Interview by Chloe LeMarche of University of California-San Francisco
Vanessa Kerry talks about her commitment to global health and work at Mass General’s Center for Global HealthSeptember 21, 2010
As the future of global health and global health education is debated, Dr. Haile Debas, founding Executive Director of Global Health Sciences at the University of California, San Francisco, points to a five-year partnership between UCSF and the Muhimbili University of Health and Allied Sciences (MUHAS) as an example of how the future can look. As Dr. Debas tells it:
“Our collaboration has focused on education and building the institutional capacity of MUHAS. The first area of progress is in curriculum development. MUHAS is converting its curriculum from being traditional to competency-based.
We looked at what is needed if you are going to be a doctor in Dar es Salaam. UCSF and MUHAS students interviewed MUHAS graduates about how the program had prepared them for their work. What were the deficits? What competencies did they need? So, instead of having vague lectures that deal with human health, the new curriculum deals with women’s health, maternal, neonatal and child health. So when students finish school they are competent to deal with the main problems, prevention and treatment. In the old way, you could learn all kinds of fancy things, but they may or may not have relevance. Other important areas of competency are infectious diseases and violence. Violence is a big problem, both domestic and motor vehicle accidents. Based on these kinds of findings, MUHAS has adjusted its curriculum.
The other area of collaboration has been a very big effort on faculty development. They don’t have enough faculty. The faculty they do have are poorly paid, overworked, and have no time to keep up their skills. For 10 years, because of the requirements of World Bank and IMF loans, governments were told not to spend any money on higher education. So there was a hiring freeze for ten years. For the past four years, UCSF has sent post-doctoral fellows to teach basic science in students’ preclinical years. We are helping them develop masters programs in basic sciences like anatomy, physiology and biochemistry.
The third thing we are doing is constructing an education building — the Center for Health Professionals Education — that centralizes educational activity. It has a curriculum innovation center, education technology center, clinical skills center, and surgical skills center where students learn to do life-saving procedures, like inserting chest tubes or performing difficult deliveries. We are also working on information technology. Because the Internet and electricity are so unreliable, we have just developed with UC Berkeley a plan for using wireless technology to enable MUHAS to communicate with its satellite sites as far as 100 kilometers away.
Based on the UCSF work, which was funded by the Bill & Melinda Gates Foundation, the NIH and PEPFAR are now funding a similar partnership initiative, with the first awards to some 10 schools set to be announced later this fall.
This really is the way to build capacity. U.S. faculty can go to African countries and do nice research, and when they are done, it’s finished. This way there is a long-term investment, and capacity building, institution to institution.”
Interview by Bee Wuethrich
Anvarali Velji hosted this engaging series of presentations on ways various groups have approached global health training.
Richard Dunning started things off by presenting the results of a web-based survey used to poll trainees in medicine, public health, and nursing programs at four US universities (Johns Hopkins, UCSF, University of Pennsylvania, and the UW). The survey disclosed a high level of interest in global health, yet also identified barriers for participation in international experiences. Among the 2,090 respondents, 76% had already had an international experience, most of which had been in developing countries, and over half expressed an interest in a global health career. The importance of international experiences was highlighted by the fact that 61% attributed their interest in global health to a prior international experience. By extrapolating the data, it was estimated that at least 10% of all health sciences trainees are interested in global health, although time pressure, lack of funding, and uncertainties around how to arrange international opportunities were key barriers to participating in global health experiences.
Patricia Conrad presented an overview of the EnviroVet Summer Institute. This innovative 7-week program that represents a collaboration between UC Davis, the University of Illinois, Sokoine University of Agriculture in Tanzania, Florida Atlantic University, White Oak Conservation Center, and Tanzania’s National Parks. The institute is part of the One Health movement, which promotes an understanding of the linkages between human, animal, and environmental health. The field-based training uses a trans-disciplinary approach to inspire veterinary students to become leaders in global health. As an example, she described a situation where a local river has been drying up in a rural part of Tanzania, leading to increasing contact of humans, livestock, and wildlife as they compete for the remaining water sources. This situation has created increased potential for the spread of zoonotic diseases, including Mycobacterium bovis, and participating students have worked with local researchers to seek solutions.
Donna Denno and Suzinne Pak-Gorstein presented work that has been done to create core competencies in global health education. Using the ACGME framework, a working group of medical educators developed the first set of guidelines proposing key knowledge, skills, and behaviors that should be central to the global health training of pediatric residents. These core competencies are now being used at several universities to create and assess learning plans for global health training. They were included in the 2008 GHEC Guidebook for Developing Residency Programs in Global Health (available at http://globalhealtheducation.org/resources/Pages/default.aspx), and are currently being expanded to apply to additional residencies.
Maneesh Batra described the University of Washington’s efforts to create a sustainable and ethical international experience for pediatric residents interested in global child health. The program includes a month of didactic training, followed by an eight-week field experience during the third year of residency. The program pairs UW residents with residents from the University of Nairobi, and is focused on addressing health inequities through community health development, rather than by providing direct clinical care. Feedback from participants has been very positive, and Dr. Batra feels that this program provides a model for how a short-term global health experience can be structured to benefit both US trainees and developing country partners.
Gabrielle O’Malley discussed a collaborative effort between the University of Washington and the University of Namibia to strengthen training for MPH students. She highlighted the importance of relationship-building in ensuring programmatic success, particularly fostering mutual trust and respect and promoting good communication. She also discussed the use of distance-learning techniques as one way to address the educational challenges faced by countries with sparse and widespread populations.
The final speaker, Julie Maslowsky, described the process through which the University of Michigan developed a set of pearls to guide students engaging in international research and service-learning activities. A multidisciplinary task force, including 40 students, worked for eight months to create a resource that would be useful before, during, and after an international experience. The resulting guidelines, the Student Handbook on Global Engagement, can be accessed online at this link: www.globalhealth.umich.edu/pdf/CGH%20standards%20handbook.pdf.
During the question and answer session, the importance of mentor training, program sustainability, and defining and measuring program outcomes were discussed.
Prepared by David Roesel
Student Perspective: Mike Arndt, UW grad student, talks about the growth of global health on college campusesSeptember 20, 2010
The last several decades have witnessed the greatest prolongation of life in the history of humanity. That’s the good news. The bad news: a growing global burden of chronic disease. Fortunately, groups like the National Institutes of Health’s Fogarty International Center are helping to ease the pain.
The Fogarty International Clinical Research Scholars Program gives U.S. and developing country advanced degree students in the health sciences a year of mentored clinical research training at a site in the developing world, with the intention of grooming new global health leaders from multiple disciplines. The door is open not only to “traditional” medical professionals, but also to others, from bioengineers to dentists, all “geeks for global health” are welcome to apply, said Roger Glass, Director of the Fogarty. He cited the case of bioengineering students from a Texas university, who used a beer cooler and an old car battery to create a low-cost refrigeration for vaccines.
Three Fogarty scholars spoke at the CUGH session. They were: a cardiologist who worked in Kenya, an ob-gyn who worked in Zambia; and an HIV researcher who worked in Peru.
Gerald Bloomfield, MD, a cardiology fellow at Duke worked at the Moi Teaching and Referral Hospital in Eloret, Kenya, for a year. Among his projects were: home-based screening for hypertension, which will enroll 600,000 patients over next few years; the creation of a two-year clinical research training experience in global cardiovascular disease research; and the study of atherosclerosis in sub-Saharan Africa and its relationship to HIV and cardiovascular disease.
Krista Pfaendler, MD, an ob-gyn at the University of Cincinnati, relayed her experience in Zambia. She helped to create a screening program for human papilloma virus (HPV) for women in that country. Starting from scratch in 2006, the program has now screened 50,000 women for the virus that causes cervical cancer—the leading cause of cancer-related deaths in women in Zambia. It has established 17 clinics in the country and is training and collaborating with doctors and nurses in Cameroon, Botswana, Uganda, South Africa, Nigeria, and China.
The third former Fogarty fellow, Magaly Blas, MD, is now a research professor in Cayetano Heredia Peruvian University. Her fellowship involved training physicians and nurses in how to search for medical information on the Internet and developing online video-based interventions to increase HIV testing among men who have sex with men.
While none of the three seemed to fit the strict definition of a “Geek for Global Health,” they certainly bring new dimensions of expertise to a Global Health practice for the 21rst Century.
Prepared by Bee Wuethrich
Gerald Keusch opened up this plenary session by stating that universities can play a key role in improving global health through their strength in promoting research and innovation, disseminating knowledge, and advocating for increased funding. He noted that global health is unique in that it touches on nearly all aspects of university activities, beyond just the health sciences.
Chris Murray posed the question of whether the “golden age” of global health funding is coming to an end as a result of the current economic crisis. He presented an overview of the dramatic increase in global health funding since 1990 to the present, during which development assistance for health rose from $9 billion to $27 billion. (Ravishankar (2009). The Lancet. 373:2113-24). He concludes that global health is still in an expansion phase, but that the realities of the global recession will lead to increasing pressure on governments to justify investments in global health during the next several years. In response to this, there will be increasing demand to show that money put into global health translates into improved outcomes for the world’s poor.
Nils Daulaire opened his comments by stating, “I am from the government, and I am here to help.” He pointed out that although the total percentage of the Health and Human Services budget allocated for global health is only 0.25%, that this still translates into a total dollar amount of $2.5 billion per year. He discussed the role of the Office of Global Affairs a commitment to building long-term partnerships with developing countries, helping to coordinate the activities and agendas of a wide range of federal and international agencies, and working to increase attention to the importance of chronic diseases. He also highlighted the Obama administration’s Global Health Initiative, which has allocated $60 billion dollars over six years to aims to expand upon the previous administration’s commitments to combat AIDS, TB, and malaria, and will promote increasing attention to maternal-child health and the health needs of women.
Roger Glass explained the ways in which the Fogarty International Center provides “early childhood education” in global health. He pointed out the many of the current leaders in global health had their passions for global health ignited by research experiences in low-income countries early in their training. The Fogarty Center seeks to help train the next generation of leaders by supporting similar experiences for health sciences professionals during the formative parts of their careers. He described the Fogarty Center as a “watering can” that can promote long-term, collaborative relationships between investigators and academic institutions in the US and their counterparts in developing countries.
Val Snewin discussed the ways in which the Wellcome Trust seeks to “achieve extraordinary improvements in human and animal health” by supporting global health investigators in the UK and low- and middle-income countries. With a total annual budget of 720 million pounds, the UK-based charity helps to support individual investigators, with the philosophy that they in turn will build strong teams and strengthen local research capacity. She pointed out that although clinical trials are important, the context of global health is broadening to include things like the social sciences and water and sanitation efforts. She highlighted the African Institutions Initiative, which has donated 28 million pounds to promote equitable and sustainable South-South and North-South partnerships. Dr. Snewin stated that ultimately, health research capacity strengthening is about nurturing people, and helping create environments in which research and innovation can take place.
Victoria Marquez-Mees rounded out the session by sharing her experiences working with the Carlos Slim Health Institute in Mexico. She discussed the ways in which this NGO is working to improve health in Latin America, including maternal-child health and chronic diseases such as diabetes. She posed the question of “How do you address a series of weakest links?” referring to the need to improve capacity in multiple areas, including administrative capacity, health care delivery, and medical informatics. The Carlos Slim Health Institute has taken a number of approaches to these challenges, ranging from harnessing the power of genomic sciences and communication technology, to building educational and training capacity, to seeking locally-relevant ways to strength people’s ability to take charge of their own health. “We need to move beyond the physician-based model,” she said, to applause. “Ultimately, the target has to be the health of the people.”
Overall, it was an engaging series of talks by people representing a broad range of approaches to global-health capacity-building.
Prepared by David Roesel, Univ. of Washington
King Holmes of U of Washington welcomed more than 800 attendees to the second annual meeting of the CUGH.
Haile Debas of UCSF awarded Tachi Yamada of The Bill and Melinda Gates Foundation with the CUGH Leadership Award
Debas continued with an update on the state of the CUGH over the past 12 months. He reported the membership has increased to 60 universities.
First Plenary: Building Academic Partnerships for Global Health
Global Health 4.0
Peter Piot, of the London School of Hygiene & Tropical Medicine, took us through a history of global health education, from an early focus on tropical medicine to the emerging Global Health 4.0. The tension between what exists and what is emerging is shaped by the context of a changing world: in the next decades three of four of the world’s top economies will be in Asia. Competition for energy, land, water, and commodities will increase; population growth and demographic change/aging will continue, as will with the growing pandemic of non-communicable diseases.
Piot argued for expanding the concept of global health to be based on interdisciplinary action focused on ending health disparities. Global health is not a geographic concept but a field of inquiry that must address health disparities everywhere. Its center of gravity must move from universities in North America and Europe to a truly global network of centers of excellence. “Are we North American or European institutions with a global mission or global institutions…?” he asked.
Global Health 4.0 must also move from focusing almost exclusively on infectious disease to dealing with broader health issues; and from addressing individuals and populations, to addressing individuals, populations and the environment. And it must complete the unfinished health agenda, which includes resolving the dilemmas of high maternal mortality and child health; lapsed reproductive health and family planning; high malnutrition; limited access to primary health care and continuing major health disparities.
How to do it in the context of the skyrocketing cost of higher education? It’s a challenge, yet the debate and decisions made today should move us to Global Health 4.0.
Developing Medical Education in sub-Saharan Africa
Studies were a hot topic of discussion during the opening session, “Building Academic Partnerships for Global Health.” Fitzhugh Mullan, of the George Washington University Department of Health Policy, reported on a Bill & Melinda Gates Foundation-funded two-year study on medical education in sub-Saharan Africa. The study set out to answer the question: if one was to fund medical education in Africa, where would one begin? What principles, areas, schools, and educational interventions should be supported? The study used a survey (72% response rate) and conducted week-long site visits to 10 of Africa’s 164 medical schools. Among the findings: of all medical schools, 20 percent are private; for most schools, tuition is less than $1000 a year; five years after graduation, the largest grouping of graduates are working outside their home country.
Mullan focused on some of the implications of those findings: the need to grow and support faculty in African medical schools; to build medical educational infrastructure, from dorms to bandwidth; and the need to fund research that both generates new knowledge relevant to the country and which advances faculty development. But it was the “brain drain” of talent from developing to developed nations that Mullan focused on most.
He urged adoption of the principle of United States self sufficiency in health care provider and the adoption of policies that will increase the number of medical and nursing school graduates in the U.S. The point prompted a question later in the evening: Why focus on closing the drain rather than opening the faucet? Why not invest on increasing the supply of physicians in those countries, rather than decreasing the number of people leaving?
Mullan replied that it’s not easy to produce physicians. “Does it make sense for a struggling organization in the U.S. to train physicians? It’s not a simple proposition.” Piot favored supporting countries who are willing to tackle the challenge of training.
A graduate student originally from Zambia posed the questions: I am done with my studies. I want to go back home and work. How do I do it?
At the Cusp of Medical Education Reform
We are at the cusp of fundamental reform of the medical education system, according to Lincoln Chen, President of the U.S.-based China Medical Board. Chen reported on a monumental study, now in press, on the state and direction of medic al education.
Designed to provide a forward look at professional medical education for the 21rst century, the study considered physician training, nursing and public health. “We asked not only what or how to teach, but also where to teach,” Chen said. It looked at the interaction of the education and health systems.
One of the findings: the 2,400 medical schools in the world are poorly aligned in terms of their physical location and the burden of disease. In fact, there is a “gross mismatch between institutional capacity and burden of disease.”
Furthermore, most curriculums are not needs driven. “The needs of society should determine competencies and shape the curriculum,” Chen said.
There must be mutual sharing of ideas. Faculty and students from the developed world should go to poor countries to train. One example of the power of sharing ideas and experiences is oral rehydration solution for the treatment of severe childhood diarrhea. Chen pointed out that ORS would never have been invented as a treatment for childhood diarrheal disease in the United States, because this country has plenty of intravenous fluids and the means of delivering them.
Solutions to the current dysfunction on professional medical education lie in harnessing the power of global knowledge and resource flows for the promotion of equity.
Among the world’s 200 countries, the difference in per capita income is 100 fold. The difference in healthcare expenditures, from the largest to the least, is 1000 fold. – Lincoln Chen, President, China Medical Board