Perspective
Becoming a Physician
The New Medical “Missionaries” — Grooming the Next Generation of Global Health Workers
N Engl J Med 2006; 354:1771-1773April 27, 2006
- Article
Noelle Benzekri is a first-year medical student with a mission. Even before the 27-year-old New York native spent a year as a clinic assistant and polio vaccinateur in Senegal, she knew that global health was her calling. “It's the reason I decided to go to medical school,” the former philosophy major acknowledged at a recent meeting of our journal club on global health at the University of California, Los Angeles (UCLA). Spurred by memories of her African patients, Benzekri intends to return to Africa someday to train local health workers to deliver care to the poorest of the poor.
The journal club has become a magnet for UCLA students, trainees, and faculty members who share Benzekri's hopes for greater global equity in health. Many attendees have already worked overseas; others have contributed domestically and now wish to apply their skills and experience abroad. All are hungry to discuss diseases of poverty as well as international policy and aid programs. In the curricula at most medical schools and postgraduate institutions in the United States, these topics receive little time and attention. A new generation of activists could change that.
Take, for example, Sue Tuddenham, a classmate of Benzekri's and a journal-club member. After graduating from Yale, she completed a degree in international relations at the London School of Economics, worked in the Hanoi office of the Population Council, and then took a job with the International Trachoma Initiative evaluating trachoma-control programs in Niger, Tanzania, and Vietnam. During her first week of medical school, she was already seeking mentors for a career in global health policy. Tuddenham and Benzekri have organized a series of lectures on global health at UCLA.
Both students are eager to return overseas once they have a few more courses and clinical skills under their belts. And they are not alone. In 2003, at least 20 percent of students graduating from U.S. medical schools had participated in overseas activities related to international health during medical school, as compared with 6 percent of 1984 graduates.1,2 On many U.S. medical campuses, introductory courses in global health and related student-run interest groups are flourishing.
Since 1991, the Global Health Education Consortium (GHEC) has helped to foster this growth of interest. A nonprofit organization representing medical schools in the United States, Canada, and Central America, the GHEC held a conference in 2005 entitled “Training the Global Health Workforce,” which brought together students, academic leaders, and professionals from the nonprofit sector and the World Bank. The 2005 conference of the Association of American Medical Colleges (AAMC) also highlighted global health and featured an address by former secretary of state Madeleine Albright. The GHEC and the AAMC, in collaboration with the Foundation for Advancement of International Medical Education and Research, are now conducting a survey to learn more about organized international opportunities at U.S. medical schools. Groups such as the GHEC and the American Society of Tropical Medicine and Hygiene (ASTMH) also are advocating an updated, standardized curriculum in global health.
Back on their campuses, internationally minded students are often inspired by peers who have already rotated abroad. Tuddenham and Benzekri, for instance, may look to Sagar Vaidya, an M.D.–Ph.D. candidate who has volunteered at a rural clinic in Mexico and has also completed clerkships in India and Vietnam. Or Shilpa Sayana and her husband, Rishi Manchanda, residents in internal medicine who recently participated in a rollout of antiretroviral drugs in Durban, South Africa. Sayana grew up in Botswana and studied women's reproductive health in Egypt. Manchanda's résumé includes clinical stints in Botswana and Mozambique, plus a year in India studying primary care services.
Such trainees will always find exciting international medical opportunities if they search hard enough and are willing to pay their own expenses. But their schools and residency programs rarely give anything more than moral support and elective credit. As a result, the few travel fellowships available to medical trainees are flooded with applicants each year. Last year, an ASTMH-sponsored program received 130 applications and awarded 10 student fellowships for projects in a variety of venues, including an entomologic field site in Senegal, a war-torn setting in Uganda, and a mobile, railroad-based hospital in India (see graph
Numbers of Applicants and Funded Benjamin H. Kean Traveling Fellowships in Tropical Medicine from the American Society of Tropical Medicine and Hygiene (ASTMH).).At the postgraduate level, the Yale–Johnson & Johnson Physician Scholars in International Health program has long been committed to education and service abroad, and it underwrites some of its awardees' expenses. The program currently sponsors rotations of four to eight weeks in Brazil, Eritrea, Haiti, Honduras, India, Mexico, Nepal, Russia, South Africa, Uganda, Vietnam, and Zambia, as well as at the U.S. Indian Health Service. Two thirds of Yale's residents in internal medicine, medicine and pediatrics, and primary care take part, as do another 30 physicians selected annually from a national pool of applicants. Graduates of this program express a greater commitment to underserved populations at home and abroad than do nonparticipants.3
Rarely, a department head will use discretionary funds to pay for trainees' overseas electives — as Gautam Chaudhuri, executive chair of the UCLA department of obstetrics and gynecology, has done. Nearly all of UCLA's OB-GYN residents, traveling in pairs and accompanied by at least one faculty member, now spend three weeks in Eritrea, a country in which the rates of complications during childbirth are among the highest in the world. The visiting doctors often repair vesicovaginal and rectovaginal fistulas that have resulted from prolonged, obstructed labor.
What is fueling the hunger for overseas learning among the next generation of medical professionals? Many of these young people “have already traveled a lot,” says Michele Barry, cofounder of the Yale program, and media coverage has raised their awareness of global health issues. In addition, she notes, first-generation Americans whose families come from developing countries often want to give back to less privileged people and regions of the world.
No matter what motivates them at the outset, long-term benefits can accrue from trainees' spending even a few weeks overseas — and not just broadened clinical and cultural competence. As medical educators, Barry and her colleague Frank Bia see practical, domestic benefits from the program they launched on a shoestring 25 years ago. They believe that the weeks residents spend in low-resource settings teach cost-conscious practice and back-to-basics diagnosis. According to Malini Anand, a chief OB-GYN resident at UCLA, returning residents also continue to bear witness — to colleagues, family, and friends — regarding the health conditions they have seen. Their reports, in turn, increase public awareness, which may be partly responsible for the recent increase in U.S. foreign aid for global health.
Historically, so-called missionary medicine was focused on spreading religion as well as compassionate care. Today, the forces behind global health efforts are more secular. Nonetheless, the movement continues to be motivated by a sense of mission — a word with a Latin root, mittere (to send), that suggests an important question: If there is new fervor for global health on the part of medical professionals and international policymakers, shouldn't the “sending” process be more organized — and the vision bigger and bolder?
In a 2005 report, the Institute of Medicine recommended establishing a federally funded U.S. Global Health Service that would send midcareer professionals overseas to help augment local responses to human immunodeficiency virus infection and AIDS, tuberculosis, and malaria; provide fellowships and partial repayment of student loans; foster international health care partnerships; and create a global health employment clearinghouse for paid or volunteer positions.4 The establishment of such a federal program would offer some hope of support for young professionals who are ready to dedicate themselves to global health.
An interview with Mike Westerhaus, Khayree Butler, and James Maguire can be heard at www.nejm.org.
Source Information
Drs. Panosian and Coates are professors of medicine at the David Geffen School of Medicine and cofounders of the Program in Global Health at the Division of Infectious Diseases — both at the University of California, Los Angeles, Los Angeles.
- References
References
1
1984 Medical Student Graduation Questionnaire: summary report for all schools. Washington, D.C.: Association of American Medical Colleges, 1984.
2
2003 Medical School Graduation Questionnaire: all schools report. Washington, D.C.: Association of American Medical Colleges, 2003.
3
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;61:1019-1023
Web of Science | Medline4
Mullan F, Panosian C, Cuff P, eds. Healers abroad: Americans responding to the human resource crisis in HIV/AIDS. Washington, D.C.: National Academies Press, 2005.
- Citing Articles (24)
Citing Articles
1
Hiroshi Nishigori, Osamu Takahashi, Naomi Sugimoto, Kiyoshi Kitamura, Graham T. McMahon. (2012) A national survey of international electives for medical students in Japan: 2009–2010. Medical Teacher 34:1, 71-73
CrossRef2
Timothy Lahey. (2011) Perspective: A Proposed Medical School Curriculum to Help Students Recognize and Resolve Ethical Issues of Global Health Outreach Work. Academic Medicine1
CrossRef3
Peggy Guey-Chi Chen, Leslie Ann Curry, Susannah May Bernheim, David Berg, Aysegul Gozu, Marcella Nunez-Smith. (2011) Professional Challenges of Non-U.S.-Born International Medical Graduates and Recommendations for Support During Residency Training. Academic Medicine 86:11, 1383-1388
CrossRef4
Walter K. Patrick. (2011) The Asia Pacific Academic Consortium for Global Public Health and Medicine: Stabilizing South-South Academic Collaboration. Infectious Disease Clinics of North America 25:3, 537-554
CrossRef5
K. A. Kelly McQueen, Kathleen M. Casey. (2011) The Impact of Global Anesthesia and Surgery: Professional Partnerships and Humanitarian Outreach. International Anesthesiology Clinics 48:2, 79-90
CrossRef6
Rodney D. Welling, Ezana M. Azene, Vivek Kalia, Krit Pongpirul, Anna Starikovsky, Ryan Sydnor, Matthew P. Lungren, Benjamin Johnson, Cary Kimble, Sarah Wiktorek, Tom Drum, Brad Short, Justin Cooper, Nagi F. Khouri, William W. Mayo-Smith, Mahadevappa Mahesh, Barry B. Goldberg, Brian S. Garra, Kristen K. DeStigter, Jonathan S. Lewin, Daniel J. Mollura. (2011) White Paper Report of the 2010 RAD-AID Conference on International Radiology for Developing Countries: Identifying Sustainable Strategies for Imaging Services in the Developing World. Journal of the American College of Radiology 8:8, 556-562
CrossRef7
Deborah Murdoch Eaton, Anthony Redmond, Nigel Bax. (2011) Training healthcare professionals for the future: Internationalism and effective inclusion of global health training. Medical Teacher 33:7, 562-569
CrossRef8
Matthew P. Lungren, Jeffrey J. Horvath, Rodney D. Welling, Ezana M. Azene, Anna Starikovsky, Mustafa R. Bashir, Daniel J. Mollura, Charles Maxfield. (2011) Global Health Training in Radiology Residency Programs. Academic Radiology 18:6, 782-791
CrossRef9
Betsey Brada. (2011) “Not Here”: Making the Spaces and Subjects of “Global Health” in Botswana. Culture, Medicine, and Psychiatry 35:2, 285-312
CrossRef10
Brett D. Nelson, Amy Saltzman, Patrick T. Lee. (2011) Bridging the global health training gap: Design and evaluation of a new clinical global health course at Harvard Medical School. Medical Teacher1-7
CrossRef11
Faith-Michael E. Uzoka, Joseph Osuji, Okure Obot. (2011) Clinical decision support system (DSS) in the diagnosis of malaria: A case comparison of two soft computing methodologies. Expert Systems with Applications 38:3, 1537-1553
CrossRef12
Lynda Redwood-Campbell, Barry Pakes, Katherine Rouleau, Colla J MacDonald, Neil Arya, Eva Purkey, Karen Schultz, Reena Dhatt, Briana Wilson, Abdullahel Hadi, Kevin Pottie. (2011) Developing a curriculum framework for global health in family medicine: emerging principles, competencies, and educational approaches. BMC Medical Education 11:1, 46
CrossRef13
Panosian, Claire, . (2010) Courting Danger while Doing Good — Protecting Global Health Workers from Harm. New England Journal of Medicine 363:26, 2484-2485
Full Text14
Iman K. Martin, Baffour Awuah, Lisa A. Newman. (2010) Guide for investigators conducting international cancer research involving developing nations. Cancer 116:6, 1396-1399
CrossRef15
M. Margaret Knudson. (2010) Trauma/critical care surgery. The American Journal of Surgery 199:2, 266-268
CrossRef16
Raquel González, Elisa Sicuri. (2010) Insights into social responsibility in global health. Wiener klinische Wochenschrift 122:3-4, 59-61
CrossRef17
Patricia A. Conrad, Jonna A. Mazet, Deana Clifford, Cheryl Scott, Michael Wilkes. (2009) Evolution of a transdisciplinary “One Medicine–One Health” approach to global health education at the University of California, Davis. Preventive Veterinary Medicine 92:4, 268-274
CrossRef18
Andrew Bazemore, Philip Diller. (2009) Global choices: international health and medical student residency preferences. Medical Education 43:11, 1079-1080
CrossRef19
Sudha P. Jayaraman, Alexander L. Ayzengart, Laura H. Goetz, Doruk Ozgediz, Diana L. Farmer. (2009) Global Health in General Surgery Residency: A National Survey. Journal of the American College of Surgeons 208:3, 426-433
CrossRef20
Amy Levi. (2009) The Ethics of Nursing Student International Clinical Experiences. Journal of Obstetric, Gynecologic, & Neonatal Nursing 38:1, 94-99
CrossRef21
Howard Wolinsky. (2008) Tropical travel medicine. A growing interest in tropical medicine reflects the increasing incidence of tropical disease in the Western world. EMBO reports 9:8, 714-716
CrossRef22
Edward O’Neil. (2008) Who We Are and Might Be: In Global Health, Excellence Demands Equity. American Journal of Kidney Diseases 51:1, 145-154
CrossRef23
Parminder Suchdev, Kym Ahrens, Eleanor Click, Lori Macklin, Doris Evangelista, Elinor Graham. (2007) A Model for Sustainable Short-Term International Medical Trips. Ambulatory Pediatrics 7:4, 317-320
CrossRef24
Katharine Garman, Robert Hughes. (2006) Medicine, Medsin, and global health. The Lancet 368:9530, 103-104
CrossRef
