Abstract & Commentary Mobilizing for Global Health
By Philip R. Fischer, MD, DTM&H
Professor of Pediatrics, Department of Pediatric and Adolescent medicine, Mayo Clinic, Rochester, MN.
Dr. Fischer reports no financial relationships in this field of study.
SYNOPSIS: The Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital created a global health corps named the Pediatric AIDS Corps in June 2005. Over a period of five years, 128 physicians were employed overseas by the Pediatric AIDS Corps with generally high levels of satisfaction and favorable impact on health. A review of that experience offers insights to guide national and personal involvement in global health activities.
SOURCE: Schultze GE, et al. The Pediatric AIDS Corps: A 5-year evaluation. Pediatrics 2014;133:e1548.
From July 2006 through June 2011, the Pediatric AIDS Corps employed 128 physicians to provide care and education directed at improving the treatment of HIV-infected infants and children in under-resourced countries. Using surveys, program leaders then assessed impacts of the program.
Of the 128 physician participants, 111 (88% of the 126 still living at the time of the study) completed follow-up surveys. All respondents were happy with their decision to participate in the program, and all but one would recommend the program to others. The majority (87%) reported that the experience affected their future career choices, with most choosing to remain focused on global health and about half choosing to pursue further training.
Most (73%) survey respondents thought that patient care was the most rewarding aspect of the program. Nonetheless, there were difficulties, including dealing with patient deaths, accepting the limitations of the local health care system, and coping with local managerial decisions. In addition, 41% had problems returning home, with personal issues and job-related difficulty being the most common reasons. However, the feelings about the overseas work and the personal relationships that developed lingered as the "best parts" of participation in the program.
While overseas, 42% reported being victims of crimes. Eleven percent identified depression as a problem while serving abroad, and 2% required international evacuation for stabilization of psychiatric conditions. Latent tuberculosis developed in 7% of participants. Interestingly, only 27% of those for whom malaria prophylaxis was indicated were compliant with their treatment; seven individuals were treated for malaria at least once.
There are potential implications of this new review of Baylor’s experience with the Pediatric AIDS Corps. First, as suggested by the authors, one can consider implementation of a national global health corps program. Second, individuals might choose to personally engage in global health activities.
Increasingly, Americans are following an established European habit of taking a "gap year" between the completion of high school and matriculation into university studies. Favorable benefits of inter-cultural and geographically distant experiences are anticipated as students become better prepared for further studies and career decision-making. Americans have also used the completion of university education as an opportunity to spend time overseas providing tangible service instead of simply soaking in the benefits of travel. Since 1961, Peace Corps has mobilized over 200,000 young Americans to spend two years working in 139 countries of the world. AmeriCorps, begun in 1994, similarly mobilizes college graduates for domestic service, and Teach for America places new teachers in schools in low-income areas.
Increasingly, Americans want to serve. The new generation of freshly trained health care professionals wants to provide valuable benefit to the global community. In 2012, Peace Corps launched the Global Health Service Project to provide adjunct faculty for training centers in other countries; in July 2013, the first cohort of 31 medical and nursing professionals went to serve in Tanzania, Malawi, and Uganda. (http://www.peacecorps.gov/volunteer/globalhealth/?from=hpsl)
Thus, the Baylor experience is instructive. Through one institution, 128 physicians were mobilized to serve HIV-infected patients in Africa and Asia. As with "gap years" for younger students, the experience was viewed favorably and impacted subsequent career decisions. As with Peace Corps, significant work was done to the benefit of local populations. Other academic institutions and non-governmental groups employ smaller numbers of physicians spending one to two years overseas, and faith-based groups place many professionals in short- and long-term service locations. What if a national group organized two-year post-training international experiences for physicians? It is anticipated that benefits to self and others would be accrued, and a larger national organization would be able to offer such opportunities to far more individuals than have been able to participate with the Baylor program. Whether the educationally-focused Global Health Service Project grows to fulfill this opportunity or whether other clinically-oriented organizations rise to the challenge, there is good opportunity to mobilize American health care workers for global service.
Of course, potentially starting a new national service group raises lots of logistic issues. Who should pay? How should government, non-government, and academic groups interact in organizing such a program? How would recipient/host sites be selected? Even while answering those questions, the Baylor group offers good data that can prompt us to continue conversations about a global health service corps.
Along the way, though, what about those of us who look back on our training from a greater distance? What can we do to more fully engage on the enthusiastic "bandwagon" of global health? What preparation would be useful?
CHALLENGE OF SERVICE:'ATTITUDE MATTERS'
There is still some disconnection between the fields of "tropical medicine" and "global health." From infectious disease backgrounds, we are comfortable dealing clinically with contagious conditions and diseases of poverty. Across the "aisle," however, our global health colleagues prompt us to consider epidemiology and public good; they prompt us to view health pro-actively rather than as the mere treatment and subsequent absence of disease. In less-resourced regions of the world, limited economic means can favorably impact more lives for more years when they are dedicated to health promotion and disease prevention than when they are focused on curative treatment. Each of us getting involved in international service should be aware of the principles and practices involved in healthcare, and we should carefully see how our personal involvement best fits in.
There are resources to help us understand both the principles and practices of sound medicine in other countries. Unite for Sight (http://www.uniteforsight.org/global-health-university/) offers online training. Several institutions (listed under "Approved Diploma Courses" at http://www.astmh.org/Education.htm) offer approved short (about two-month) courses that prepare future overseas workers and can lead to specific certification. Academic centers and professional organizations offer conferences that help prepare and network professionals for international work; examples are the Global Health and Innovation Conference each spring at Yale University and the Global Missions Health Conference each fall in Kentucky.
Where and with whom should we go? There are many groups that offer logistical support for people wanting to provide either clinical or educational service. Interested individuals can connect with whatever faith-based, institutional, or professional groups seem most suited to them. As the Baylor experience demonstrates, illnesses such as tuberculosis and depression can complicate terms of service, and it is wise to have adequate personal and institutional support to be able to deal with the rigors of overseas work.
And, attitude matters. Moving from a resource-rich area to serve in a resource-limited area leads some people to think that they are better or more right than the people they are serving. We should also be careful not to assume that the provision of resources solves health problems. (Books like Dead Aid by Dambisa Moyo and Toxic Charity by Robert Lupton can challenge us to see beyond finances as we look to help others.) We should all go as humble learners to participate with colleagues.
As we travel and serve, though, we might still struggle with big issues. Should the use of resources be prioritized from the top down, or should people at the "grass roots" peripheral places choose how to spend money? We can get guidance from people like Jeffrey Sachs (The End of Poverty) and William Easterly (The White Man’s Burden), but we will still have to decide how we each fit in. Even well-meaning people with great training can end up causing more harm than good (as discussed in When Helping Hurts by Steve Corbett and Brian Fikkert and in When Healthcare Hurts by Gary Seager).
Thus, the now-published Baylor experience is informative for infectious disease professionals, but it goes farther in inciting us to consider a national response to global health needs and in inspiring us to get involved personally.