knowledge of the local organization, and has to be carefully individualized based on the level of training and expertise. However, fellows can contribute by bringing an honest desire to critically understand the unique challenges faced in LICs and share their experience of practice from their home country.
Education represents an absolute priority in LICs. Fellowship programs are available in only a few LICs, and the quality of training is varied and challenged by overwhelmingly busy schedules, minimal supervision, and limited time available for formal teaching. Time and financial constraints limit physicians' access to peer-reviewed journals and their ability to attend conferences. Visiting fellows can provide training but also a unique opportunity for peer mentorship through long-lasting relationships and the potential for future collaboration.
Finally, research has been officially recognized as a priority in global health,6 but it requires time, human resources, and financial and technical infrastructures (information technology, databases, data collection and input, etc.). Because of their level of training, visiting fellows are capable of directly leading research projects, developing tools, or educating peers and data managers.
Are Subspecialties in LICs a Priority?
All who work to provide health care in LICs, whether they are subspecialty fellows or general practitioners, face unique challenges. In LICs, where basic health needs may not yet be met, working in a highly specialized setting poses a number of ethical dilemmas. Should we focus on basic health needs, which concern the majority of the population and for which affordable remedies are often available? Or should we address any disease, or at least any disease for which an effective treatment is available, regardless of its cost? The major argument favoring basic, large-scale interventions is that relatively simple and affordable innovations can save or deeply affect the lives of millions of patients. However, there are arguments to support the development of subspecialties in LICs. We will use pediatric oncology as a paradigm to illustrate this position.
In 1998, Masera7 reported his experience in Nicaragua, advocating the development of pediatric oncology services in LICs. He argued that, as the burden of disease and mortality from infectious agents and malnutrition decreases, cancer is emerging as a leading, disease-related cause of pediatric death in LICs, similar to the Western world.8 Because the population growth rate in LICs is much higher than in the developed world, more than 80% of pediatric cancer patients live in LICs.9 With many common childhood cancers now considered curable with standard and relatively affordable therapies, we must commit to addressing the needs of and providing care to a population that globally represents the majority of our cancer burden. Cancer care institutions can also become a model to develop an LIC's health care system and introduce innovations applicable to other areas of general practice or other subspecialties. Education of cancer care staff will spread to other areas of the health care workforce. Finally, philanthropic donations are sometimes bound to specific goals, but the advances that result from such resources can ultimately benefit all patients.
None of these arguments is definitive, and the balance between the interest of the community and the right to health of each individual may vary according to different situations and local factors. It has been shown that the annual income of a country and the proportion of income dedicated to the health care system represent the most important predictors of improvement of health care indicators.9 In countries with extremely low income, cancer may not yet represent a priority. However, it can become one in middle-income countries. Once a pediatric oncology program is started, economic criteria still dictate the priorities, and treatment is initially developed and offered only for diseases with high incidence (e.g., leukemia), high cure rate, and not requiring sophisticated facilities (e.g., bone marrow transplantation unit, specialized surgery, or radiation therapy). All professionals and stakeholders involved must debate effectively to tailor choices to the specific and evolving socioeconomic situations. The World Health Organization (WHO) constitution10 and the United Nations (UN) Convention on the Rights of the Child11 provide a legal framework for the discussion. The WHO constitution defines the “right to health” as the right of everyone to enjoy the highest attainable standard of physical and mental health.10 In Article 24, the UN Convention on the Rights of the Child includes health as one such right of children: “States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health.” It elaborates further on the responsibility of the international community to “full realization of the right” with particular attention to the needs of developing countries.11
Based on the basic rights of every child to life and health expressed in all international declarations, and on these declarations' call for commitment of wealthy countries to promote the development of LICs, a number of programs have been developed by single institutions or international societies, aimed at improving survival from childhood cancer in LICs. St. Jude Children's Research Hospital, for instance, has established an International Outreach Program which counts 21 partner institutions in 15 different countries. Initial steps have been taken in many other countries—for instance, Lebanon, Jordan, Burundi, and Uganda. Successful programs have led to a dramatic improvement in survival rates for childhood cancers.
An Argument for Global Health Training in Pediatric Hematology and Oncology
Despite increasingly recognized needs and past successes, international health has not become an integral part of curricula of pediatric hematology and oncology fellowships or pediatric residency. The establishment of the first fellowship in pediatric global health at Harvard Medical School in 2008 was an important first step. More recently, the Association of American Medical Colleges has launched the Global Health Opportunities Program12 to develop collaborations between institutions in LICs and high-income countries and to facilitate international electives for final-year medical students. Here we suggest that, despite the many complex issues involved, considering the role of global health experiences in the educational program for pediatric hematology and oncology trainees represents a moral imperative.
In the era of globalization, we must proactively embrace all children as our patients, and advocate for equity. The cost of treatment in LICs is much lower than in Western countries. Resources allocated in LICs have, therefore, a tremendous potential to save lives. As managers of health care resources, we have an obligation to allocate resources in the most effective way, including relocating them to other countries through twinning programs or other cooperative initiatives. Trainees should pursue a thorough knowledge and understanding of global health and economic issues to develop appropriate advocacy and resource management skills.
Locally, as our society is increasingly multicultural and many children have mixed ethnic backgrounds, understanding not only the genetic and ethnic differences but also the cultural and religious approaches to life in different cultures may improve respectful and effective communication between physicians and their patients at home and abroad.
The Royal College of Physicians and Surgeons of Canada sets ambitious objectives for pediatric hematology and oncology residents, outlining a complex role as medical experts but also as communicators, managers, patients' advocates, scholars, collaborators, and professionals.13 Dr. Angelini found at TMH great examples of physicians who embody this ideal despite unimaginable obstacles and limited resources, caring for their patients with a holistic approach and, certainly, fulfilling our mission, as stated in the modern Hippocratic Oath:
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
We have a lot to learn.
The authors are grateful to all the patients, their families, and the health care providers whose relentless work and dedication contributed to originate the idea of this paper.
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