Theresa A. Townley, MD, MPH, is Assistant Professor, Internal Medicine and Pediatrics at Creighton University, Omaha, NE.
Dr. Townley would like to thank Doctors Without Borders/Médecins Sans Frontières for providing her with the opportunity to work in global health and Tom Hall, Karen Lam and The Global Health Education Consortium for their assistance with this article.
Address correspondence to: Theresa A. Townley, MD, MPH, email: firstname.lastname@example.org.
For many physicians and other health professionals, time spent working in a low-resource setting is one of the most riveting and reaffirming experiences in their medical careers. Although an international experience is often seen as a distinct chapter in one’s professional life, the questions that arise in areas such as cross-cultural communication, health care access, appropriate technology, community mobilization and cost containment will continue to evolve throughout one’s career. Often this experience will inform a life of service and a commitment to global welfare. Although many are familiar with the appalling statistics of global inequity, the witness of this poverty transforms these numbers into the lived reality of mothers and fathers scraping by and making difficult choices to raise their children. The crush of this poverty is felt hardest by children, who bear the brunt of disability, deprivation, and death.
Indeed, beyond an emotionally motivating experience, participants in international health experiences reported, after both the initial evaluation and 2 years later, positive influences on their clinical and language skills, sensitivity to cultural and socioeconomic factors, awareness of the role of communication in clinical care, and attitudes toward careers working with the underserved.1 International experiences have been shown to improve clinical diagnostic skills,2 and increase knowledge of tropical disease among both internal medicine and pediatric residents.3,4
Recently, the term “global health” is increasingly replacing the term “international health.” Global health refers to “health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions.”5 In addition, global health further broadens discussion beyond tropical infectious disease to encompass chronic disease management, health disparity, human rights, and environmental issues, and capitalizes on the synergy that can develop when considering these similar issues in both resource-poor and resource-rich settings.
Finally, with increasing globalization and inequity, global health experiences, rather than elective, may be truly necessary experiences. Currently, 500 million people cross an international border each year, and almost any place in the world can be reached in 36 hours. This exponential growth in travel and the shrinking of travel time creates conditions in which local epidemics can quickly become global catastrophes. The lack of an adequate public health infrastructure, the trend toward urbanization, the aging of the population, and the potential emergence of numerous diseases with global warming exacerbate the potential for humanitarian disasters. Experience in global health can better prepare physicians with skills in public health, emerging diseases, communication, and response to vulnerable populations — tools that are crucial in disaster prevention and management. More importantly, however, global health experiences can engender health professionals who realize that solid health systems are essential for ensuring global security and global equity.
Goals of the trip
The first step in the process is to consider the purpose of your trip: what you hope to learn and what you hope to achieve. How will you feel if you do not achieve what you hoped to achieve? What will be the impact on the local people? How will you effectively engage the people with whom you will work? It is important to consider one’s skills, talents, and expertise when deciding to take on a global health project, but with the realization that the complexity of unforeseen circumstances may thwart even the best-conceived plans. In addition, you may arrive in a community with an entirely different set of goals than yours.
Some of the most attractive projects — such as those offering a technological fix in the form of medications or vaccines — may not be in line with the community’s strengths, and may not allow adequate time for developing collaborative relationships. Such an experience will require a flexibility that may become increasingly difficult depending on your expertise.
It may be best to be prepared to do a quick assessment of community resources and strengths (vs. needs) to be able to retrofit your project. Consider, also, if you will be comfortable spending time on details outside your expertise. For example, an HIV expert may have to spend time protecting a pharmacy against graft or developing institutional protocols. Although it is not possible to consider the myriad potential consequences stemming from one’s work, those who are more prepared, aware of common pitfalls, and circumspect are more likely to have a more fulfilling experience.
A set of reflective questions and cases about clinical scenarios in the chapter, “Ethical Issues” in Global Health Training in Graduate Medical Education: A Guidebook crystallizes many of the ethical dilemmas one is likely to experience in a low-resource setting.6 These tools may also be helpful for resource people, those leading groups, or those reflecting with students/groups before or after their return. Doctors without Borders/Médecins Sans Frontières (MSF) field research website details an ethical framework for projects, including operational and research projects.7 More in-depth resources are available,8.9 and clearly anyone considering a research proposal needs more extensive consideration of ethical implications, IRB approval and mutually beneficial long-term goals.
Project Time Frame
Often, longer time frames are recommended to get a more in-depth understanding of the culture and the health situation of a locale; however, short-term trips (2 weeks to 2 months) may be more feasible for US-based professionals and more reasonable for novices. Although often labeled as a “band-aid,” shorter trips may lead to a more intense work experience and may foster a collegial, rather than a dependent, relationship. Shorter-term projects also typically need to be funded in some way by the participants.
In order to avoid the “band-aid” label, a shorter-term trip should be a piece of a longer-term project with definable goals and principles. As Suchdev et al have suggested, these projects should include the following tenets: emission; collaboration; education; service; teamwork; sustainability; and education.10
Longer time frames (1 to 2 years) certainly require more extensive planning, but may be more suitable for people in transition such as during medical school, after residency, or before settling into a longer-term job. Also, professionals with school-age children may find that a 1-year project fits better with the school year. Many global health professionals have found that some aspects of child care and education, such as the exposure to other cultures and languages, are definite benefits of a global health position. Others feel that such work is best completed before having children, with young children, or after children have left home. Although international schools are available worldwide, high school can be a more difficult time for children internationally.
Health professionals from the private practice world, as well as academics, albeit with significant support from their colleagues, have been able to work with a longer-term commitment. Some type of salary support, travel reimbursement, health insurance (including medical evacuation coverage), and often loan deferment may be reasonable to expect for a lengthier time commitment. This payment, however, is unlikely to be comparable to a US salary. Projects may involve strictly medical work, administrative-type work, scientific research, or operational research. Again, before committing to a long-term project it is important that the goals of the organization sponsoring the project align with yours, that an ethical framework exists for all projects, a process for ongoing evaluation is in place and that data drive the implementation and continuation of projects.
Training Courses, Health Resources
There are a number of resources that can be used to help determine the type of project and prepare for travel. In terms of academic preparation, both in Canada and in the US, there has been a call for a global health curriculum to be a key part of the medical school curriculum.11,12 This may involve incorporating global health issues into the ongoing curriculum, having a journal club with a global health focus, or having a distinct course in global health. For many schools, some type of a curriculum is a prerequisite for involvement in a medical student elective. The Global Health Education Consortium (GHEC), in collaboration with the American Medical Students Association (AMSA), the International Federation of Medical Students Association (IFSMA-USA), and the Canadian Federation of Medical Students, has developed a guidebook for institutions interested in developing or improving a global health curriculum.13 Other projects have called for a revamping of medical school curricula to better align medical education with unmet global and domestic social needs.14 Other resources available for training are listed in Sidebar 1.
In preparation for a global health experience in a low-resource setting, minimal core competencies have been suggested for health care professionals and health care professional students. The GHEC has developed the Modules Project, in which numerous peer-reviewed modules are available in the form of PowerPoint presentations with notes that can be downloaded and used for a global health curriculum.13
Once in-country, resources are now available that can decrease the academic isolation experienced by many providers in remote or low-resource settings and provide greater ability to practice evidence-based medicine in a low-resource setting (see Sidebar 2, page 379).
These resources can decrease the academic isolation experienced by many providers doing international work and offer greater ability to practice evidence-based medicine in a low-resource setting.
- Health InterNetwork Access to Research (HINARI) is a program to improve access to scientific information in low-resource countries by providing high quality, timely, relevant biomedical and social science journals at affordable prices. Access to HINARI requires a relationship to the institution with the HINARI registration. Individuals are not eligible: www.who.int/hinari/en.
- The International Network for the Availability of Scientific Publications (INASP) was created by the International Council for Science to respond to the need for access to research information in low-income countries. INASP also supports libraries and regional online publications. Articles can be accessed on a sliding-fee type service and low-income countries can access a limited number of articles for free: www.inasp.info.
- For individuals, many journals are now available free in low-income countries either immediately or after a 6-month embargo. Public Library of Science (PLOS) medicine has been specifically developed as a free access online journal in which the authors are responsible for the cost of publishing, although individuals can qualify for a fee waiver: www.plos.org
- Doctors Without Borders/Médecins Sans Frontières (MSF) has developed a website in which full-text articles published in peer-reviewed journals are available. This site also contains news and commentary, as well as ethics discussions: www.doctorswithoutborders.org.
- The GHEC has an extensive bibliography designed for entry-level to intermediate learners that includes more than 800 citations in 27 topic categories. These resources have been reviewed and recommended by GHEC members based on timeliness (except for “classics”), Internet accessibility, lower cost (except for some books), and absence of highly technical language: www.globalhealtheducation.org.
- The Johns Hopkins Bloomberg School of Health’s OpenCourseWare project offers access to literature to those without Internet connnections: www.ocw.jhsph.edu.
Diseases of travel should be considered before embarking on an adventure. Certainly, those with chronic conditions or with young children need to be more cautious. The CDC offers advice for travelers; however, travel clinics can provide travelers with appropriate vaccinations, prophylaxis for malaria, recommendations for travelers’ diarrhea, HIV prophylaxis and other preventive advice. For those advising students and residents, it is important to counsel that unintentional injury because of motor vehicle accidents and drowning are often more common reasons for medical evacuation than illness. In addition, alcohol or mood-altering substances will aggravate risk of disease and unintentional injury. For illness occurring in-country, ASTMH15 provides a directory of physicians searchable by country, as well as Health Hints for the Tropics XIII, a guidebook on traveler’s health.16 An entertaining guide is Chris Sanford’s The Adventurous Guide To Health,17 which can provide practical guidance on how to avoid preventable diseases. For work in more remote or dangerous situations, extra precautions may need to be taken. The sponsoring non-governmental organization’s (NGO’s) plans for access to medicine, medical evacuation, HIV prophylaxis, and security plans should be investigated.
Career Goals and Global Health
Pre- and early health professional students
Most of these students are not yet qualified to practice in their intended specialties, but can gain valuable knowledge in the organizational, logistical, and interdisciplinary skills needed to initiate and sustain global health projects. Positions may be available in research or with a NGO. One such research opportunity is through the National Center on Minority Health and Health Disparities (MHIRT), a program that offers undergraduates opportunities to work and conduct research with mentors in diverse locations during a term on a variety of diseases and health conditions.18 Although these programs are sponsored by certain institutions, they are open to applications from students from other institutions.
Recently, medical students at Creighton University began Project Cura, which includes student-directed global service trips after the first year of school. These trips have involved diverse activities, from working with gang prevention in urban slums to working with Mother Theresa programs. Although the students do not provide medical care, they have gained tremendous appreciation for the multidisciplinary services needed to provide quality medical care in these settings.
Advanced Health Care Professional Students
There has been an explosion in opportunities available for health care professional students, which range from student-directed projects with assistance from faculty to schools with institutional relations with clinics and medical schools. There are a number of places to look for opportunities beyond your own institution. A tremendous opportunity has developed recently for medical students with the creation of the Fogarty fellowship from the NIH Fogarty International Center.19 In this fellowship, medical students apply in a competitive process to work between their third and fourth year of medical school at one of the Fogarty overseas sites in the field of clinical research. Students are also trained before departure, and they continue to meet after the year has finished. Some travel grants are offered by organizations, such as the Benjamin Kean grant offered through the ASTMH,20 the Carole Hill scholarship through the GHEC13 and support for pediatric residents from the AAP-SOICH to defray travel expenses.21 Creative ways to fund electives are described in the AMSA section on international health.22
The development of global health in pediatric residencies has been addressed in another article.23 Indeed, global health experiences have been demonstrated to aid in the recruitment of more competitive applicants.3,4,24 The second edition of Global Health Training Graduate Medical Education: A Guidebook6 is a tremendous resource for residents interested in global health experiences. It includes sections on global health residency programs, as well as proposed ACGME core competencies for a global health elective focused on pediatrics. Again, the AAP-SOICH lists a number of opportunities available for residents and also sponsors a scholarship to help defray travel costs.21
Faculty or Private Practitioners
A number of positions are now open to those who are private practitioners or faculty. The Yale Johnson & Johnson Physician scholarship offers a grant for those interested in primarily clinical work.25 In addition, Health Frontiers has established a pediatric residency in Laos, which recruits a residency director to assist in administrative duties, as well as clinical and didactic teaching.26 Recently, the Fogarty Center started the International Research Scientist Development Award (IRSDA), which is a new program similar to the NIH K01 awards with the intent of developing career researchers in international health.19 In the Baylor International Pediatric AIDS Initiative (BIPAI), physicians spend 1 month in a training course before embarking on a 1-year project involving pediatric AIDS patients.27 In addition, a number of NGOs offer positions for health professionals such as Doctors Without Borders; Partners In Health; and Doctors for Global Health.7,28,29
The Return Home
Although one returns to friends and family, returning to your home country may be one of the most difficult parts of a trip. Indeed, a simple trip to the supermarket after a time spent rationing food can be an overwhelming if not a surreal experience. Among humanitarian relief workers, rates of depression; anxiety; alcoholism; and frank post-traumatic stress disorder have been noted to be high.30,31 The homecoming period is a high-risk period for these disorders. Although the psychological toll has been documented among humanitarian relief workers, many of the same elements of an emergency situation — potential for personal violence, overwhelming poverty, and inadequate resources — can infiltrate even more stable projects. This can be more difficult for those who did not achieve what they hoped to achieve, even if this was due to political, organizational, or health problems beyond one’s control.
It is recommended that workers engage in a reflective process once the work has been completed, perhaps by writing, even if your trip was brief or if questions persist. One question that is often helpful is, “What did you learn about your own country while you were away?” The most crucial point is to continue this work, to continue to speak out for the vulnerable and voiceless, perhaps by returning to that country or by staying in your own country and addressing those institutions that drive global inequity.
- Haq C, Rothenberg D, Gjerde C, et al. “New World Views: preparing physicians in training for global health work.”Family Medicine. 2001; 33(3): 178–86.
- Gupta et al. “The International Health Program: The fifteen year Experience with Yale University’s Internal Medicine Residency Program.”American Journal of Tropical Medicine and Hygiene1999; 61(6).
- Willer WC, Corey GR, Laalinger GJ, Durack DT. International Health and internal medicine residency training: the Duke University experience. Am J Med1995;99(3):291–7. doi:10.1016/S0002-9343(99)80162-4 [CrossRef]
- Federico et al. A successful International Child Health Elective: The University of Colorado’s Department of Pediatrics experience. Arch Pediatr Adolesc Med. 2006Feb; 160(2):191–6. doi:10.1001/archpedi.160.2.191 [CrossRef]
- Institute of Medicine (U.S.). Board on International Health. America’s vital interest in global health: protecting our people, enhancing our economy, and advancing our international interests. Washington, D.C.: National Academy Press; 1997.
- Chase JA, Evert J, eds. Global Health Training in Graduate Medical Education: A Guidebook. 2nd Edition. San Francisco: Global Health Education Consortium, 2011globalhealtheducation.org/resources/Documents/Both%20Students%20And%20Faculty/GH_Training_in_GME_Guidebook_2Ed.pdf. Accessed on April 25, 2011.
- fieldresearch.msf.org/msf/handle/10144/12364. Accessed June 23, 2011.
- Velji A, Bryant JH“Global Health Ethics” in Understanding Global Health. Markle Ed McGraw Hill, Lange Medical, 2007.
- Tindana PO, Singh JA, et al. Grand Challenges in Global Health: Community Engagement in Research in Developing Countries. PLOS Med20074(9): e273. doi:10.1371/journal.pmed.0040273 [CrossRef]
- Suchdev P, Ahrens K, Click E, Macklin L, Evangelista D, Graham E. A model for sustainable short-term international medical trips. Amb Ped. 7(4): 317–320.
- Brewer TF. AFMC Resource Group on Global Health: Creating Global Health Curricula for Canadian Medical Students 2007. Association of Faculties of Medicine; Ottawa2007:1–8.
- Drain P, Primack A, Hunt D, Fawzi W, Holmes K, Gardner PGlobal Health in Medical Education: A Call for More Training and Opportunities. Academic Medicine2007; 82:226–230. doi:10.1097/ACM.0b013e3180305cf9 [CrossRef]
- globalhealtheducation.org. Accessed June 21, 2011.
- Frenk J, et al. Health Professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010: 373:1923–58. Published online, Nov 29 2010, doi: doi:10.1016/S0140-6736(08)61345-8 [CrossRef] .
- www.astmh.org. Accessed June 21, 2011.
- Health Hints for the Tropics XIII. Available online at: www.astmh.org/Health_Hints_for_the_Tropics.htm. Accessed June 23, 2011.
- Sanford C. The Adventurous Traveler’s Guide to Health. Seattle, WA. University of Washington Press:2008.
- www.nimhd.nih.gov/our_programs/mhirt.asp. Accessed May 15, 2011.
- www.fic.nih.gov/programs/training_grants/nih_fogarty.htm. Accessed June 23, 2011.
- www.astmh.org/ASTMH_Sponsored_Fellowships/3319.htm. Accessed June 20, 2011.
- www.aap.org/sections/ich/index.htm. Accessed June 22, 2011.
- O’Neil E. A Practical Guide to Global Health Service. USA. American Medical Association: 2006.
- Stanton B, et al. Global Health Training for Pediatric Residents. Pediatric Annals2008;37(12):786–787, 792–796. doi:10.3928/00904481-20081201-11 [CrossRef]
- Bazemore AW, Heinen M, Goldenhar LM, Szaflarski M, Lindsell CJ, Diller P. The Effect of Offering International Health Training Opportunities on Family Medicine Recruiting. Fam Med. 2007; 39(4):255–60.
- medicine.yale.edu/intmed/globalhealthscholars/index.aspx. Accessed June 11, 2011.
- Gordon G, Vongvichit E, Hansana V, Torjesen KA Model for Improving Physician Performance in Developing Countries: A Three-Year Postgraduate Training Program in Laos. Academic Medicine81:399–404.
- www.bayloraids.org. Accessed June 11, 2011.
- www.pih.org. Accessed June 21, 2011.
- www.dghonline.org. Accessed June 21, 2011.
- Cardozo B. L., Salama P. (2002). Mental health of humanitarian aid workers in complex emergencies. In: Danieli Y, ed. Sharing the front line and the back hills: Peacekeepers, humanitarian aid workers and the media in the midst of crisis (pp. 242–257). Amityville, NY: Baywood.
- Eriksson C. B., Vande Kemp H., Gorusch R., Hoke S., Foy D. W. (2001). Trauma exposure and PTSD symptoms in international relief and development personnel. Journal of Traumatic Stress, 14(1), 205–212. doi:10.1023/A:1007804119319 [CrossRef]
- Drain P, Huffman SA, Pirtle SE, Chan K. Caring for the World: A Guide to Resources. University of Toronto Press, 2008.