This is the first time global health curricula in US medical schools have been systematically described, and the current recommendations for GH education reviewed. GH student interest groups were used as a proxy for medical student interest in the field. The findings indicate that this interest is uniformly high across all types of medical schools. The demand for global health education is demonstrably rising, as is university-level engagement [17].
We agree in the main with Houpt et al. that the distinction between domestic and international health problems may no longer be a useful one [1]. Since then, additional work supports this viewpoint across the health sciences [5, 10].
We did not find uniformity in the way medical school curricula in the US followed published GH guidelines. A recent review undertook a similar survey of GH in Canada [18]; while it did not assess the quality of education nor provide recommendations for GH education, it also found little standardization of GH curricula in Canadian medical schools.
While many studies were observational in nature and did not provide control groups, several demonstrated benefits of medical trainees’ exposure to GH education. Older data indicate higher scores on the USMLE board exam for those with GH exposure [19]; however, the demonstrated value of a GH curriculum probably cannot, and perhaps should not, be measured solely by test results. A more likely benefit is increased awareness of the role of public health in medicine and greater awareness of social and economic barriers to patient care [20, 21].
No published studies explored these issues among medical students in a rigorous (i.e. randomized prospective or case–control) fashion. However, the studies reviewed, as well as our collective experience of decades of GH education, suggest that trainees return with a greater awareness of the many factors that affect the health of individuals and populations, in the US or abroad [21, 22].
This review suggests that among those with GH exposure as students, there is an increased chance of future practice in underserved areas of the United States, as well as in primary care, or both [20, 23]. This mirrors the observation from Europe that those with GH training are more likely to work in rural practices, in primary care [24]. It remains unclear whether this is a result of a self-selection, i.e. those already inclined towards this type of practice chose to go abroad during medical school, rather than a greater appreciation of underserved health due to their GH experiences. It is also unclear whether the desire to work in underserved areas is sustained over time.
This correlation has also been found in studies of Canadian GH programs in medical schools, and they are equally cautious in ascribing primary care motivations to the GH experiences alone [18]. However, such an association may be useful in maximizing this inclination through GH and other experiences.
We found that more schools (47%) provided an abroad experience than a didactic one locally (39%). This may be due to the challenge of freeing up clinical faculty time to teach classroom courses. In our view, the provision of both is preferable to each one by itself, since it allows the linkage of theoretical and practical information, conforming to the template for undergraduate medical education in general.
Recommendations
Development of curricular guidance
We favor core competencies applicable to global health for (a) medical students; (b) physicians working in a significant health-related capacity outside the US. Many if not most of these competencies should be applicable to underserved communities in the US as well, and are mirrored in UK guidelines as well [16].
Growing student interest in GH is an opportunity for US medical school educators. Student interest in GH can be harnessed to teach them principles of preventive medicine and public health which would help in virtually any patient- or population-based field, and applies to primary care and specialty training.
It has been recommended that the LCME establish a standard curriculum in global health as a necessary minimum [1]. However, there is no convincing evidence that a standard 30-hour curriculum provides competency in the scope or complexity of global health. Indeed, such training may take the form of a full residency in countries such as the UK, before a physician can be considered competent in tropical medicine [25]. As mentioned earlier, unlike US schools of public health, which have well-defined global health curricula [26], there is presently a lack of uniformity in such offerings in US and Canadian medical schools [27]. As the field of GH in medicine matures, there may initially need to be a balance between prescriptiveness and libertarianism. There is general agreement on the concepts of GH competencies, sharing of lessons learned, and collaborations, in medical school and residency [28–32]. However, this consensus stops short of a standardized, testable GH curriculum for all medical schools, although some experts have issued a call for standardization on the definition of global health and GH education [10, 28]. Similar to how the Flexner report brought coherence to medical education, so too should the foundations of GH build from an evidence-based core [5, 33–35].
As individual educators, we have been challenged with providing a baseline level of GH knowledge to all students or to tailor a curriculum to the self-selected few. The solution may be a basic curriculum applicable to all medical students, with progressively more advanced electives available, including a Master’s in Public Health (MPH) or similar degree, where applicable. Based on their resources and interest, schools may choose to adopt a high-intensity model incorporating many levels targeting students of varying motivation, or a lower-intensity model providing a baseline level of GH topics to all medical students, or a combination of both.
Contemporary GH thinking requires sustainable, systems-based approaches to solutions, rather than reductive interventions. GH competencies should, at the minimum, include the recognition of an epidemiologic transition, such that the dual burden of infectious and chronic diseases now threaten the developing world [36].
While traditional ‘tropical diseases’ such as malaria (and newer diseases affecting the developing world such as HIV/AIDS) should continue to be taught, the emphasis should be on educational elements applicable universally. Over the last decade, the concept of social determinants of health (SDH) has been recognized as critical to GH worldwide and disproportionately so in the developing world [37, 38]. A foundational education in GH including principles of epidemiology, burden of disease and SDH is thus far more likely to equip the US medical student with critical thinking skills applicable abroad or in the US, compared with a curriculum focusing solely on diseases/treatments of the tropics.
As one example of a layered model, the global health curriculum at the University of Vermont College of Medicine provides a baseline level of GH education to all medical students, via introductory lectures at Orientation; matching with a global health-oriented faculty member on request; and a ‘Bridge’ curriculum in GH between the clerkship and senior year of medical school. A didactic 1-month elective in global health is available to all seniors, as is a 1-month abroad elective at one of two partner sites in Bangladesh, with an equal emphasis on development of the host center [39]. Each year, approximately 15–20 students (18-25% of the class) opt for the didactic elective, and 3–5 for the experiential, abroad elective. Each year for the last 3 years, at least one student has pursued an MPH degree for further training in global and community health.
Within didactic electives, there remains a need for a textbook of GH in medicine. There are many introductory textbooks of global public health available, some with readings suitable for an introductory course on GH in medical school [40–44]. Some are essentially field manuals for tropical medicine diagnosis and treatment [45, 46]. None, however, is aimed primarily at a comprehensive GH approach for the clinical sciences student. A defining textbook would allow all medical schools (despite differing levels of expertise among the faculty) access to a standard source of rigorous curricular information in global health. The optimum solution may be to supplement a standardized set of readings with a robust online component of updated information, updates, and supplementary material.
Engaging ethically with global partners
In the case of global health electives abroad, there should be clear expectations for a “best practice” relationship with a host institution. While such models have been described [39], many in the developing world remain vulnerable to exploitation by more powerful interests, within and beyond their borders [47–49].
There is not only a burden placed upon host institutions and communities by having visiting learners, but also the ethical and moral imperative to conduct clinical experiences with the same expectations as US-based work, regarding supervision and extent of involvement in patient care. Such concerns may seem archaic but evidence of exploitation continues to surface [50–52]; relatively recent accounts of inappropriate use of trainees abroad [49] make it imperative that the conduct of US trainees and their faculty be above reproach.
It is important to define the student role to be observational or participatory, and if the latter, to what extent. Any work undertaken should be at the level of training assessed by their home (US) medical school. In general, procedures they would not be allowed to do in the US would be similarly restricted abroad. Ethical guidelines for global health work have been articulated and are available [53–56]. Furthermore, the role of students in such work has specifically been addressed [57, 58]; these guidelines should be adapted for inclusion in all GH curricula.
There are other issues related to international partnerships which are beyond the scope of this paper; these include the debate over ‘brain drain’, e.g., whether the effect that bringing trainees to the US would have on the developing/donor country [59, 60]. Twinning programs between two (or more) partners have the potential to achieve educational goals in an ethical fashion. Recent work by the Commission on Education of Health Professionals for the 21st Century has emphasized this and pointed to the success of such programs in Kenya, Nigeria and Uganda, twinned with counterpart institutions in the UK and North America [5].
While ethical engagement is understood by most as an important need, the related issue of reciprocity often comes up. This is particularly relevant to medicine for two reasons. First, while heeding the dictum of primum non nocere (L. first do no harm) is essential, it is but the bare minimum. Simply doing no harm does not excuse us from the need to actually do good. Second, unlike counterparts in public health who regularly engage with developing countries while conducting research and training programs, clinical medicine has many fewer examples of sustainable medical partnership programs. As medical professionals engage further with global health and with counterparts in public health, there is an opportunity for shared learning.
The need for leadership involvement
In order to promote and advocate for GH within and without, these initiatives need support from the highest levels of the university. GH in US medical schools is belatedly benefiting from leadership involvement. At the second meeting of the CUGH in September 2010, a roundtable included eight presidents of member universities, indicating their present and ongoing commitment to GH education [12]; such a commitment is a pre-requisite to membership in the organization.
There is a risk management aspect to this: when sending medical students abroad, university/hospital legal departments may need to be involved due to issues of risk, liability, health, and airlifting policies. These risks can be managed, but if they are overstated, the GH initiatives themselves may come under question. In order to promote and advocate for GH within and without, such initiatives need support from the highest levels of the university.
It is our recommendation that medical institutions involved in GH education should have university-wide participation, and the endorsement of the university president and medical school dean. Abroad initiatives should also involve leadership of the counterpart institution. Reasons for leadership support include the need for political will to support an initiative without (initially) an obvious clinical funding stream. They may also support the need for protected faculty time to teach, work on grants for GH, engage in elective management, and build/maintain sustainable relationships with partners.
Some US health centers have launched university-wide initiatives such as centers, institutes or even departments (and in some cases, across more than one institution) devoted to GH [61, 62]. The exact institutional structure, however, is less important than establishing productive funding streams and collaborations -- within and between universities, and with global educational partners -- for successful global health education, research, and practice.
