I sat in the clinic working on the multiplication table problems my mom had assigned me earlier that morning. Working next to the patients waiting to see my parents, I tried not to let myself become distracted by the elderly Nepali women who liked running their grubby old fingers through my blonde hair. When it was a busy day in the clinic and we had to stay late my dad would give me a writing assignment to pass the time. People would walk for days to visit the clinic my parents ran in Bandipur, in the foothills of the Himalaya. They were the only physicians for nearly a 50 mile radius so I tended to get a lot of writing assignments. The model of global health I witnessed at age nine in Nepal represents the traditional and now outmoded style of practicing medicine in an international setting, a model often referred to as the “medical tourism” model of global health. The standard was for western physicians to set up shop in remote parts of the developing world and serve those most in the need: people with no other access to health care. While well-meaning, this approach to practicing medicine abroad has fallen by the wayside as we trend toward more sustainable models.
The increasingly globalized nature of healthcare delivery has brought with it a dramatic increase in the number of participants in global health electives from all facets of healthcare training including medical, nursing, public health, and veterinary medicine. The explosion of interest in participating in global health electives requires that the models of training in global health reflect a more sustainable approach to international exchange in medicine. An important and well recognized component of this sustainable approach is the need for a bi-directional exchange of personnel and capacity building through teaching.
Less than a year after graduating college, my father and I joined Health in Harmony, a conservation medicine NGO working in West Kalimantan, Indonesia on the island of Borneo. Here we witnessed an approach to global health that differed markedly from our former experience working on the slopes of the Himalaya. Visiting physicians, including my father, worked strictly in a teaching capacity, training young Indonesian practitioners who came to the clinic to gain experience in rural healthcare delivery and to escape the madness of Jakarta. Though dramatically different from his prior experience working internationally, the model of global health in Borneo remained gratifying for my father insofar as he was able to learn how local physicians were able to practice extraordinary medicine in a severely resource limited setting. Indeed, recognizing the value of tapping into the immense clinical expertise of these local practitioners, Yale and Stanford had both sent students to work in the Health in Harmony clinic on a global health elective. In turn, Indonesian practitioners traveled to Yale to learn from the opposite side of the resource spectrum, allowing for a truly bidirectional exchange.
While the problem of sustainability in global health is well recognized and has emerged as a target for reform, numerous other challenges still exist. Chief among these challenges is the problem of the impermanence of commitment to the global health initiative in students participating in global health electives. Not unlike the one and done phenomenon seen with elite NCAA basketball players disappearing to the NBA after their freshmen season, the current paradigm of the global health elective sees many students participating in international electives during their fourth year, rarely leading to any lasting commitment. A part of this problem can admittedly be attributed to structural issues including debt repayment and finding employment where international work can be accommodated. However, as with the problem of bidirectional exchange, the fact that so few medical students engage in global health in the long term can be ascribed to the holdover medical tourism paradigm of the global health elective. We cannot expect students to fully appreciate the value that comes from working internationally after a single global health attachment, haphazardly inserted into an education largely devoid of supplementary global health training. Therefore, new models should seek to integrate international electives into a larger framework of global health education.
The elective that I am participating in through the University of Vermont College of Medicine explicitly addresses the problem of retention of global health elective students. My education as a global health scholar began with a six week rotation in Zimbabwe’s Parirenyatwa (Pari) Hospital in Harare following my first year in medical school. Walking through the wards of Pari, it was not uncommon to see patients in status epilepticus, patients with HIV encephalitis, and patients with miliary TB. Though I have seen firsthand the efficacy of traditional healing practices, the result of relying solely on traditional practices, particularly in a country where the prevalence of HIV is estimated at around 16%, can be devastating—and in our case, difficult to stomach. Too often we encounter patients with CD4 counts in the single digits. When asked why they defaulted on their Highly Active Anti-Retroviral Therapy (HAART), many of these patients will tell you that their traditional or spiritual healer told them that they were negative. While, according to the local medical students, this problem is improving and patients are recognizing the need for a combined approach to their ailments, it can be heart wrenching to hear these stories.
My experience in Zimbabwe accounts for just the beginning of my education in global health. Over the next three years as a medical student, I will participate in further training and ultimately return to Pari Hospital as a fourth year. This early exposure combined with the continuing education represents a new model of the global health elective aimed at developing a new generation of physicians who appreciate the increasingly globalized nature of healthcare and who are more likely to remain committed to integrating global health service into their careers. I am excited to be a part of this program—a collaboration between UVM and Western Connecticut Health Network—that seems uniquely poised to help transform the way we think about global health education.