Secondary Logo

Journal Logo

Perspectives

Rethinking Goals: Transforming Short-Term Global Health Experiences Into Engagements

Ventres, William B. MD, MA; Wilson, Brenda K. PhD

Author Information
doi: 10.1097/ACM.0000000000002841
  • Free

Abstract

Short-term experiences in global health (STEGHs) offer important learning opportunities for medical students and residents.1 Among many other particulars while in STEGHs,2,3 students and residents learn about disease through exposure to pathologies not commonly encountered in the United States.4 They learn to associate social determinants with health outcomes, especially in environments where connections between adverse social determinants and poor health outcomes are patently evident.5 They learn about ethical guidelines for limiting harm while working in host communities and are reminded of how the practice of global health can be a call to service, honoring the many caring reasons people enter the health care professions in the first place.6,7

These are all valid lessons. However, based on our observations domestically and internationally, we are concerned that these lessons are framed more by biomedical models of training and practice in the United States than by a sincere aspiration to explore the broader social and systemic forces that drive inequity and promulgate illness. These models inhibit any appreciation of how forces such as political domination and community exclusion create and sustain social determinants that, in turn, adversely affect health outcomes.8 The models also obscure how individuals and institutions, however unwittingly, are complicit in their origin and maintenance.9 Indeed, the lessons STEGHs offer students and residents are fundamentally different from most others they learn in medical training. Recognizing this reality is essential for shifting the focus of STEGHs from discrete learning experiences toward critical engagements10—immersions that nurture among STEGH participants, in collaboration with host communities, the changes in consciousness and action that a transformational understanding of global health implies.11

In this Perspective, we examine the following questions: What barriers inhibit transformative learning through STEGHs? What learning goals should medical educators prioritize for STEGH participants? How can we emphasize these learning goals for medical students and residents?

Barriers to Engaged Learning

We contend that the professional socialization of U.S. medical students and residents makes it hard for them to realize the value of the diverse perspectives that emerge from interactions with people of different backgrounds. It is hard for them to comprehend health care systems that vary markedly from that to which they are accustomed in the United States. Having observed a variety of students, residents, and health professionals involved in global health activities, we have noted that several well-entrenched interests maintain this socialization and commonly inhibit the ability to become aware of new perceptions and insights. The interests that most commonly threaten engaged learning through STEGHs are of ideological, personal, and professional character.

Ideological interests—whether academic, commercial, institutional, military, political, or religious in nature—can pervert the core educational and humanitarian purposes of service–learning experiences. These interests especially sway STEGH participants who have scant awareness of how geography, history, politics, and other socioeconomic structures shape individual and community health outcomes.12 Personal interests—such as attachment to materialism, ambition, and power—can distort honorable intentions and limit the open exploration of global inequities, local health problems, and cultural differences.13 They can reinforce perspectives born of familiarity rather than stimulate thoughtful consideration of unfamiliar points of view. Professional interests—particularly the admiration of the technological and pecuniary successes of our profit- and outcome-oriented medical–industrial complex—can perpetuate the uninformed conviction that the U.S. health care system is the best in the world. They can also foster reproduction of its failures (including fragmentation of care and exorbitantly high costs),14 which contribute to measures of morbidity and mortality that fall well short of those in comparable resource-rich countries.15

Reorienting Goals

To counteract these interests and encourage engaged learning via involvement in STEGHs,16 we suggest that STEGH participants expand their awareness by moving beyond the desired competencies and ethical standards that guide conduct on these immersive international educational encounters.17,18 Rather than focusing on these or other normative objectives, such as identifying atypical pathologies and achieving productivity targets, we suggest that participants attend to 5 key learning goals: develop contextual inquisitiveness, grow in insightful understanding, nurture global humility, cultivate structural awareness, and critically engage in the pursuit of creating equitable and just societies. We posit that by turning their attention to these 5 goals, metaphorically opening the door to profound changes in their professional identity formation,19 participants in STEGHs can learn to think and act in ways that promote systemic change.

These goals are based on our experience and informed by writings in the social medicine and behavioral sciences literature. They are truly goals that all of us involved in global health endeavors would do well to learn and teach.

Develop contextual inquisitiveness

Curiosity is particularly valuable when we find ourselves immersed in foreign environments, where routine daily encounters regularly challenge our habitual ways of thinking and doing. Still, curiosity alone is a sterile attribute when not accompanied by a genuine willingness to explore beneath and beyond perceived differences. As one example, simply asking questions that examine dissimilarities between “us” and “them,”20 without trying to explore the reasons underlying such differences, commonly reinforces negative stereotyping and blaming attitudes.21,22 Searching for and investigating commonalities are equally important pursuits, as is being present to hear the stories of others.

Contextual inquisitiveness is the process of observing, inquiring, and listening, attuning our senses to appreciate the patterns, rhythms, and associations that emerge from meaningful communication.23 This kind of inquisitiveness functions not only as a vehicle for expressing interest in and affinity toward others but also as a means for self-exploration.24 Absent the expectation of a change in consciousness born of a shared relational presence with those living on the margins of dominant culture, the imaginative benefits of STEGHs diminish, perhaps irreparably. We all might as well stay in the relative comfort of our home institutions rather than venture around the globe to encounter and live in solidarity with those whom we purposely hope to help.25

Grow in insightful understanding

Many factors affect health and illness, the relative status of which is our principal concern as health care professionals. Whether we use the biopsychosocial model or other organizational frameworks to aid in grasping the complexity of these factors,26,27 the process of trying to make sense of context in unfamiliar settings is important.28 Enhancing our powers of perceptiveness to gain insight into the lives of others and the environments in which they live is a key step in developing our ability to comprehend the intricate dynamics that influence both populations and individuals.

This ability, as much as any of us is truly able to realize, comes through practiced habits of respect for people’s personal and cultural histories, knowledge of the political and economic contexts in which these histories have evolved, compassionate discernment of how suffering and resiliency manifest in distinctive milieus, and genuine appreciation of diversity in its many varied dimensions.29 It also comes by way of examining thoroughly our own lived and envisioned past, ongoing present, and anticipated future, delving into their meanings from perspectives both individual in nature and representative of our personal, professional, and geopolitical socializations.30 Participation in STEGHs does not necessarily trigger such explorations, but we are all enriched when it does: Enhancing self-awareness through insightful understanding is part of the constantly evolving process of learning global health practice.

Nurture global humility

In recent years, the concept of cultural humility has appeared as a means to help health professionals manage working across boundaries of race and ethnicity in the United States.31 What is needed while working internationally is global humility—the sense of awe and wonder at what we do not understand in relationship to health and illness combined with the acknowledgment that we have much to learn from host communities.32–34 Global humility also means that we—cognizant of our limitations and biases—have much to learn from those thoughtful colleagues whose perspectives and methods challenge the ideas and practices born of our particular professional backgrounds in the United States.

That these recognitions can arise from participation in STEGHs should be obvious; however, underlying (and often unconscious) issues of power, yearnings for control, and the conceit that what we have, others in the world must want often diminish our capacity to make honest self-assessments of our global health activities. Global humility offers us a more nuanced view of our role in curing illness and promoting health, greater accuracy (and less risk) in managing the potent therapies that we now have at our disposal, and greater attention to how people assign meaning to their lives. It also helps offset the tendency to succumb to the “pathologies of power,” including ignorance and arrogance, that reproduce the historical and structural forces known to increase health inequities.35

Cultivate structural awareness

With the literature on STEGHs focusing on educational core competencies and ethical principles,2,3,17,18 coupled with the trend toward seeing international work as a path to professional success,36 it can be easy to concentrate more on our own interests and needs than those of others. Some self-serving perspectives may reflect a kind of “ethical self-fashioning” that can inadvertently deflect attention away from social forces that detrimentally affect the health of people in marginalized communities.37 Although it is unrealistic to expect students and residents to alter the root causes of poor health outcomes during their limited stays in host communities, the aims of shifting educational attention toward appreciating these causes and schooling STEGH participants in the skills of advocacy in service of change are not unrealistic. Absent such appreciation and skill development, STEGHs risk prioritizing personal and professional advancement over the target objective of reducing the burden of illness by empowering the host community.38 Cultivating structural awareness can counteract this tendency.

Structural awareness is the process of systematically attending to the historical, social, cultural, political, and economic contexts of host communities. It is the first step toward generating an honest understanding of the root causes of inequity and poor health (and, conversely, of equity and health). Expanding awareness of structural forces is ideally accomplished using person-centered and location-specific experiential teaching methods over the duration of any STEGH experience (predeparture, while in the host community, and upon return). Applying an anthropological gaze and a structural competency approach can help students and residents assess how these forces play out among individuals living in host communities and consider, alongside those individuals, how to initiate and sustain the transformative process of working cooperatively in pursuit of social justice.39,40

Critically engage in the pursuit of creating equitable and just societies

Critically engaged participation means opening our eyes and ears to see and hear how the social and structural causes of many diseases play out in people’s lives.41 Equally important, it means perceiving ourselves as active subjects working to build just societies rather than as passive objects who accept current social structures that engender poor health outcomes.42 For students and residents, it means learning to ask why global inequities exist in the first place and acknowledging that such inequities exist in the United States as well as in other countries. It means allowing their considered responses to guide where, how, and with whom they choose to practice, acting as agents of structural change by promoting expansion of accessible, appropriate, and acceptable health care services. It means accepting that their personal and professional successes are inextricably tied to the success of others, and it provides a justification for working to improve the health of the economically poor and socially marginalized.43 Last, it means conceding that the goals for learning in STEGHs may be most useful as they return home.

Discussion

STEGHs provide a pathway for students and residents from the United States to learn about global health, “the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide.”44 Learning global health, however, signifies much more than observing the application of human and material resources in areas of perceived need or encountering foreign environments and customs through the medium of medicine. It is recognizing that health outcomes around the world are intimately connected to forces such as oppression and exploitation.45 Learning global health is about understanding how these forces are manifest in everyday social interactions with people in marginalized communities both internationally and domestically. It is also about becoming aware of the roles that individual social responsibility and institutional social accountability can play in ameliorating the effects of these forces and promoting health.46

Grasping such meaningful distinctions means moving beyond the passivity of experiences to action-oriented engagements in global health—engagements based first and foremost on a commitment to learn how to contribute to the construction and safeguarding of equitable and just societies that improve the health and dignity of all. As much as they function as educational opportunities for students and residents, global health engagements encourage mutual exchanges that foster interpersonal dialogue, intentional practice, and social action aimed at advancing human well-being.47

Reconceptualizing experiences as engagements moves students and residents from considering individual-level interventions and outcomes common to biomedical models of training to becoming aware of how structural forces contribute to inequities in both health outcomes and health promotion. It moves them from approaching STEGHs simply as a means to augment their knowledge, attitudes, and skills to seeing STEGHs as opportunities to transform the intellectual lenses—their nascent professional identities19—through which they perceive the world and their work in it. It encourages long-term commitments to critical engagement in marginalized communities by prioritizing social justice as an object of ongoing attention.

What might such a reconceptualization look like in practice, and how might those who organize and offer STEGHs integrate the goals we suggest into global health immersions? Although a complete discussion of these questions is well beyond the scope of this Perspective, we recommend several steps. First, highlight the 5 goals we discussed here. Unless educators and program administrators do so, students and residents will continue to attend to the normative institutional objectives currently in place.

Second, introduce these goals well before students or residents venture abroad, using longitudinal, community-based, service–learning activities as platforms for building new insights. Require such activities at home as prerequisites for involvement in any STEGH, and teach a structural competency approach during predeparture preparation.

Third, arrange STEGHs around emergent issues that deal directly with how adverse social determinants constrain health and well-being, allowing students and residents to hear from those living in host communities and bear witness to the challenges they face. Deliberately provide opportunities for students and residents to express their thoughts and feelings about their global health encounters—during their time in the host community and afterward—using inclusive, responsive, and appreciative educational strategies.48,49

Fourth, add intentions and relationships as domains of learning, augmenting those—knowledge, attitudes, and skills—that frame traditional curricula. Educate with a focus on awareness of complexity and inclusivity, acknowledging both the strengths and limits of our own assumptions, values, and experiences.50

Last, integrate these goals into all aspects of medical education, from explaining the basic sciences to preparing for independent clinical practice. Such a change would, of course, demand that we refocus our own thinking as medical educators in the United States, spending more time and effort addressing at home the same issues we expose our students and residents to when they travel around the world.

Any such reconceptualization of STEGHs should focus on students and residents observing, listening, and learning alongside carefully selected, trusted host partners who also value the structural orientation these goals and approaches emphasize. The lessons of engagement are simply not compatible with paternalistic interventions that favor U.S.-controlled agendas and motivate many to take part in global health activities, however well-meaning their intentions may be.51 We also caution all involved individuals—educators, administrators, and participants alike—about imagining STEGHs as a means to effect social change in international settings. Short-term engagements in global health have much less to do with suggesting how others lead their lives than with redefining how we lead ours.

Some will undoubtedly argue that the goals we outline are purely attitudinal in nature and that the acquisition of competencies, learning to apply state-of-the-art technologies and therapeutic modalities where they are lacking, is a more appropriate measure for gauging the success of participating in STEGHs. We agree that the goals we present have attitudinal aspects to them; however, they also feature the development of professional capabilities crucial to realizing socially accountable aims.52 As such, they are applicable to not only students and residents but also seasoned clinicians, educators, administrators, and others who facilitate learning through STEGHs. Given their emphasis on understanding complexity, context, and culture, these goals are also worthy of consideration by U.S. institutions interested in launching or expanding community-engaged interventions.53 Putting these goals into practice can support initiatives intended to advance health equity for all people,54 whether near or far.

Conclusions

We suggest redirecting learning goals in STEGHs away from normative objectives and toward those favoring a heightened appreciation of how social forces create the social determinants that affect health outcomes. In addition, we propose that students and residents in STEGHs begin to explore the process of becoming agents of structural change alongside members of host communities. Such a reframing of goals, to develop contextual inquisitiveness, grow in insightful understanding, nurture global humility, cultivate structural awareness, and critically engage in the pursuit of creating equitable and just societies, can pave the way for transforming professional identities in service of health equity. By thus reconceptualizing short-term global health experiences as engagements, medical students and residents—indeed, all health professionals involved in global health activities—can improve their abilities to attend to the concerns of those living in areas of need, enhance social justice, and improve the health of all people, individually and in community with others, wherever they may be.

Acknowledgments:

The authors thank Jerome Crowder, PhD, Calvin Wilson, MD, and the anonymous reviewers for their contributions to the writing of this article. They also thank the Institute for the Medical Humanities, University of Texas Medical Branch, Galveston, where B.K. Wilson completed a doctoral program and W.B. Ventres was a scholar in residence, and the Brocher Foundation, Geneva, Switzerland, where W.B. Ventres was a visiting scholar on global health ethics.

References

1. Evert J, Drain P, Hall T. Developing Global Health Programming: A Guidebook for Medical and Professional Schools. 2014. 2nd ed. San Francisco, CA: Global Health Education Collaborations Press; https://www.cfhi.org/sites/default/files/files/pages/developingglobalhealthprogramming_0.pdf. Accessed November 25, 2018.
2. Hagopian A, Spigner C, Gorstein JL, et al. Developing competencies for a graduate school curriculum in international health. Public Health Rep. 2008;123:408–414.
3. Jogerst K, Callender B, Adams V, et al. Identifying interprofessional global health competencies for 21st-century health professionals. Ann Glob Health. 2015;81:239–247.
4. Freedman DO, Gotuzzo E, Seas C, et al. Educational programs to enhance medical expertise in tropical diseases: The Gorgas course experience 1996–2001. Am J Trop Med Hyg. 2002;66:526–532.
5. Pfeiffer J, Beschta J, Hohl S, Gloyd S, Hagopian A, Wasserheit J. Competency-based curricula to transform global health: Redesign with the end in mind. Acad Med. 2013;88:131–136.
6. Melby MK, Loh LC, Evert J, Prater C, Lin H, Khan OA. Beyond medical “missions” to impact-driven short-term experiences in global health (STEGHs): Ethical principles to optimize community benefit and learner experience. Acad Med. 2016;91:633–638.
7. Haq C, Lukolyo H, Graber LK, Elansary M, Khoshnood K, Rastegar A. With so much need, where do I serve? Virtual Mentor. 2010;12:149–158.
8. Braveman P, Gottlieb L. The social determinants of health: It’s time to consider the causes of the causes. Public Health Rep. 2014;129(suppl 2):19–31.
9. Sullivan N. International clinical volunteering in Tanzania: A postcolonial analysis of a global health business. Glob Public Health. 2018;13:310–324.
10. Friere P. Pedagogy of the Oppressed. 2007.New York, NY: Continuum.
11. Horton R. Offline: Liberty vs equity in global health. Lancet. 2018;391:1134.
12. Stewart KA, Swain KK. Global health humanities: Defining an emerging field. Lancet. 2016;388:2586–2587.
13. McCarthy AE, Petrosoniak A, Varpio L. The complex relationship global health humanities: Defining an emerging field involved in global health: A qualitative description. BMC Med Educ. 2013;13:136.
14. Schneider EC, Squires D. From last to first—Could the U.S. health care system become the best in the world? N Engl J Med. 2017;377:901–904.
15. Avendano M, Kawachi I. Why do Americans have shorter life expectancy and worse health than do people in other high-income countries? Annu Rev Public Health. 2014;35:307–325.
16. Merizow J. Transformative Dimensions of Adult Learning. 1991.San Francisco, CA: Jossey-Bass.
17. Crump JA, Sugarman J; Working Group on Ethics Guidelines for Global Health Training (WEIGHT). Ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg. 2010;83:1178–1182.
18. Lasker JN, Aldrink M, Balasubramaniam R, et al. Guidelines for responsible short-term global health activities: Developing common principles. Global Health. 2018;14:18.
19. Wald HS. Professional identity (trans)formation in medical education: Reflection, relationship, resilience. Acad Med. 2015;90:701–706.
20. Ventres W, Haq C. Toward a cultural consciousness of self in relationship: From “us and them” to “we”. Fam Med. 2014;46:691–695.
21. Viruell-Fuentes EA. Beyond acculturation: Immigration, discrimination, and health research among Mexicans in the United States. Soc Sci Med. 2007;65:1524–1535.
22. Finnegan A, Morse M, Nadas M, Westerhaus M. Where we fall down: Tensions in teaching social medicine and global health. Ann Glob Health. 2017;83:347–355.
23. Pigg SL. On sitting and doing: Ethnography as action in global health. Soc Sci Med. 2013;99:127–134.
24. Kleinman A, Benson P. Culture, moral experience and medicine. Mt Sinai J Med. 2006;73:834–839.
25. Nelson G, Prilleltensky I, MacGillivary H. Building value-based partnerships: Toward solidarity with oppressed groups. Am J Community Psychol. 2001;29:649–677.
26. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535–544.
27. Garrafa V, Porto D. Intervention bioethics: A proposal for peripheral countries in a context of power and injustice. Bioethics. 2003;17:399–416.
28. Harcourt W. Revisiting global body politics in Nepal: A reflexive analysis. Glob Public Health. 2016;11:236–251.
29. Kleinman A. Four social theories for global health. Lancet. 2010;375:1518–1519.
30. Gibson C, Woollard R, Kapoor V, Ponka D. Narratives in family medicine: A global perspective: The Besrour papers: A series on the state of family medicine in the world. Can Fam Physician. 2017;63:121–127.
31. Tervalon M, Murray-García J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9:117–125.
32. Downing R. Global Health Means Listening. 2018.Nairobi, Kenya: Manqa Books.
33. Ventres WB. Intentional exploration on international service learning trips: Three questions for global health. Ann Glob Health. 2017;83:584–587.
34. Biehl J, Petryna A. When People Come First: Critical Studies in Global Health. 2013.Princeton, NJ: Princeton University Press.
35. Farmer P. Pathologies of Power: Health, Human Rights, and the New War on the Poor. 2005.Berkeley, CA: University of California Press.
36. Palazuelos D, Dhillon R. Addressing the “global health tax” and “wild cards”: practical challenges to building academic careers in global health. Acad Med. 2016;91:30–35.
37. Shaw SJ, Armin J. The ethical self-fashioning of physicians and health care systems in culturally appropriate health care. Cult Med Psychiatry. 2011;35:236–261.
38. Abedini NC, Gruppen LD, Kolars JC, Kumagai AK. Understanding the effects of short-term international service–learning trips on medical students. Acad Med. 2012;87:820–828.
39. Ventres W, Crowder J. When I say … anthropological gaze. Med Educ. 2018;52:590–591.
40. Metzl JM, Hansen H. Structural competency: Theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126–133.
41. Ventres WB, Fort MP. Eyes wide open: An essay on developing an engaged awareness in global medicine and public health. BMC Int Health Hum Rights. 2014;14:29.
42. Hoggan CD. Transformative learning as metatheory: Definition, criteria, and typology. Adult Educ Q. 2016;66:57–75.
43. Ventres W, Dharamsi S, Ferrer R. From social determinants to social interdependency: Theory, reflection, and engagement. Soc Med. 2017;11:84–89.
44. Koplan JP, Bond TC, Merson MH, et al.; Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet. 2009;373:1993–1995.
45. Horton R. Offline: Frantz Fanon and the origins of global health. Lancet. 2018;392:720.
46. Wollard RF. Caring for a common future: Medical schools’ social accountability. Med Educ. 2006;40:301–313.
47. Wilson BK. An Unruly Mélange in a Postcolonial State: The Cultural Politics of Short-Term Global Health Engagements in Dominican Republic Bateyes [dissertation]. 2019.Galveston, TX: University of Texas Medical Branch.
48. Prout S, Lin I, Nattabi B, Green C. ‘I could never have learned this in a lecture’: Transformative learning in rural health education. Adv Health Sci Educ Theory Pract. 2014;19:147–159.
49. McAllister M. Transformative teaching in nursing education: Preparing for the possible. Collegian. 2005;12:13–18.
50. Kumagai AK, Lypson ML. Beyond cultural competence: Critical consciousness, social justice, and multicultural education. Acad Med. 2009;84:782–787.
51. Bauer I. More harm than good? The questionable ethics of medical volunteering and international student placements. Trop Dis Travel Med Vaccines. 2017;3:5.
52. Rourke J. AM last page. Social accountability of medical schools. Acad Med. 2013;88:430.
53. Strasser R, Worley P, Cristobal F, et al. Putting communities in the driver’s seat: The realities of community-engaged medical education. Acad Med. 2015;90:1466–1470.
54. Hone T, Macinko J, Millett C. Revisiting Alma-Ata: What is the role of primary health care in achieving the sustainable development goals? Lancet. 2018;392:1461–1472.
Copyright © 2019 by the Association of American Medical Colleges