More than 40 years ago I began my medical education as a volunteer in a rural medical clinic in Mexico. I remember visiting a woman in her home who was having seizures and facial spasms. I was perplexed by her presentation and reviewed textbooks in our library on the differential diagnosis of new-onset seizures and facial spasms. When I returned to ask the patient more questions, she described a recent wound on her foot from a nail. It turned out that she had tetanus. I treated her with intravenous fluids, muscle relaxants, and other supportive measures in her home because her family would not transport her to a hospital in a city three hours away, since the huge expense would have likely cost them their farm. They were poor village farmers and had no source of income except for the farm, and no medical insurance. After an excruciating two days, the woman died. She had never been immunized against tetanus. This was one of the first patients who had died under my care, and I found myself devastated by the realization that had this woman been in the United States, only a 12-hour auto ride away, she probably would have been immunized and would not have died.
A few months later, an epidemic of whooping cough struck the village, and I will never forget the sounds of children with spasms of coughing and whoops that rang out in the night. Although we purchased vaccine in Mexico City, it was too late for some of the children, who died of the pertussis. There were no local doctors or any other medical providers in the village, and volunteer doctors, nurses, and students like me provided intermittent, stopgap medical care with donated medications and supplies. The volunteer health providers trained local villagers when possible, and eventually started a community health worker program that offered some local medical resources. While the training of local individuals addressed some of the previous language and cultural gaps associated with the volunteers, I still worried that the infusion of outside resources and new medical concepts might have unintended consequences for the village culture. Even Americans of moderate means could solve problems that were impossible for local villagers, just by reaching into their pockets and pulling out their wallets, and the temptation to do this for the villagers was powerful.
What I encountered at the time was probably typical of many global health projects that utilized outside volunteers and addressed preventable problems, particularly infectious diseases affecting children. While public health measures to provide safe water, sanitation, and family planning and to prevent infectious diseases through vaccination were high priorities, there was also a very urgent need for acute care services to treat many of the diseases that were sensitive to routine medical care. Pneumonia, dehydration, dental abscesses, infections on the hands or feet, and complications of pregnancy all could be treated with the medications and supplies of a clinic. And our clinic sometimes did save lives. Gradually, clean water systems for drinking water and food preparation replaced the villagers’ use of river water, Mexican physicians replaced the U.S. volunteers, and immunizations reached most of the rural population. Unfortunately, new problems emerged as the major causes of mortality and morbidity: drugs, alcohol, and related violence; motor vehicle crashes; strokes; depression; and cancer. While much has changed, some vestiges of the past remain, such as disparities in the quality of care between the rich and poor and differences in access to care in the urban and rural areas.
Ongoing efforts around the world to address old and new global health problems through medical education have prompted us at Academic Medicine to ask what can be learned from such efforts and how the journal can help inform readers about those efforts and encourage future ones. An inspiration for these questions was an article in a 2014 supplement to Academic Medicine in which Frehywot et al1 described the development of a community of practice of medical educators in Africa, with subsequent information exchange and scholarly products. That collaboration encouraged us to continue to learn about the best medical education models and most promising educational innovations that can lead to improved health and health care at a cost that all countries can afford.
In the rest of this editorial I discuss global health and global health education and identify some priority areas I believe need attention. My comments are the start of a more sustained conversation about global health education that will begin at the end of this year, when this topic will replace the current New Conversations focus on medical education and health reform in the United States.
There are new and serious challenges in global health, such as large-scale human migration, violence, terrorism, climate change, the emergence of new infections, a growing aging population, and increased costs of health care. Around the world, each of these challenges and others will place significant strains on our ability to meet the health care needs of our populations and to pay for that care, regardless of whether funds are collected and disbursed through governmental or private financing mechanisms. However, I believe there are opportunities to learn about how to use resources equitably to reach all parts of a population so that we avoid the kinds of preventable tragedies and health care disparities that I observed 40 years ago in that rural Mexican village. While the challenges of global health and global health education are complex and daunting, the potential opportunities to make a difference are enormous, and there are strong ethical and public health arguments to commit our energies to making the most of these opportunities. This is why the journal will soon have a new focus in New Conversations to encourage our communities to think and communicate creatively about global health education. Fortunately, we already have the benefit of previous important efforts to build on.
Frenk et al2 outlined many of the global problems in our current education system for health professionals, including
fragmented, outdated, static curricula … mismatch of competencies to patient and population needs, poor teamwork, persistent gender stratification of professional status, narrow technical focus without broader contextual understanding, episodic encounters rather than continuous care, predominant hospital orientation at the expense of primary care.…
As they considered these and other problems, they noted five features in the globalization of health professions education:
- The recognition of one global pool of qualified health professionals and those training to become health professionals
- The global challenges and aspirations of primary health care in different contexts
- The interdependence of all health issues
- The movement of medical schools in developed countries to establish foreign affiliated campuses
- The development of global health as a distinct organizational unit and field of study at medical schools
Frenk et al noted that in regard to educating health professionals, poor countries will be constrained by financial limitations that may not affect the wealthier countries, while the wealthier countries may be more constrained by issues of professional credentialing, and these differences will lead to a variety of local solutions that should be shared. They concluded that “professional educators are key players, since change will not be possible without their leadership.” One recommendation involved workforce planning, “harmonizing the supply and demand of health professionals to meet the health needs of the population.” Gorman3 has described the melding of workforce predictions, population data, and health systems modifications as key factors in intelligent workforce analysis; he believes such analysis will be critical in an environment of likely deficits in the global workforce.
Kim and Evans4 from the World Bank made the connection between global health education and access to and costs of health care services. They identified two priorities related to health care in developing countries: reducing and eventually eliminating impoverishment caused by health care expenses; and improving access to basic health care. While neither of these priorities is traditionally considered within the realm of medical education, the authors believe that they can be accomplished by increasing the number and quality of health professionals worldwide.
Discussions about the potential for global health professions education to affect health care quality can be confusing because they are often geographically focused. For example, included under the rubric of global health education are the education of U.S. students about global health (including their overseas experiences), the education of foreign students either in their home country or in another country, and various transnational educational projects that could include clinical, research, and educational components. In this issue of the journal, Kasper et al5 suggest that global health is not geography bound but, rather, is about social relationships and interconnectedness. They describe a preclinical course focused on the social determinants of health and social medicine that are relevant in any location; the course will prepare the student to analyze and address medical problems based on an understanding of how various factors—such as poverty, violence, and education—can affect medical problems and their treatments. They note that while the resources to address the problems may differ, the problems can be analyzed using a similar framework regardless of whether the patient is in Africa, Haiti, or Boston.
Also in this issue, Melby et al6 address short-term overseas projects that students often find attractive for providing a global health experience. They maintain that projects must have community benefits as well as good student educational experiences and identify four principles that short-term projects should fulfill: emphasis on cross-cultural effectiveness skills and cultural humility; bidirectional participatory relationships; local capacity building; and long-term sustainability. Crump and Sugarman,7 in addressing the same topic, cautioned about the need to protect the student’s health and prevent the student from being placed into a clinical situation that exceeds his or her capabilities.
Also in this issue, Halperin and Goldberg8 raise concerns about the financial and quality-of-care impacts of the medical education of U.S. citizens in Caribbean medical schools. They describe market-based competition for U.S. clinical clerkship sites that may affect U.S. students training in U.S. medical schools. Burdick et al9 respond to some of the concerns raised by Halperin and Goldberg and acknowledge their concerns about clinical training site shortages. They state that 5.3% of active physicians in the United States are U.S. international medical graduates and note the important contributions these physicians make to our country’s primary care.
As we consider how to prepare a global workforce to address the many health needs around the globe, I pose the following questions for our community’s consideration.
What is the purpose of global health education? If we can agree that the goal of global health is to optimize the health and health care of the world’s populations and reduce the chances of impoverishment from health care costs, how can global health education contribute to that goal? Can we share knowledge, experience, and resources between countries to better reach their populations? Where would short-term global projects fit within such an overarching goal? Would we value the training of nonphysician health care providers in poor countries differently from such training in wealthy countries? A unified goal of global health education might help us allocate our limited resources most effectively.
What are the responsibilities of the health education communities of wealthier countries to be advocates for and give assistance to health educators and providers from countries less well off? Since poverty, education, and health are not distributed evenly around the world, what are the implications of such disparities for global health education to produce and utilize a health care workforce? For threats to health with clear global interconnections between nations, such as air pollution that crosses borders, spread of infectious disease between countries, or global climate change, how can global health education help address these threats?
Finally, how can we in the global medical education community develop a global health identity? While the past hundred years have witnessed a rapid rise in human longevity and the diminishment or disappearance of many diseases, mistrust and fear between peoples of the world based on race, gender, culture, and religion continue to impede the development of a global identity that would facilitate collaboration and sharing in medical education. How can we in the global medical education community overcome these problems to create a more global health identity? The problems we will face in the future will likely involve the effects of a burgeoning human population, environmental stresses, climate change, and the need to solve problems on a global scale with institutions built in the past for different sets of problems. Around the world, educators, among many others, also retain a psychological and cultural heritage that is not very different from that of their grandparents, and many important values and beliefs—some of which now impede needed change—still hold sway in some parts of the world. How can we medical educators everywhere speed the evolution of a new global identity through medical education to better prepare ourselves for global problem solving?
Our New Conversation on global health education will likely traverse a bumpy and diverse landscape, as indicated by the comments of Halperin and Goldberg8 and Burdick et al.9 However, I believe that through dialogue we will find the best answers. Through New Conversations on global health education, we at Academic Medicine wish to
- generate greater understanding of diverse strategies and systems for training physicians and other caregivers;
- stimulate more thought about how to optimize training opportunities across nations; and
- encourage dialogue about the mobility of providers around the world.
We are interested in New Conversations contributions that address a wide variety of global health education topics, including but not limited to the following:
- Diverse approaches and structures of health professions education in different parts of the world, including the format, organization, and content of training; degrees; certifications; and definitions of specialties
- Effects on students of exposing them to diverse settings, populations, health problems, and implementation strategies
- Credentialing and accreditation systems to support mobility of providers
- Global workforce projections and adjustments of educational focus to meet the projected needs
- Global curriculum reform to identify universal principles and content
- Global health policy, health services research, and international research collaboration
- Health care costs and control of costs through education in different health care settings
- Addressing health disparities through global health education
- Global ethics and professionalism
- Global professional identity formation
In her guest editorial in this issue,10Academic Medicine Deputy Editor Dr. Debra F. Weinstein summarizes our reasons for choosing this topic for New Conversations. She offers additional insight into the types of submissions we are seeking and the questions we are trying to answer.
I believe that many of you have perspectives, experiences, and ideas to contribute. Global health education approaches and programs that work in one country could take root in others if we can know about, understand, share, and nurture them. In addition, I think it may sometimes be the questions you can raise that will be as important as the answers. I ask that you submit contributions on this second New Conversations topic—guided by the questions, examples, and goals stated in this editorial—to be considered for publication in the journal. Please submit contributions through the journal’s online submission system, Editorial Manager (www.editorialmanager.com/acadmed), using the article type “New Conversations.” Submissions should be scholarly contributions that follow the journal’s regular submission criteria for Commentaries, Perspectives, Research Reports, Articles, and Innovation Reports. (For more information about those criteria, please see the journal’s Complete Instructions for Authors at http://journals.lww.com/academicmedicine/Pages/InstructionsforAuthors.aspx.) Submissions will be peer reviewed.
We will carry on the conversation outside the pages of the journal as well. Our blog AM Rounds (academicmedicineblog.org) will feature a series of discussions related to the New Conversations contributions that are published in the journal. I also encourage you to discuss New Conversations on Twitter using the hashtag #AcMedConversations by offering your opinions, posing questions, and responding to the opinions and questions posed by your colleagues. We will be using the journal’s Twitter handle, @AcadMedJournal, to do the same.
The perspectives of our international readers will be particularly important in this New Conversation about global health education. Educators and others around the globe have valuable experiences and ideas to share. I encourage our international readers to submit contributions to this second New Conversation to share their thoughts and experiences and thereby inform the discussion around the world.
I will consider New Conversations submissions at any time—there is no deadline for submitting a contribution. Although we may not publish New Conversations contributions in every issue of the journal, we hope to have many of them to share in the pages of the journal and beyond as this second New Conversation unfolds.
We seek your best ideas and your support so that global health education can lead in creating global trust and partnerships that will be critical for everyone in this changing world.
David P. Sklar, MD