Lisa V. Adams, MD sheds light on how global health has become its own discipline and how future medical students will define competencies and equities in global health.

img_1860

Over the last decade, the field of global health has grown by every conceivable measure. Students at all levels – sometimes as early as high school – are participating in global health projects and programs. As a result, more students are entering medical school with a range of overseas experiences under their belts, and are eager for advanced training. Many applicants inquire about formal global health opportunities during their medical school interviews, suggesting that global health may be a factor in their choice of a medical school. The medical student’s interest and desire for clinical opportunities in global health often continue into his or her residency and fellowship training. Several residency programs now offer global health tracks within, or across, specialties. Many non-profit organizations also offer volunteer service-learning opportunities for students, while organizations such as Child Family Health International1 are devoted exclusively to providing structured volunteer community-based programs to educate students and institutions on global health. However, in spite of this growth in the number of programs, opportunities and funding, demand among our learners appears to outstrip our offerings.

In response to the high demand among students and the emergence of global health as its own discipline, many medical schools are establishing global health programs, centers and institutes. These new entities are often charged with defining curricular and co-curricular opportunities and determining what defines competence in global health. The field of global health has also piqued the interest of mid-career and retiring faculty, some because of earlier overseas experiences, and others who seek to apply their skills where the need is greatest, now that they have more time. Lastly, research opportunities in both communicable and non-communicable diseases seem to be on the rise, with several new requests for applications announced in recent years. These opportunities have targeted clinical researchers as well as those engaged in global health training and provision of technical assistance.2

Witnessing this remarkable growth has many global health educators wondering whether the training and guidance that we provide to students today will be applicable in the next decade, or beyond. Global health did not exist as an academic discipline when I was in medical school 25 years ago. It is unlikely that those early clinicians who blazed the path in the era of tropical medicine, and later international health (the precursors to global health) could have anticipated the evolution of their field to the current-day practice of global health. What indications do we have to help us predict what global health study and practice will look like 25 or 30 years from now?

Recalibrating the Compass: A Focus on Health Equity

Many of us who work in global health are driven by the same motive: to heed the call so aptly described by Rwanda’s Minister of Health, Dr. Agnes Binagwaho, namely, “to work together towards a future in which where a patient lives doesn't determine if they live.”3 While we may use different terms to describe our motivations - a sense of social justice, a moral or religious imperative, a sense of fairness, a recognition of health as a human right - I would posit that many of us are driven by a desire to reduce or eliminate health inequities in the world. Indeed, one of the most cited definitions of global health, published in the Lancet by Koplan et al., firmly puts health equity at the core of global health. Specifically, they define global health as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.4 If health equity is a common thread, we should be certain that our students have a strong foundation in understanding what health equity is, and how it can be achieved.

As with global health, definitions of health equity, or more often health inequities, abound, but most encompass the concepts of systematic differences that result in worse health or greater health risks experienced by disadvantaged groups, often identified by social, racial, ethnic, economic or demographic distinctions.5,6 Reducing or addressing health inequities, sometimes referred to as health disparities, has been well studied in a variety of settings, especially across different populations in high- or middle-income countries. Applying this knowledge to global health settings will intersect with health systems strengthening to ensure, among other things, health care access and quality. If global health training or capacity-building will strengthen the health care workforce and improve quality, then global health research will create knowledge to improve the diagnosis and management of various diseases and organization of services, while global health practice will increase access. All of these (training, research and practice) together can improve overall health care delivery. By understanding the systematic nature of health care inequalities, clinicians can design innovative systematic solutions.

Furthermore, since today’s challenges in global health are multifactorial and complex, the solutions must be multidisciplinary. Tomorrow’s (and arguably today’s) global health practitioners must work well within multidisciplinary teams - with nurses and other allied health professionals, but also with educators, engineers, politicians and manufacturers. They must understand the various roles and contributions that colleagues across many disciplines can make. They must learn how to become what Rishi Manchanda calls, in his new book by the same name, “upstream doctors” - providers who can heal the acute problem, while looking upstream to the root problem and engaging aligned colleagues and services to address the causes. Eliminating or reducing health care inequities from the health care system may not guarantee the same health care outcomes for all, but it will certainly go a long way towards that goal.

The Importance of Partnerships

Experts in global health recognize the importance of strong in-country collaborations in order to be effective, efficient and responsive to host country priorities. How to build effective partnerships has been the challenge. While there may not be (there likely isn’t) a single approach that applies to all, or even most, international collaborations, there are some common characteristics that form the foundation for effective and equitable partnerships.

In the past, international health partnerships were often unbalanced. At worst, the United States or European institution provided assistance to those in the global south as a charitable act, with at times the condescending attitude of helping “the poor natives” improve themselves. Equally unacceptable were the situations in which the US or European partners used the local teaching hospital as a site at which to train their students, or for their faculty to conduct research with little or no recognition of the host country partner’s participation or contributions. While these types of partnerships are more rare today, and such attitudes regarded as offensive, the truth is that there is often still a subtle undercurrent of a superior/inferior dichotomy to many international collaborations. It is ironic that the work aimed at reducing inequities in health should replicate inequities in professional relationships.

Partnering in Rwanda

Fortunately, today there are many examples of university partnerships where the effective transfer of knowledge and skills is occurring, and the leadership is squarely in the hands of the host-country partner. One such example that I have been involved with is the Rwanda Human Resources for Health Program.

Launched in 2012, this program is a comprehensive seven-year commitment to rebuild the Rwandan medical education system, with the overall goal of creating a sustainable, high-quality health care system. Eight medical schools, five nursing schools, two dental schools, and one health-management program comprise the consortium of US partners that send their faculty members to work for one year at a time in the teaching hospitals in Rwanda. This program has many unique features: the inclusion of multiple specialties and several health professions, the lengthy duration of stay for the faculty, and the number of collaborating schools, all of which have been described in detail elsewhere.7 An important feature of this partnership, as we consider equitable engagement, is that the Rwandan Ministry of Health is providing the leadership for this program. A comprehensive memorandum of understanding outlines the relationships and responsibilities of each partner, but the US partners serve at the invitation and under the direction of the Rwandan leadership team. In this relationship, we strive for Rwandan-manufactured and Rwandan-owned solutions to the health education problems. Not every Ministry of Health in every county would be willing or able to assume such a massive undertaking, and to be prepared for a revolutionary change in their health care system, but those countries that are ready for such responsibility ought to be given the reins.

Partnerships like this one are well positioned to evolve into a meeting of equals: not necessarily equal in terms of financial investments or Gross National Products, but equal relationships in which each partner brings complementary skills and expertise to the table. We in the global north already know we have much to learn from our counterparts in the global south - both because great ideas are born everywhere, and because resource constraints often have historically led to impressive efficiency and innovation in health care delivery. The concept of “reverse innovation” has been described in the business world8,9 and is now being applied to health care.10 An open mind and humility required.

Next, we must commit to create research and educational collaboratives in which each participating institution contributes in a unique and significant way. Additionally, if we expect these types of partnerships to become the norm in global health, we need to ensure that our students are well equipped as good partners who know how to build equitable and successful collaborations across cultures, disciplines and distance. Required courses may begin to resemble those more common to a business school curriculum - i.e. courses on negotiation and management - or may belong to the social science disciplines such as anthropology or sociology. A global health curriculum of the future will require flexibility and will draw upon the expertise of many colleagues outside of the traditional medical sciences.

Redefining Roles

Beyond building effective and equitable partnerships, clinicians also need to consider the role for a US-trained global health practitioner of the future. As discussed, the traditional pattern of global-north-to-global-south assistance no longer applies. Access to information is not the major bottleneck it once was for many students in low-income countries. Internet bandwidth continues to improve, and open-access journals are gaining in popularity and prestige.

In addition, the World Health Organization’s HINARI (Health InterNetwork Access to Research Initiative) Programme, established with the support of major publishers, now provides people in low-income countries with access to a wide range of electronic medical journals and other resources.11 Videotaped lectures and downloadable slide decks are available from many reputable Internet sites. As our colleagues in Africa, Asia and South America gain access to the content, strengthen their own universities, and take advantage of the many scholarship programs to train their own leaders at internationally-renowned institutions, what role will the US graduate, with similar classroom learning and only a few months of overseas experience, have to offer to these international partners?

The reality is that there are still - and may be for some years to come - sites in the developing world where there is either no doctor or too few doctors with sufficient training. While these positions will always be best filled by those who understand the culture and speak the language of the patients, there are some foreign doctors who make long-term commitments, and, despite always being somewhat outsiders, assimilate as much as any outsider can, while offering a real service to the population. In addition, until skill transfer is complete, there are patients in low-resource areas who benefit from short-term visits by foreign surgical teams to repair cleft palates, close obstetric fistulas and replace damaged heart valves.

However, in the next decade or two, as health care workforces overseas are strengthened; as skill transfer to the rising generation of young, mobile and tech-savvy health care professionals occurs; and as our US colleagues enter existing equitable partnerships or establish new ones, what role will the US global health practitioner play?

The good news is that every specialty has a place on the global health stage. Most collaborations now cut across many, if not all specialties, from dermatology to pathology; thereby students are free to pursue the specialty they are passionate about, without fearing any loss of options for future work in global health. As our international counterparts emerge as the top experts in traditional global health fields, like maternal and child health and infectious disease, US global health physicians will need to build partnerships in which they can add value.

In the big picture of global health, the majority of students share a desire to achieve health equity for all. While the term “health equity” does not generate the same buzz as the concept of “global health” does at the present time, someday it will. If we want our students to be versatile to practice wherever there are health inequities, we should refocus their training accordingly.

We have a lot to learn from colleagues who focus on domestic health equity, and joining forces with them will surely make us a stronger force for good. There are more similarities than differences in working with underserved populations who have been subjected to systematic health inequities, regardless of whether they live in rural New Hampshire or urban Dar es Salaam. We need to teach our students to recognize these similarities, and equip them to take on the challenges, regardless of the setting. Looking to the future, such training will generate the most effective global health practitioners - some of whom may opt to practice in a very familiar part of the globe, in local communities where the needs are surprisingly stark.

Conclusion

As we move beyond the north-assists-south pattern in global health, we must adapt the roles of our global health specialists and adjust their training accordingly. Realizing that a desire for health equity is at the heart of most global health work provides one direction. Challenging our students to focus on health equity as the underlying issue should well prepare them for a life of global health work - and a career that may take them around the globe, or have them land in their own backyard. 

About the Author

Lisa V. Adams, MD is the Associate Dean for Global Health at Dartmouth's Geisel School of Medicine. She is the Director of Geisel's Center for Health Equity and Advisor for the Global Health Initiative at Dartmouth College’s John Sloan Dickey Center for International Understanding. In these roles, she develops and oversees crosscutting global health programs involving faculty and students. Her area of expertise is domestic and international tuberculosis care and control. She has provided technical assistance to the national tuberculosis programs in Ghana, Swaziland and Tanzania on the development of pediatric tuberculosis clinical guidelines, pediatric TB care delivery and TB program monitoring. At Dartmouth, she teaches courses on global health to medical and college students. She is a collaborator of the DarDar Programs, a partnership between Dartmouth/Geisel and Muhimbili University of Health and Allied Sciences focused on tuberculosis and tuberculosis/HIV care and research. Most recently she spent six months in Rwanda as Dartmouth’s lead in Rwanda’s Human Resources for Health Program

References

  1. Child Family Health www.cfhi.org. Accessed August 14, 2013.
  2. Collins F, Beaudet A, Draghia-Akli R, et A database on global health research in Africa. Lancet Global Health. 2013; 1(2): e64-5.
  3. Binagwaho Rwandan health minister hits back at critics of drug company deal. The Guardian. May 21, 2013. http://www.theguardian.com/world/2013/may/21/rwanda-health-
minister. Accessed August 14, 2013.
  1. Koplan JP, Bond TC, Merson MH, et Towards a common definition of global health. Lancet. 2009; 373(9679): 1993-5.
  2. Braveman Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006; 27: 167-94.
  3. Starfield B, Gérvas J, Mangin Clinical care and health disparities. Annu Rev Public Health. 2012; 33: 89-106.
  4. Binagwaho A, Kyamanywa P, Farmer PE, et al. The human resources for health program in Rwanda--new partnership. N Engl J Med. 2013 Nov 21;369(21):2054-9. doi: 10.1056/NEJMsr1302176.
  5. Immelt JR, Govindarajan V, Trimble How GE is disrupting itself. Harvard Business Review. October, 2009. http://hbr.org/2009/10/how-ge-is-disrupting-itself/ar/1. Accessed August 14, 2013.
  6. Govindarajan The case for “reverse innovation” now. Bloomberg Businessweek. October 26, 2009. http://www.businessweek.com/stories/2009-10-26/the-case-for-reverse-innovation-
nowbusinessweek-business-news-stock-market-and-financial-advice. Accessed August 14, 2013.
  1. Reverse Innovation Health Care International Centre for Health Innovation. http://ichilglobalhealth.ca/about/. Accessed September 15, 2013.
  2. HINARI Access to Research in Health Programme. World Health Organization. http://www.who.int/hinari/en/. Accessed August 15, 2013.