AMA Journal of Ethics^®

Universities and medical schools in high-income countries are scrambling to develop global health curricula for their undergraduate and postgraduate trainees in order to demonstrate their leading role in this burgeoning field. Missing from the topics of discourse is the matter of just why we are caught up in this global health education frenzy.

At a recent global health education meeting, someone stated that the ultimate goal of the global health programs that we facilitate for our trainees is to improve the health of the world’s people. Yet I sense our motivations are not purely noble. If our primary goal were to improve global health outcomes there are likely more efficient and effective ways to accomplish this. There is no evidence that the number of medical trainees who have visited an international location correlates with improved health outcomes in that setting. As a guilty participant in the rush to design global health education curricula, I’d like to start an honest dialogue about why we’re doing this.

At a meeting with a group of postgraduate medical trainees at the University of Toronto, I asked them to brainstorm a list of reasons why students or universities want to be involved in global health education (see table 1). Then we tried to assign them to one of three categories:

1. Motivations I’d rather suppress
2. Motivations I can tolerate
3. Motivations to which I aspire

Motivations I’d Rather Suppress

Students quickly recognize that some of their motivation is the potential glamour and mystique associated with global health training. I am personally convinced that at some level, I’m motivated by a form of neocolonialism or Orientalism [1]. Edward Said has suggested that academic and literary fascination with the “other” can be not only condescending but domineering and exploitative. In the same way that a literary figure may be on a quest to find adventure or to bring home some mystic object, I’d like to admit that my motivations for involvement with global health have surely been mixed with a desire for professional intrigue and escapades to punctuate what may be an otherwise dreary career.

Other motivations I’d rather not admit would be the ruinous combination of self-aggrandizement, superiority and sensationalism. Many of us involved in global health initiatives may not consciously be searching for self-affirmation but we find our work reinforced by praise received for these ambitious efforts. There is great danger for those who work in the area of global health and may subconsciously develop a false sense of superiority from this work. The risk is well described by Nigerian author Chinua Achebe in the context of the role of the foreign correspondent. He acknowledges that such reporters have a role to play in telling important stories and bringing media attention to global crises. But he cautions about the “moral danger of indulging in sensationalism and dehumanizing the sufferer” [2]. Surely there are similar hazards for those engaged in global health education. Though these risks may not be entirely avoidable, it is worthwhile to be aware of the danger. Achebe points out that “when we are comfortable and inattentive, we run the risk of committing grave injustices absent-mindedly” [3].

Motivations I Can Tolerate

Having admitted some impurities in my motives, I’m not ready to abandon the task. I expect there are many decision makers at universities and medical schools whose motivations are much less complicated than my own. One possible motivation may be the reality of market-driven education. In the case of global health education, the market for global health programs is powerfully driven by consumers—in this case the trainees. Students from all medical specialties and many non-medical fields have created what’s been described as a tsunami of interest in global health programs. The university who hesitates in developing them will be lost.

For the most part I can tolerate this motivation but there may be cause for caution. It may be that the demands of students need to be shaped and challenged. These marvelously altruistic young people should be exposed early in their education to a challenging discussion of what really does impact global health outcomes. And many of us may not want to pay the price of addressing the overarching determinants of global health outcomes.

Ultimately, I am willing to tolerate a motivation driven by learner demand. In fact, I’m willing to take advantage of such demands and will admit to the recruitment value of global health education. For example, I believe in the importance of Family Medicine. This specialty has the opportunity to be in the forefront of provision of global health curricula. So if it takes the provision of such curricula to attract the best and the brightest minds to postgraduate training in primary care, this I can abide.

Another tolerable motivation may be the exposure of trainees to the realities of health and social conditions in low-income countries. A Hausa proverb, “Dutsen dake ruwa bai san ana rana ba,” means “The stone that is in the water does not know that the sun is hot.” Many trainees have spent their whole life “in the water”—in the protected conditions of a high-income country. Though the background realities that affect global health outcomes could be studied without international travel, few would deny the value of directly witnessing these conditions.

Finally, I can tolerate one more oft-cited motivation, though it smacks of self-preservation. Global health advocates often point to the fact that someone half a world away can get on a plane with their infectious disease and less than a day later land in a high-income country previously free of this disease. These protective instincts help us argue that we should teach global health but we must acknowledge the implications. Do we imply that certain diseases such as XDR-TB don’t matter if they keep their distance, but we want to learn about them if there’s a chance they’ll contaminate our world?

Motivations to Which I Aspire

What would be the finest motivation for global health education of which I can currently conceive? Why am I still willing to commit part of this phase of my career to improving global health teaching?

I don’t want to produce “global health practitioners.” The last thing we need in medicine is another silo or subspecialty. And there seems to be confusion trying to identify to what population or needs a global health practitioner is required to respond. Instead, I am driven by a desire to train excellent physicians with a global state of mind [4].

In fact, I suspect that it is the absence of a global state of mind that has driven this uprising of sorts on the part of medical trainees demanding global health curricula. They have identified the fact that the educational model of recent generations has been narrow in its focus. Young students have recognized the limitations of a biomedical framework that focuses primarily on the health needs of the world’s wealthiest citizens. They also appreciate the collaborative, reciprocal learning that occurs when they interact with patients and colleagues from other cultures and locations [5].

With this in mind, the goal is not to teach or study global health as a distinct subject or skill-set. But every topic of medicine needs to be reconsidered from a global perspective. I aspire to teach global health as a way of looking at wellness and the world. The excellent 21st century physician, no matter where she or he has trained, should be able to look at any medical problem or any patient encounter in its global context.

In my search for the most satisfactory motivation for global health education, I find a clue from the trainees who developed the list in table 1. They recognize the global community and their responsibility as advocates. This concept as a driver for global health education is best described by Martin Luther King Jr., who said that “injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly” [6].

I like to paraphrase King by noting that ill health anywhere is a threat to wellness everywhere. None of us are truly well or whole if we ignore the health status of others in the world. Our destiny is indeed connected. Achebe, too, notes that “we cannot trample on the humanity of others without devaluing our own. The Igbo, always practical, put it concretely in their proverb ‘Onye ji onye n-ani ju onwe ya’: ‘He who will hold another down in the mud must stay in the mud to keep him down’” [7].

The finest motivation for global health education is the recognition of our common humanity, our shared destiny, and the interconnected determinants of health. We should continue our efforts to train excellent physicians with a global state of mind. May the training proceed in a spirit of humility, reciprocity and solidarity.

Table 1

Brainstorming exercise for postgraduate trainees: Why are you interested in global health education?

Motivations I’d rather suppress

• For the excitement and mystique
• “Glamour” of becoming an MSF doctor
• Because global health is “sexy”
• Because it’s trendy
• I want to be like David Suzuki
• “Vacation-electives”
• A love of adventure travel
• Get more points for your frequent-flyer program

Motivations I can tolerate

• Sense of reward
• Feeling useful
• Feel more reward helping those with greater need vs. helping those who have so much
• I’m selfish. I love to travel and work, so why not combine both and benefit society at the same time?
• A yearning for purpose
• Meet other people who are like-minded
• Curiosity about the world
• Guilt—too much given to me—time to give back
• Interesting medical problems
• To broaden my clinical experience
• To contribute to the country where my parents grew up
• To better understand the background of immigrant populations in Canada
• I worked for MSF last year and found it immensely rewarding
• Encourages government and private donations to university programs
• To attract high-profile staff to universities
• Universities are interested because they want to market themselves and this is another way to look good to the public
• Universities want to attract students

Motivations to which I aspire

• Recognizing that I am part of a global community
• Because my definition of community is broad and physicians are a resource to the community
• Because physicians need to be advocates for all patients
• “Reverse entitlement”—feeling as though my upbringing and country of birth have given me so much that I have a responsibility to repay it to those less fortunate
• Exchange of ideas and cultures
• Because resources should be redistributed to where they are needed
• Learn about disparities of health delivery and health care
• Learn how different cultures approach the same health issues
• Learn how borders affect health
• Learn about how international policies relate to global health
• To better understand the social determinants of health
• Many of the principles of international health also apply to medical practice here (e.g. underserviced populations and aboriginal health)
• To gain a balanced perspective on life
• Justice—health as a human right