Not just more global health—smarter global health

The recently published commentary on global health curriculum in family medicine training is a welcome start in a dialogue on this critical issue facing the Canadian physician community.¹ While it provides a good overview of the potential benefits and the elements by which global health training could be improved in Canada, it stops just short of exploring the deeper issues surrounding greater participation in global health educational experiences.

The biggest issue in the analysis is the expansion of the definition of global health to include domestic opportunities with underserved populations as well as opportunities abroad. While correctly citing the 2009 definition of global health by Koplan et al,² the addition of “advocating and providing care for underserved populations within Canada, such as the homeless, refugees and immigrants, and remote communities”¹ arguably falls within the traditional role of the family physician as advocate³ as well as the specialty of public health and preventive medicine.

The pursuit of domestic educational experiences with marginalized groups in Canada differs greatly from an experience in a foreign country. There is a relative amount of ease and clarity surrounding the former over the latter, specifically regarding curriculum development, establishment of formal training programs, the population served, the priorities and responsibilities of physicians in those settings, and ethical considerations. The commentary itself gives brief notice to domestic issues before plunging heavily into overseas-focused predeparture training, centralized global health offices, and mentorship documents from programs focused on lower- and middle-income countries.

Therefore, using a common definition of global health experiences as efforts made abroad, we wish to expand on some of the commentary’s themes surrounding global health curriculum development.

First, the deep interest held by junior doctors and trainees is not new. In fact, beyond single experiences, studies have demonstrated that trainees completing clinical placements abroad remain interested in incorporating such opportunities into their future careers.^4,5 However, young physicians face substantial barriers both in pursuing initial experiences in the field, and in incorporating such interests into their careers. These include financial obligations, time demands, scheduling conflicts, poorly publicized opportunities, family commitments, security concerns, and additional training requirements.^6–8

Any development of formal programs would need to address these issues to ensure trainee experiences are both viable and valuable. Furthermore, recognizing the benefits provided by global health–minded physicians, the family physician community should make use of this passion and ensure resident experiences are not one-off “clinical vacations”; formal programs could provide opportunities and mitigate barriers for junior doctors wishing to incorporate global health into their careers.

Second, with the mitigation of barriers, we must carefully examine the ethical considerations of short-term elective training overseas. While the recent commentary highlights the clear benefits of participation accorded to the trainee,¹ the benefits derived from such experiences by the host community abroad are less clear. Beyond the obvious issues of resource scarcity, cultural and language barriers, and need for local knowledge and skill sets, literature highlights the power imbalance that exists between visiting trainees and destitute populations abroad. Such imbalances expose local patients to potential exploitation, and might also interrupt the efforts of these communities to develop local, self-sustained health care capacity.⁹

Studies examining the expansion of the United Kingdom’s role in global health highlight the importance of ensuring that trainee experiences abroad fit with the country’s needs and plans and, more important, that pre-existing inequities are not exacerbated through the misguided application of financial, human, or material resources for the sake of the trainee.^10,11 In the same way, the family medicine community should stand vigilant in ensuring that benefits derived from such experiences are not solely in our favour.

Finally, returning to the definitional issue described earlier, we must carefully consider the community at home and family medicine’s relation to public health. Given the myriad ways Canadians support medical training, the question remains: do Canadian resident physicians have a duty to serve the Canadian public first and foremost in their practice of medicine? Many Canadians argue correctly that we have our own problems here at home; the most marginalized populations in our nation likely face more challenges than the middle-class citizens of many developing nations. Any response to this question would cite respect for career autonomy, which itself has given rise to physician distribution issues in Canada, notably the urban-rural divide.¹²

Specific to global health, however, the question of “best fit” of practice objectives is even starker. An experience in maternal child health in an indigent developing world community develops a vastly different skill set from a rotation in harm reduction at a downtown addiction clinic in Toronto, Ont. Importantly, the latter experience speaks less to global health and more to the specialty of public health in Canada, highlighting the need for strong advocacy partnerships between family medicine training programs and public health physicians and agencies.

Our group shares the authors’ enthusiasm for the development and promotion of global health as a key component of residency training in family medicine. This article is another siren’s call to harness the idealism that exists among trainees and young doctors. Far more critical, however, is a realistic approach to the development of appropriate, mutually beneficial, and sustainable opportunities that are accessible to trainees and junior doctors. As U2’s front man Bono once said, “the world needs more Canada.”¹³ When it comes to global health, however, we need to be clear about what we mean, where we plan to do it, and the most ethical and equitable way to carry it out.