Turning the Tide with Global Medicine

A NextGen Free-Standing Perspective Article

"There is no them. There is only us," begins Dr. Stephanie Davis, a first year resident in medicine and pediatrics. She is quoting one of the mottos of the Global Health Council to an auditorium of University of Michigan medical students to share her passion for global health. This phrase, "global health," has captured an increasing amount of public attention, arguably as much as one of its driving forces–globalization. Prof. Christopher Murray, director of the Global Health Initiative at Harvard University, believes that potential effects of globalization on public health include both the advantages of a shorter diffusion time for biotechnologies and increased benchmarking as well as the disadvantages of infectious disease pandemics and accelerated brain drain of medical personnel from developing countries to the developed. It is unquestionable that globalization brings with it the increased potential for flow between countries with and countries without, but the direction of that flow is often changing.

With a growing awareness of the potential benefits and harms of globalization on global health, big donor governments have become more willing to take political action and financial responsibility. Some examples of such commitments include debt forgiveness, the G8's pledge in 2005 to double aid to Africa in five years, and the UN Millenium Development Goals for 2015 that include reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria, and other diseases. Mega-donor foundations, such as the Gates Foundation, and pharmaceutical companies are also placing increased priority on global health. However, many would argue that these steps, while commendable, are not enough.

The Growing Interest

"In the early 1980's, two Harvard medical students out of their class of 160 were strongly interested in global health." said Dr. Jim Yong Kim. He added with amusement, "We were thought of as odd." In 2003, more than 20% of graduating US medical students reported an international health experience during their medical training, compared to the 6% of students graduating in 1984. Dr. Michele Barry, director and co-founder of the Yale International Health Program (IHP), attributes this "exponentially growing" interest in global health to the greater opportunities for travel – both personal and clinical. In addition, medical students in New York City have attributed their interest to the ethnic diversity of their community, and more specifically, their patients. In fact, Dr. Davis is hardly alone in her global health presentation: many of the students with her in the auditorium have already arranged summer research and clinical experiences abroad, from the Kanungu clinics in Uganda to a home for Ethiopian pediatric heart transplant patients in Holon, Israel.

Some medical students describe their interest to be founded out of a sense of duty, which has led the New England Journal of Medicine to dub them as the new wave of secular "medical missionaries." (4) "When medical students enter medical school, they are among the most idealistic...International health and commitment to social justice is providing a fuel for their idealism," reasons Dr. Kim. (3) With global healthcare becoming more grassroots and collaborative, students have gained the privilege to interact with local expertise and infrastructure to provide integrated treatment. (1) As a result of these expanding opportunities, students can also include increased reliance on the physical exam, proficiency in a foreign language, and development of a broader understanding of socioeconomic influences on health to be among their goals. A retrospective study of IHP participants observes: "Many, perhaps most, of those pursuing international electives are driven by the desire to address the inequalities of risk and access so readily documented throughout what is termed 'the developing world.'"

These international experiences are convincing more and more among the medical community of the need for integrated care. Just as treating the sick often means treating the poor, physicians are being challenged to work with public health officials and confront the issues of poverty to provide better healthcare. Andrew Moscrop, a medical student from the University College of London, writes about his elective in Bangladesh:

"The scabies ointments began to seem meaningless in an area where three or four children shared a single bed. Advice on hygiene and hand-washing to prevent genitourinary infections was valueless in an environment where children picked through rubbish piles to find a meal. Here, among the poorest of the city's poor, money, not medicine, was the crucial health determinant."

Supported by the results of HIV/AIDS programs, public health officials are concluding that prevention and treatment are more synergistically powerful than either alone. This perspective challenges the medical community to brainstorm innovative ways to deliver effective therapies, and the notion of treatment is being expanded to include an "in-depth examination of the underlying causes of disease, including the social, political, and economic forces involved." (7)

The Call for Change

Despite the growing interest, disadvantages of globalization for global health are already being realized. For instance, the global market in research and development provides little financial incentive for providing access to essential medicines or developing drugs for infectious diseases. This disparity is referred to as the "10/90" research gap, in which 10% of biomedical research accounts for 90% of the global disease burden. To worsen matters, many developing countries are reporting a substantial brain drain of educated citizens to the West. (5)

Yet just as globalization allows for restricted access of essential medicines, it also allows for the provision of these resources. Organizations such as Médecins Sans Frontiéres, Physicians for Human Rights, Partners in Health, and Physicians for Social Responsibility hope to inspire social movement to change the current flow of resources. As Dr. Kim argues, "If you are diagnosed with diabetes in a developing country, you die because you don't have insulin. But there's no reason why we can't have refrigerated insulin. They have Coca-cola." (3) Many global health advocates agree, protesting that the current market is being driven by profit rather than need. (5)

Dave Chokshi, a second year medical student at the University of Pennsylvania School of Medicine, emphasizes that involvement in advocacy for global health can occur at any point along one's medical education. Mr. Chokshi is a part of Universities Allied for Essential Medicines (UAEM), which seeks to improve access to university-derived biomedical end products in developing countries and to increase the amount of research conducted on diseases that primarily affect these countries. The organization began when Médecins Sans Frontiéres requested rights to use a generic version of an antiretroviral drug for HIV in South Africa. At the time, Yale owned the patent for that drug and had licensed its intellectual property rights to Bristol-Myers Squibb. Student-led lobbying led to the first patent concession for a HIV drug. Similar student advocacy campaigns are ongoing for an antiretroviral from Emory University and a cholera vaccine from the University of Maryland. (9) Mr. Chokshi promotes UAEM as an opportunity "for medical students to train to be more effective physician advocates." In UAEM, students have a privileged position within the university to advocate for making "access-minded provisions standard language in all university intellectual property agreements." (10) The organization has now expanded its membership to twenty-five universities, including undergraduates and graduate students, and is a significant example of global health advocacy at varied educational levels and backgrounds.

The Response in Medical Education

Today, interest in global health still surpasses the opportunities available and the changes implemented. International health programs report "high levels of student competition" and "applicants that outnumber the spaces available." (5,6) The increasing number of requests by students for global health in their medical curriculum has resulted in the creation and elaboration of coursework on infectious diseases, medical foreign language classes, and international health experiences. One of the most long-standing programs in international health education for residents is the IHP, which is solely sponsored by the pharmaceutical company, Johnson and Johnson. IHP also began with a call for change: Southeast Asian immigrants were relocated to New Haven. In response, a volunteer residents clinic was set up, which led to a demand for complementary clinical overseas rotations. (7) IHP's mission states that "by placing physicians in the developing world, we hope to instill a sense of global citizenry."

Indeed, most of the IHP applicants already seem to have a sense of global citizenship. Many have had previous international health experiences and have specifically chosen internal medicine, medicine and pediatrics, and emergency medicine specialties to tailor their clinical skills for use in global health. For the past twenty years, over 300 residents-in-training have been financed to work and teach for up to eight weeks in underserved locations such as Eritrea, Nepal, Zambia, and Haiti. (5) These participants are more likely to care for impoverished and immigrant populations and to have a more optimistic view of healthcare delivery in developing nations. (7) International health programs for medical students also report similar findings.

Other residency programs are also following suit. Collaborating with Makerere University in Uganda, the UCSF general surgery residency program was among the first surgical residencies in the United States to establish an international program. Four years ago, Brigham and Women's Hospital established a residency program in Global Health Equity for all medical disciplines. As for medical students, while Dr. Kim reported only two students interested in global health from his graduating class, Harvard Medical School now sends about fifty students for clinical experiences abroad each year. Steps are also under way to create a global health concentration through collaboration between the Harvard School of Public Health and the Medical School. Medical school admissions now often include brochures of their international health programs, catering to the interests of the incoming class.

For pre-medical and medical students, the most common international health experiences are short-term. While IHP has been shown to confirm and strengthen pre-existing interests in global health, short-term trips serve to "plant a seed of interest." (5) These three to four week trips are often not cost-effective, and Dr. Davis recommends students to accept "starting out as a negative asset. That's higher education. The alternative to learning is doing well-intentioned damage." (1) To ensure against "medical tourism," sponsors of international health experiences have been working hard to become more organized and to include training sessions prior to departure. These training sessions highlight the need for integrated care, highlighting the links of health to social, political, cultural, and even geographical environments. As a result, students are better prepared to deal with feelings of frustration and isolation: issues of funding, malpractice, licensure, cultural barriers, and socioeconomic disparities can be overwhelming. Training sessions often include counseling for students to deal with these emotions by sharing their experience with their team members and community once they return.

Personal Impact

With the increased amount of global health in medical training, knowledge derived from the updated curriculum can be used abroad, but also at home. "You say to yourself as you're studying here in America that you are learning about 'international health.' But when you travel to the place you studied in your textbooks, you will realize that to the locals, you are the one that is international," observes pediatric infectious disease specialists, Dr. Alex Blackwood and Dr. Deepa Mukundan. With global health encompassing health outcomes for everyone, discussions inevitably lead to an introspective examination of our national system of healthcare. One practicing physician who had participated in an international health experience in medical school writes, "In many ways, my current choice is international: working with the Navajo in the United States." (11)

Whether a pre-med, practicing physician, or anywhere in between, these changes in the medical field do not dictate a moral imperative to work in the developing world or devote one's career to tropical medicines. They do not require specific scheduling or strategizing beyond that of one's personal journey to discover a professional passion. "Stay open-minded and be honest to yourself," advises Dr. Barry. (5) Dr. Kim adds, "There is no real formula. The most important thing for any pre-med to do is to figure out what they want to do... We do not need a field of very unhappy people who feel like they should be in global health. They should be in it because this is what they want to do." Whatever one's career, contribution, or mindset toward global health, globalization's impact on healthcare is a dynamic one. If anything, it is practical to be aware of its ebbs and flows. As for future predictions, Dr. Kim concluded his interview with confidence, "I think the tide has turned. I think it is changing, and I think it is changing for the good. One health care worker for every 1000 people - I think that is very reasonable." (3) 

Karen Lo is a writer for the Next Generation and a member of the University of Michigan Medical School, Class of 2009.

Work Cited
  1. Davis, S. World health in forty minutes. Student Alliance for Global REACH Presentation. Mar 15 2006.
  2. Murray, C. Lecture 25: Globalization. Social Analysis 76 Presentation. 2005.
  3. Interview. Dr. Jim Kim, co-chief of the Division of Social Medicine and Health Inequalities at the Brigham and Women's Hospital, co-founder of Partners in Health, Director of the World Health Organization's HIV/AIDS department, Associate Professor of Medicine and Medical Anthropology at Harvard Medical School, and Director of the Program in Infectious Disease and Social Change at Harvard Medical School.
  4. Panosian C and Coates TJ. The new medical "missionaries" – grooming the next generation of global health workers. N Engl J Med 2006;354(17):1771-3.
  5. Interview. Dr. Michele Barry, Professor of Medicine and Public Health at Yale University School of Medicine, Director and co-founder of the Yale International Health Program, health consultant for the Ford Foundation overseas programs, chairperson of the American Society of Tropical Medicine's new certification examination and educational initiative in tropical medicine and traveler's health, and co-founder of the International Travelers Clinic at Yale University.
  6. Imperato PJ. Elective for US medical students: the 25-year experience of the State University of New York, Downstate Medical Center. J Community Health 2004; 29(5): 337-73.
  7. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Program: the fifteen-year experience with Yale University's Internal Medicine Residency Program. Am J Trop Med Hyg 1999;61:1019-23.
  8. Hope R. The Elective Pack: the medical student's guide to essential international health and development. International Health and Medical Education Center (IHMEC), University College London, London. 2004.
  9. Chokshi DA. Improving access to medicines in poor countries: the role of universities. PLoS Med 2006;3(6):e136.
  10. Interview. David Chokshi, second year medical student at University of Pennsylvania School of Medicine, member of Universities Allied for Essential Medicines.
  11. Ramsey AH, Haq C, Gjerde CL, Rothenberg D. Career influence of an international health experience during medical school. Fam Med 2004;36(6):412-6.
  12. Ozgediz D, Roayaie K, Debas H, Schecter W, Farmer D. Surgery in developing countries. Arch Surg 2005;140:795-800.
  13. Blackwood A, Mukundan D. Life as a pediatric infectious disease specialist. Presentation.

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