Locked inside a body she could no longer control, five-year-old Melissa (not her real name) communicated with her mother through fear-filled eyes. The only thing that came out of her mouth was a continuous stream of drool, a worrisome sign that she would not survive this entirely preventable infection. Of the large volunteer medical team (including senior pediatricians and intensive care nurses) that cared for Melissa in the heavily damaged general hospital in Port-au-Prince, only the Haitian American respiratory therapist had ever seen or treated tetanus. The team, helpless to halt the lethal course of the disease, saw three patients succumb to it in the first weeks after the earthquake that rocked the Haitian capital. Despite their decades of combined critical care expertise, without the tetanus immunoglobulin, the tetanus vaccine, or (perhaps most important) mechanical ventilation, the army of foreign volunteers in Haiti was powerless against a disease that is virtually unknown in the United States, yet kills tens of thousands of children in the developing world every year.1 Unfortunately, the physicians who cared for Melissa were not prepared to treat tetanus. Although her family's poverty played a central role in Melissa's disease, physicians and other health care providers can only fully understand the presentation of the disease in the context of the large-scale structural and political forces that have shaped Haiti over the past two centuries and created the gross inequities her caretakers witnessed. If her providers had been familiar with this context, they might have anticipated cases of tetanus and been better prepared to diagnose and treat it.
On January 12, 2010, Haiti experienced one of the worst disasters in human history, a magnitude 7.0 earthquake that resulted in the deaths of approximately 222,000 Haitians and grievous injury to 300,000 more.2 Nine months later, Haiti found itself in the midst of another disaster, a cholera epidemic that has thus far resulted in the deaths of 4,600 people.3 In response to both catastrophes, international agencies, academic institutions, nongovernmental organizations, and associations responded by sending thousands of medical professionals, including nurses, doctors, medics, and physical therapists, to support the underresourced Haitian health system. The volunteers who came (and are still coming) to provide medical care to disaster victims worked tirelessly under extremely challenging conditions, but in many cases they had no previous work experience in resource-limited settings, minimal training in tropical disease, and no knowledge of the historical background that contributed to the catastrophes. Often, this lack of preparedness hindered their ability to care adequately for their patients.
Now is the time for the medical education community to address the gap between the will to help and the expertise to do so. In an attempt to fill this void in medical education, some of the nation's top institutions have established programs to train leaders in global health. At Brigham and Women's Hospital in Boston, for example, internal medicine residents in the Doris and Howard Hiatt Residency in Global Health Equity learn clinical, public health, and policy skills to address inequalities of access and outcomes in health.4 Postresidency fellowship programs have also emerged to expand the pool of global health physicians, including pediatricians and emergency physicians.5,6 The first class of Haitian doctors to participate in the global-health-delivery fellowship training program sponsored by Haiti's Ministry of Health, Partners In Health, Zanmi Lasante, Harvard Medical School, and Brigham and Women's Hospital, have also made extraordinary contributions to health and health care within their home country (as well as in settings across Africa).7
But as the catastrophes in Haiti and other nations have shown, a small cadre of specially trained physicians is not enough to respond to the magnitude of the need at hand. After the Bam (southeastern Iran) earthquake in 2003, over 60 countries provided medical aid. In the early stages of the aftermath of this disaster, despite an enthusiastic foreign response, fragmentation and lack of organization led to long delays in the provision of urgently needed medical and surgical care.8 Clearly, every medical volunteer should be competent in caring for those devastated by the diseases created or exacerbated by poverty and injustice. These include diseases (malaria, cholera, and tuberculosis) unfamiliar to most health care practitioners working in resource-rich settings, as well as exacerbations of noncommunicable diseases (renal disease, heart disease, and diabetes) that occur in crisis situations. But how can every clinical training program, particularly those not expressly focused on global health equity, provide meaningful experiences that teach trainees to recognize and manage a variety of illnesses in resource-limited settings? And how can these trainees understand and begin to address the social and political determinants that contribute to and perpetuate those illnesses?
Medical educators have traditionally focused on building curricula to fill gaps in training needs. While in many cases global health experiences begin as ad hoc rotations created by motivated students or faculty, the best programs purposefully include several key elements.
First, global health topics must be integrated into core medical school and residency curricula, creating a theoretical foundation for rotations.9 Medical schools should teach students the basics of international public health, medical anthropology, global health economics, and tropical diseases.10 We believe additional key global health topics, from triage skills to good global health governance, are also imperative (List 1). Many programs do not offer training in all the skills necessary to provide medical aid in resource-limited settings; for example, in a survey of doctors in the Wessex region of the United Kingdom, less than a third of the doctors likely to respond to a major incident had been involved in a related training exercise.11
Second, students and residents must have dedicated time, financial support, and opportunities to pursue global health experiences within structured clinical environments.12 The success of the first class of Haitian global health fellows highlights the importance of academic training and mentored field work in the education of global health physicians.7 Health care workers rotating abroad are most effective, and derive the most benefit from the rotation, when they have the opportunity to study the common medical illnesses and the historical and political background of a country before leaving. On arrival, they are able to expand their knowledge while providing some benefit to their host institutions.
Third, trainees must have access to mentorship and on-site supervision during these global health rotations.13 This guidance enables students and junior physicians to provide quality medical care while learning, and it ensures that trainees operating beyond their expertise do not compromise clinical standards.14,15
Although the creation of high-quality global health curricula and supervised international experiences would be a tremendous step forward, these changes only partly address the educational needs of students and residents interested in practicing effective global health. To know how a disease presents or even how to prevent and treat it in a resource-limited setting is not enough. Trainees need to understand why a particular disease may be the leading cause of morbidity and mortality in resource-poor settings even though it almost never results in death in resource-rich settings. Education in global health equity is a response to that need. A global health equity perspective, built on the foundational understanding of health as a human right and public good, expands on curricula focused on tropical diseases and other global health topics.16 Through this approach, trainees will begin to understand how war, genocide, and exploitation contribute to the health inequities they witness; they will begin to recognize the “structural violence” that so diminishes the lives of the world's poor.17 This interdisciplinary approach to global health not only provides instruction in medicine and public health but also extends teaching to areas such as economics, law, policy, and engineering. A broad understanding of how poverty and injustice impact health will enable us as health care providers to build successful systems that will support the health and livelihoods of the individuals, like Melissa, who live within them.
Melissa did survive and is currently doing well, but only because she was transferred to an institution in the United States. At this writing, she is without any sequelae of her brush with a death that would have been due to an infection for which a vaccine has existed for over a century. How much better to proactively address the inequity that led to Melissa's condition than to treat the severe complications of tetanus?
Recognizing and commending the academic institutions and organizations that allowed students, residents, nurses, and physical therapists the flexibility to help in the Haiti relief efforts is vital. These institutions are true world leaders in medicine, and their contributions are invaluable. That flexibility, however, must extend beyond a reaction to catastrophes and be channeled toward the establishment of mandatory training that prepares all health professionals to care adequately for vulnerable patients in their local communities and throughout the world where they are struggling through the ongoing catastrophe of lack of access to equitable, quality care. It is imperative that beyond simply training providers to respond to catastrophes, we help create healthy communities, a task that requires an interdisciplinary approach to global health.
The medical community is constantly preparing for the worst-case scenario. January 12, 2010, was the worst-case scenario—a large-scale disaster amplified by poverty, densely populated communities, and the lack of basic infrastructure. Nine months later, the cholera epidemic further highlighted the importance of healthy communities with sanitation, pest control, clean water, and access to essential vaccines, medicines, and healthy foods. It is time for the medical education community not only to prepare its trainees to respond to disasters and treat the illnesses of patients in resource-limited settings but also to provide the knowledge and skills to fight the injustice that fosters disease and allows such catastrophes to unfold.
The authors would like to thank Erin Le and Howard Hiatt for their constant support as they worked in Haiti, and Zoe Agoos for her help editing this manuscript. They would also like to thank the people of Haiti for their inspiring strength.
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