Abstract
Compelling moral, ethical, professional, pedagogical, and economic imperatives support the integration of global health topics within medical school curriculum. Although the process of integrating global health into medical education is well underway at some medical schools, there remain substantial challenges to initiating global health training in others. As global health is a new field, faculties and schools may benefit from resources and guidance to develop global health modules and teaching materials. This article describes the Core Competencies project undertaken by the Global Health Education Consortium and the Association of Faculties of Medicine of Canada’s Global Health Resource Group.
Keywords: Medical education, Global health, Core Competencies
What is global health?
Global health has been defined as “…the goal of improving health for all people by reducing avoidable diseases, disabilities, and deaths”1 and an “area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide”.2 These definitions highlight the multinational, multidisciplinary, and equity-oriented nature of this emerging field. Global health involves social, political, economic, and environmental considerations that affect the health of communities and individuals around the world. Yet the same interconnectedness that facilitates the globalization of diseases is also manifested through the unprecedented interaction and cooperation between governments, civil society organizations, and individuals across time zones and borders to address health issues. Examples of this cooperation include large-scale multinational health efforts such as the United Nations Millennium Development Goals or the US President’s Emergency Program for AIDS Relief.3 Technological advances that permit instant knowledge sharing around the world, creating the capacity to transform medical education and care, are also rapidly evolving. The problem is therefore linked to the solution. Globalization has produced new multidisciplinary multinational health challenges, and the global health issues of the modern world require coordinated multisectoral, multidisciplinary, and multinational efforts to achieve effective resolutions.
Global health training in medical schools: need and current state
Medical education is increasingly being pushed to adapt, internally by the explosive growth in scientific knowledge and externally by rapid transformations in the global context. In response, experts are rethinking the approach to and content of medical education for the twenty-first century, including the role for global health.4 Reasons to include global health training as part of routine medical education include, among others, the tremendous increase in student and faculty interest, the growing percentage of immigrants in the United States and Canadian domestic populations, the rapid spread of communicable diseases by international travel, and the need for all physicians to have basic knowledge of major factors affecting health and the delivery of health care.3 Global health provides a framework to address issues such as inequities in health, cultural competency, globalization of health care, and social and environmental determinants of health crucial to modern medical education.
Although the need for global health curricular content is increasingly recognized, there has been a paucity of research examining the development of global health content for medical curricula.5 In general, the literature reflects a fragmented and insufficient response on the part of medical schools to the increased student demand for global health content.6, 7 Much of the literature to date regarding global health medical education focuses on international electives or activities at individual medical schools.8, 9 A survey of global health training in Canadian medical schools in 2006 found that global health content was haphazard and lacking in uniform objectives or guidelines.5 The lack of coordination in curricular development has resulted in wide variations between medical schools in the type, quantity, and quality of global health content offered. Where global health components are provided, there are variations in the format and content of global health materials, the year in which it is taught, whether the courses are required or elective, and whether they are didactic or experiential.5
While variations in educational approaches are an important source of innovation, the lack of consensus that characterizes contemporary global health training may have detrimental consequences. In the absence of formal learning opportunities, medical students are pursuing their own programs and electives in global health, often with little or no faculty oversight.5 This situation presents the risk of students practicing beyond their competency level, which may lead to harm for patients, themselves, and the educational and clinical institutions in which they study.10
Beyond the clinical aspects, medical graduates lacking appropriate global health training will be unprepared to recognize and meet the challenges of an increasingly interdependent world and the needs of the patients and populations they will serve.3 Coordinating the development of medical education systems for a new global context of medical care requires a systematic approach supported by key organizations and accreditation bodies.5 The lack of consensus among schools and leaders regarding what constitutes fundamental elements in global health training must be addressed in order to counter the fragmentation and inconsistency of current pedagogical approaches.3, 5 One step in this process is to seek consensus regarding the core competencies that all medical students, regardless of their interest in global health, should possess before graduating. Although particular themes have been identified in the literature,7, 11 a common set of criteria will help to ensure that all medical students receive appropriate and comparable global health training.
Creating core competencies in global health
To develop common standards for global health training in US and Canadian medical schools, the Global Health Education Consortium (GHEC) and the Association of Faculties of Medicine (AFMC) of Canada’s Global Health Resource Group (GHRG) initiated a project to develop global health core curriculum guidelines appropriate for all medical students.3 A literature review was conducted to assess the state of the knowledge regarding global health competencies for undergraduate medical education. This review identified 32 relevant articles; 11 retrieved articles described curricular competencies including the global burden of disease, travel medicine, health care disparities between countries, immigrant health, primary care within diverse cultural settings, and skills to better interface with different populations, cultures, and health care systems. Whereas each of these topics was mentioned in more than 1 article, no single topic was discussed in more than 5 of the reviewed articles, suggesting a lack of consensus within the literature regarding the essential global health competencies for medical students. The review also highlighted variations in the educational approaches used to teach these competencies.
Based on this review, a separate review of existing global health program websites, and expert opinion, the Committee developed a list of core competencies in global health for general medical education. In addition, the Committee detailed the essential knowledge and skills required within each competency topic area. These suggestions were then submitted for peer review to global health experts, medical educators, and students. Using a modified Delphi method, the Committee has developed recommendations outlining 7 topic areas and 18 competencies thought to be appropriate for global health training for all medical students. These recommendations are summarized in the following sections and in Table 1 .
Table 1.
Topic Area | Competency Description |
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1. Global burden of disease |
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2. Health implications of travel, migration and displacement |
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3. A) Social and economic determinants of health |
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3. B) Population, resources and the environment |
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4. Globalization of health and healthcare |
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5. Healthcare in low-resource settings |
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6. Human rights in global health |
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These recommendations represent their authors' opinion and should not be considered as representing the opinion of the AFMC.
Abbreviations: DALY, disability-adjusted life-year; HIV, human immunodeficiency virus; QALY, quality-adjusted life-year; TB, tuberculosis; UN, United Nations; WHO, World Health Organization.
From an AFMC Resource Group on Global Health/GHEC joint committee; with permission.
Global Burden of Disease
A basic understanding of the global burden of disease is an essential part of modern medical education. This knowledge is crucial for physicians to be informed participants in discussions of priority setting and the allocation of funds for health-related activities. Medical students should have a basic understanding of how morbidity and mortality are measured for health program monitoring, what the major causes of morbidity and mortality around the globe are, and how disease risk varies by world region. This includes understanding the major categories of morbidity and mortality used by the World Health Organization (WHO) and how they vary between high-, middle-, and low-income regions. Students should also have familiarity with major public health efforts to reduce health disparities globally, such as the Millennium Development Goals; they should be able to identify a health objective from the Millennium Development Goals and to describe the function and role of the WHO in developing health care policies. Finally, medical graduates should be able to demonstrate familiarity with health care funding mechanisms, priority-setting, and funding for health-related research, as well as be able to describe challenges to the existing health care system in their region.
Health Implications of Travel, Migration, and Displacement
The proper management of patients necessitates taking into consideration varying perspectives and implications due to international travel, foreign birth, or differing cultural backgrounds. Over the past several decades, economic and social globalization, particularly through migration, has led to changing social landscapes in nations around the world. The range of health concerns experienced by migrants and travelers requires that domestic health care professionals be well trained in a broader range of health issues to meet the needs of increasingly multicultural and diverse populations. This training includes competency in cross-cultural communication and interactions.
In 2004, 763 million people crossed international borders.12 Each year, up to 8% of travelers seek health care while abroad or upon returning home.13 Although travel medicine has emerged to accommodate the need for expertise in providing pre-travel and post-travel advice,14 all physicians should know how to take a basic travel history and when to refer or treat individuals with possible travel-related illnesses. Health professionals also require some understanding of how the global economy and travel contribute to the spread of communicable diseases, such as the severe acute respiratory syndrome epidemic of 2003 or the H1N1 pandemic of 2009. These experiences demonstrate the undeniable link between global and domestic health systems, the need for training in public health practice, and the need to better comprehend the medical risks of an interconnected world.
Social and Economic Determinants of Health
Dramatic inequities in health status exist within and between countries. According to the WHO Commission on Social Determinants of Health, “These inequities in health… arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces”.15 Morbidity and mortality vary according to social determinants, including education, occupation, income, social class, gender, age, and ethnicity, among others. Consistently, a lower socioeconomic status is associated with poorer health. Physicians should understand how social and economic conditions affect health, both to recognize disease risk factors in their patients and to contribute to improving public health.
Global health strives to achieve health equity for all. Medical education has a crucial responsibility to cultivate health professionals who embrace their role as advocates for the promotion of population health and the provision of effective health care services. Integral to the professional role of physicians within society are the values of altruism and compassion16 and the need to address issues of social justice and inequities in access to health care.17, 18 Major medical organizations and licensing bodies have recognized this role and emphasized that addressing health care inequalities within and beyond domestic borders is a fundamental principle of physician professionalism.17, 19 In order to cultivate in future physicians the characteristics required to meet the needs of contemporary societies and the expectations of professional organizations, medical schools should incorporate social and economic determinants of health learning objectives as integral components of their educational programs.
Population, Resources, and the Environment
Demographic projections anticipate that the world’s population will increase by 40% by 2050, with almost all of this expansion occurring in low-income countries. This growth could have a major adverse impact on the availability of food, water, and other essential resources, as well as exacerbate pollution. Medical students should have an understanding of the health impacts of rapid population growth and unsustainable and inequitable consumption of essential resources, including water and food supply. Students should also be aware of regional variation in access to these resources and the effects of inequitable consumption on individuals and communities around the world. They should be able to describe the relationship between access to clean water, sanitation, and nutrition to individual and population health.
Globalization of Health and Health Care
Globalization affects all aspects of health care, including the ability of governments or organizations to provide adequate care, the evolution of the local health care system, disease patterns, and the movement of health care workers within a global shortage of health human resources. Medical students should be able to understand and describe general trends in and influences on the global availability and movement of health care workers, as well as know how global trends in health care practice, commerce, and culture contribute to health and the quality and availability of health care locally and internationally.
Health Care in Low-Resource Settings
Health systems in low-resource settings often differ from those in the high-resource urban environments in which medical students are typically trained. Low-resource settings, including those among marginalized populations and rural environments in high-income countries, often face considerable human resource shortages within health care, as well as broader infrastructural inadequacies and barriers to prevention and treatment programs. These barriers may include inadequate local health system infrastructures; poor public infrastructure such as roads, schools, and telecommunications; cultural and linguistic barriers; low literacy rates; lack of health insurance; costs of medicines and therapies; advanced presentation of disease; lack of provider access to continuing education; and underutilization of available resources. Medical students should be aware of the realities of health care delivery in resource-poor settings and standards of clinical appropriateness in different environments. Further, students who travel abroad to participate in elective programs in low-resource settings should receive appropriate specialized orientation and training. This training should include such topics as personal health, travel safety, and ethical challenges that they may encounter, as well as competency with respect to the historical, sociopolitical, cultural, and linguistic contexts in which they will be learning.
Besides specific training in working within low-resource settings, medical graduates should be able to demonstrate an understanding of how primary health care delivery strategies may reduce health inequalities through programs such as universal and equitable access to health services, immunization programs, essential medicines lists, maternal and child health programs, community health worker programs, and primary care as a focal point and coordinating mechanism for comprehensive health service provision at all levels.20
Human Rights in Global Health
In 1948, the Universal Declaration of Human Rights established the right of every human being to enjoy a standard of living that promotes health and ensures adequate access to medical care.21 However, despite the international community’s agreement to health as a basic human right, health inequalities within and among nations persist and in many cases are widening. Future physicians should have an understanding of the intersection between health and human rights and how social, economic, political, and cultural factors affect individual and community rights to health care.
Future developments
Compelling moral, ethical, professional, pedagogical, and economic imperatives support the integration of global health topics within medical school curriculum. Although the process of integrating global health into medical education is well underway at some medical schools, there remain substantial challenges to initiating global health training in others. As a new field, faculties and schools may benefit from resources and guidance to develop global health modules and teaching materials. The GHEC/AFMC GHRG core competencies project was undertaken with the goal of providing guidance for those programs interested in adding global health content to their curricula. In addition, it is hoped that these recommendations will stimulate discussion among medical educators, students, professional educational organizations, and accreditation bodies regarding global health training in medical education to facilitate consensus on necessary competencies for students. Through the use of the proposed set of core competencies established by this project, it is hoped that this model will be shared among medical educators and programs in an effort to build a coordinated approach to global health in medical education.
Acknowledgments
The authors acknowledge the work of the Association of Faculties of Medicine of Canada Resource Group on Global Health/Global Health Education Consortium Joint Committee in developing the proposed competency guidelines. Committee members include Kelly Anderson, Timothy Brewer (Chair), Thuy Bui, Veronic Clair, Thomas Hall, Laura Janneck, Renee King, Anne McCarthy, Neal Nathanson, Sujal Parikh, Calvin Wilson, and Karen Yeates. The Committee was aided in its review of existing global health literature by Robert Battat, Gillian Seidman, Nicholas Chadi, Mohammed Yaameen Chanda, Jessica Nehme, Jennifer Hulme, Annie Li, and Nazlie Faridi. Winnie Chan also contributed to the collection of feedback on the drafted core competencies from the global health community.
Footnotes
Funding support: The Core Competencies project was funded in part by a grant from the Donner Canadian Foundation. The funding organization did not play any role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of this article.
Conflict of interest: The authors have no conflicts to disclose.
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