AMA Journal of Ethics^®

The work of global health for physicians must evolve beyond the “prescriptive” short- term clinical model to a deeper engagement that involves collaborative priority setting and problem solving among the visiting physician team, the communities of patients they serve, and local professional caregivers to achieve shared, long-term goals [1].

The Past

Medical students, physicians, and other health professionals frequently ask how they can start working in international or global health. Students often express the desire to work with the World Health Organization or Doctors Without Borders. Some are interested in mission work; others seek jobs by means of which they can live and work in the United States and travel for 2 weeks out of the year. Biographies of international physicians and increased media attention to global health issues have stimulated the imaginations of many to “come to the rescue” of those in need.

The path of least resistance to helping those in less privileged positions is to use our wealth and power as Americans and impose our own agenda and satisfy our need to help. Highly motivated by altruism, medical students have developed a remarkable ability to go abroad and create clinics, measure countless blood pressures (perhaps for the first and last time for that particular patient), dispense over-the-counter drugs or antibiotics (that may not otherwise be locally available), and interact with patients in ways that would be considered to be beyond their level of knowledge and skill at home [2, 3]. A reflective few may raise the question, “Did I really help?”

Despite its creators’ genuine desire to help, any project arising solely from our own agenda carries a certain unconscious and unrecognized arrogance that says, “I know what you need.” It is presumptuous and disempowering. When we present ourselves in a low- income country with a package of services, are its residents really free to reject our offer? It may be difficult for an under-resourced community to turn a well-intentioned intervention down, even if it doesn’t fit in with current community policies and priorities.

Does an intervention really help if local workers have to suspend their regular responsibilities to help foreigners implement a screening program, eye camp, training session, or surgery marathon? How do local patients and clinicians feel, left with the limitations of their own health system until the next group comes, once the foreign students and health professionals disappear with their drugs and capacity? Imposing one’s own programs on others can also contribute to the emergence of a victim mentality, wherein people view themselves as needing rescue by technology or outsiders’ skills that are unavailable in their country.

The real challenge is to work within the established health system in a country, integrate work and research with national and local policies and priorities, and help build capacity. In fact, accepting this challenge is the only logical and sustainable form of engagement for those working in global health. Although already practiced in many community-based public health programs, this approach would be innovative for visiting medical students and physicians.

Design Principles for Global Health Initiatives

We encourage interested physicians and medical students to become expert in key principles and concepts in global health that will increase their consciousness of pertinent global health issues and guide their work. These principles could be applied to each program and project that physicians and medical students seek to create.

The overarching concepts to be explored when designing global health initiatives are program sustainability, capacity building, community involvement, health policy, cultural sensitivity—including the role of gender in the community—and ethics. Not all projects address all concepts, but being conscious of them will help the work overall.

Sustainability and capacity building go hand in hand. Well-planned projects that respond to local health problems and are consistent with local health priorities and policies are much more likely to be carried on by the community and ministry of health. The same goes for programs that build the capacity of local professionals, students, or faculty to carry out programs or research.

Understanding international health priorities requires knowledge of the funding goals of large, multilateral donors (United Nations, World Bank), the international agencies of wealthy countries that are often called bilateral donors (United States Agency for International Development, United Kingdom Department for International Development), and private foundations (Bill and Melinda Gates). Over the years, major international health conferences have had a major impact on global health policies (Bamako Initiative, Alma Ata Declaration, United Nations International Conference on Population and Development).

National health priorities can be understood by examining both the burden of disease and key health indicators obtained from national health datasets. It is also crucial to gain understanding of how national health systems are set up and how they implement health policy. Community assessments, surveys, and focus groups yield an understanding of local health priorities, and students in global health should be familiar with the techniques to assess communities.

Understanding the cultural context—including how gender roles operate in society—is an ongoing challenge. As much as we try to incorporate cultural awareness into programs, we are bound to fall short of complete understanding. Nonetheless, sensitivity and awareness to the realities that the cultural context creates put you on a path toward a more effective partnership.

Ethical concerns are a part of the global health picture and have cultural realities as well. Students abroad face numerous ethical challenges related to clinical activities and procedures, development of research questions and application of research-related results, and obtaining informed consent. Different standards and quality of care, overcrowding, patient autonomy, and access to care all contribute to an unfamiliar context where previous assumptions about ethics may not apply. In this circumstance, it is useful to examine principles of ethics in global health and review case studies of past dilemmas faced by American researchers. By partnering with local institutions of higher learning, students can also be confident that they are following local or national guidelines for standard of care and research. Many projects need institutional review board (IRB) approval from both in-country advisory boards and a U.S. review board; students should allow ample time to satisfy these regulations.

University partnerships have the potential to provide a sustainable mechanism for capacity building and research and can establish a context for medical student participation in educational, clinical, and research projects. Through the context of an existing partnership between universities in developed and developing countries, medical students can focus on and engage in activities that promote and strengthen the partnerships. If such a partnership does not exist, you can explore creating one with interested faculty at your school.

The University of Michigan Department of Obstetrics and Gynecology has a long-term partnership with the University of Ghana, the Kwame Nkrumah University of Science and Technology School of Medical Sciences, and the Ministry of Health of Ghana. It started through a Carnegie Foundation-funded program in partnership with universities in the United States and Great Britain, the American College of Obstetricians and Gynecologists, and the Royal College of Obstetricians and Gynecologists. The program assisted in the development of postgraduate training in ob-gyn in Ghana [4 ]. Before ob-gyn training occurred in Ghana, many who went out of the country to train did not return. Since in-country training started in 1986, 60 of 61 Ghanaian ob-gyn physicians certified by the West African College of Surgeons have remained in-country to work as faculty and in the private sector. This partnership has no doubt yielded numerous health benefits for Ghanaians and has provided opportunities for bilateral student and faculty exchanges. It has also created a platform for ongoing and expanding research into human resources for health [5].

We are moving into a new era of global health in medicine, away from the hero model that disempowers communities by attempting to rescue them, and toward a co-creative model where global health problems are solved by adapting known solutions to new environments and sustainable capacity is created. We encourage you to become conduits of this energy and evoke this new era in authentic global engagement.