Sklar, David P. MD
Jambo is a common Swahili greeting. It literally means “a thing” or “an affair” but has come to mean “hello,” based upon the custom of asking how things are going. I heard it frequently when I was in East Africa as a medical student 40 years ago. Another Swahili word, mambo, is the plural of jambo. It is also used as a greeting. As mambo and jambo illustrate, in Swahili a plural can be formed by changes at the beginning of a word rather than at the end. I remember how confusing this and other differences between Swahili and English were for me during my early days in Tanzania. It does not surprise me that mambo and jambo are felt by some1 to be the origin of the English term mumbo jumbo, one meaning of which is “gibberish.” Although there are other theories, that one makes sense to me. I believe that this kind of reaction to what seems incomprehensible (but isn’t) is emblematic of the history of miscommunication between Westerners and Africans in culture, language, power, and money. Such miscommunication has impeded previous efforts to collaborate to solve problems together.
The idea of solving countries’ problems together is changing some of the words used to describe relationships between countries in the area of health care. Frenk et al2 describe the change from the term international health to the current concept of global health. International health typically related to the detection of epidemics across borders and to the challenges of health needs of indigenous populations in poor countries. According to these authors, international health activities involved “aid and defense,” usually provided by individuals or groups from developed countries to those in less developed countries. The concept of international health also contained a strong emphasis on the potential of technology to solve health problems and less emphasis on the social, cultural, behavioral, economic, and political determinants of health.
Frenk et al see global health as a bi-directional process between the more developed and less developed countries, encompassing the health of the global population and reflecting the economic and geopolitical interdependence of populations. They go on to describe the numerous interconnections between the world’s populations related to the flow of products, people, environment, food, information, and regulation that create threats and opportunities. I would add to this list the flow of ideas, which can have a powerful motivating effect on human behavior.
It is the opportunity to influence the flow of ideas about medical education across borders that is a common goal in the articles in the supplement on the Medical Education Partnership Initiative (MEPI) that accompanies this issue of Academic Medicine. This initiative encompasses collaborative relationships between 20 U.S. medical schools and 40 African medical schools, as well as nursing collaborations and the development of communities of practice for the African medical schools, all with the goal of improving health through better medical education.
In the last 10 years, Academic Medicine has published over 50 articles related to global health and international health topics, including a special theme issue in February 2008. In addition, in this month’s journal, there are 6 additional articles on these topics.3–8 However, the MEPI program is different from previous efforts in that it attempts both to coordinate the efforts of multiple U.S. academic institutions and also to help the African institutions to connect with each other. It has been financed for 5 years starting in 2010 with $130 million of U.S. government funding. The program has attempted to alter some previous aid relationships by distributing money to the African medical schools, which would then decide how it should be allotted to U.S. partner institutions. In this issue’s supplement, Olepade-Olaopa et al9 describe five benefits of the program:
* building effective partnerships among a diverse group of stakeholders,
* creating a community of practice among the African medical schools,
* connecting the MEPI schools to their communities and their countries’ education and health ministries,
* creating a culture of ownership in the MEPI schools, and
* renewing a focus on performance metrics.
Although labeled as benefits, I would probably describe these as goals or aspirations, since I am not sure that each partnership has yet realized all of these potential benefits. The projects came with enormous challenges, which are described in the supplement’s articles about various country-specific projects related to education, research, and clinical service.
Although the focus of the funding is mostly about the benefits of the collaboration to the African countries, there is no doubt that the learning and benefits are going in both directions. Imagine the opportunities to learn about how to practice high-quality medical care without the use of expensive technology and how such experience might be applied to our U.S. health care delivery systems, which need to lower costs without reducing the quality of care. Imagine the opportunities to learn about the enhanced capabilities of nonphysician care providers when they are the only option for care for a rural population and how such experience might be translated to underserved areas of the United States. Finally, imagine the opportunities for U.S. medical students, residents, and faculty to learn about cultures, diseases, and conditions rarely encountered in their home institutions. Such experiences can enrich their education and also help prepare them in those cases when, in an increasingly globalized world, those diseases travel to the United States.
As we read about these ambitious and courageous projects, I suggest that we consider the similarities and connections we can make between our systems and those in Africa. If we can agree with Frenk and colleagues’2 definition of global health, engaging in African medical education and health care is not that different from engaging in Western medical education and health care. Although the social determinants of health may differ, the principles of improving health through addressing the social determinants remain the same. The problems of workforce maldistribution and the challenges of interprofessional teams and efficiency in care delivery are common to both locations. Considered in this way, the MEPI articles become relevant not only to those interested in global health but also to all of us involved in medical education and health care.
In addition to the research and project articles, I direct your attention to two other articles in this month’s supplement. One is by Kim and Evans10 from the World Bank. They eloquently describe some of the interconnections between economic capacity, medical education, and health. They identify two important goals: to reduce and ultimately eliminate impoverishment due to medical costs, and to increase access to basic health services. They consider MEPI a valuable asset that can help to increase the production of health professionals in Africa and ultimately help to meet the two goals stated above. Because individuals’ medical problems demand so much attention, it is often difficult to stand back and recognize the effect that population health has on a region’s economy, and how well (or not well) the effectiveness of a region’s economy affects health care delivery. In Africa and other low-resource areas of the world, the lack of money to pay for health care that would be available in a more wealthy nation is obvious, and the need for physicians to help provide stewardship for scarce resources is clear. Although resource constraints exist in the United States, the effects of our failures to provide a rational approach to resource allocation play out in less obvious ways, such as long waiting times in emergency departments rather than an inability to provide a ventilator for a critically ill child.
The other article is by Frehywot et al,11 who describe the development of a community of practice. The community of practice encompasses a series of activities, mainly among participating medical schools, to engender a group identity. These include annual conferences, site visits to the various programs, a Web site, and group projects, some of which are described in other articles in the supplement. The hope is that the community of practice will result in ongoing collaboration between the African medical schools that are participating in the MEPI project as well as ongoing collaboration between those schools and the American medical schools that are working with them. One of the revelations of the MEPI project for me has been how isolated many of the African medical schools had been prior to MEPI funding, both within their individual countries and between other African countries. The community of practice process has brought together educators from Africa to learn from each other, share resources, and provide support. This may be one of the most enduring contributions of the MEPI program.
The area of global health has become a popular topic for medical students and residents, and I suspect the MEPI project will inspire many to devote a portion of their careers to global health. This would be wonderful if it resulted in an individual’s long-term commitment to the health of an underserved community. However, many activities in international health for students and residents are short term and of variable value to the host community. Finding the right opportunity for students that balances their learning and safety with tangible benefits to the community where they work will be important. Crump and Sugarman12 have described some of the ethical issues and unintended consequences of short-term experiences for medical trainees. Although MEPI makes possible a relatively long-term relationship between institutions and governments, it raises some of the same concerns about resources, justice, communications, and safety discussed by Crump and Sugarman.
My own experience as a student illustrates how valid some of these concerns can be when medical students from one culture are working in another. During my time in Tanzania, as an English- and Spanish-speaking medical student with some knowledge of Swahili, I was asked to work with a group of Cuban doctors who were providing assistance at the hospital in the obstetrical unit. My job was to help with the process of translating Swahili to Spanish and back again. I was both nervous and excited about my opportunity to be able to contribute a useful service. There was an African nurse who helped with the Swahili-to-English translation, and I was supposed to assist with the English to Spanish. We were in the obstetrics clinic, and our first patient was a woman who seemed to be in some pain. I tried to understand her discussion with the nurse. The woman’s last menstrual period was almost 38 weeks ago, if I understood her correctly, which made her at term; her pain could be early labor. In my zeal to demonstrate my worth, I quickly explained in Spanish to the Cuban doctors what I had understood from the woman’s conversation without waiting for the nurse’s report. I expressed my concern that the woman might be in labor. The Cuban doctors requested that I check for fetal heart tones. I listened with a special fetal heart tone stethoscope that clipped over my forehead, and when I could not hear any heart tones, I became even more concerned. That was when I noticed that the doctors and the nurse were all laughing. They pointed at the woman’s sister in the corner of the room who was holding the baby that the woman had delivered a week ago. I soon learned this was the postdelivery clinic. Although I felt very silly, the mistake actually eased my entry into the team. No one was going to have to worry about where I would fit into our team’s hierarchy.
I try to remember this experience when people ask me for my “expert” opinion, particularly when I am in an unfamiliar context and with people I may not know or whose language I may not understand. Surrounded by those who are in awe of one’s country’s wealth or power, as happens at times during international aid missions, those of us from developed countries can easily become overconfident of our opinions and competence and say or do things we may regret later. I am hopeful that the MEPI project will usher in a new era of global health collaboration that will avoid some of the cultural arrogance and ignorance that led to the use of the Swahili words mambo and jambo to form the derogatory English term mumbo jumbo.
MEPI has attempted to contribute to health through medical education in a way that is respectful of the differences in wealth and culture of the partners. The stories of these collaborations can help us understand each other and how we can be most helpful and honest about our intentions and goals. Truthful, respectful collaboration may help to overcome the legacy of the past. But the cruel truth is that we from the West can still get on an airplane and be home in a matter of hours, while those whose lives we share in an aid project cannot. The basic unfairness of this fact creates a tension that affects all collaborations between poor and rich countries. I am hopeful that MEPI will live on beyond the five years of the initial funding and that new Swahili words related to our new relationships and understanding, such as rafiki (friend) and amani (peace), will replace mumbo jumbo as examples of words that entered the English language from Westerners’ experience in Africa.
David P. Sklar, MD
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