Rethinking Global Health Training in North America

Rajesh Gupta, MPH; Peter Hotez, MD, PhD

Disclosures

August 24, 2006

The face of global health has changed dramatically during the last 10 years. As the gap between the richest and poorest in the world continues to increase, the burden of preventable and treatable infectious diseases also is increasing.[1] Polio, which was on track to global eradication, has recently experienced a rise and spread to previously elimination-certified countries.[2] African trypanosomiasis (sleeping sickness) has reemerged in war-torn areas of Angola, the Democratic Republic of Congo, and the Sudan.[3] The spread of anthrax in the United States only served as another reminder of the crippling effects of infectious diseases, even those with a small absolute number of cases.[4] The resurgence of mumps in the United Kingdom is a salient reminder to the newest generation of physicians that infectious diseases of the past do not remain in history books.[5] As exemplified by the epidemiology of HIV, tuberculosis (TB), and severe acute respiratory syndrome (SARS), geographic or social borders do not serve as barriers for infectious diseases.[4,6,7]

Accordingly, funding for addressing these infectious diseases has also increased significantly over the last decade (particularly the later half). For example, the Bill and Melinda Gates Foundation has so far donated over $4 billion in resources toward improving global health. Their portfolio includes not only the high-profile diseases of HIV, TB, and malaria, but also the equally deleterious neglected diseases, such as hookworm, leishmaniasis, lymphatic filariasis, measles, polio, guinea worm, trachoma, schistosomiasis, etc.[8] Additionally, The Global Fund to Fight AIDS, Tuberculosis and Malaria (although still woefully underfunded) has committed $3 billion in funding to programs addressing these 3 diseases.[9,10] Political support has also increased, particularly from resource-wealthy countries. The US government is recognizing the importance of funding such activities, as evidenced by the President's Emergency Plan for AIDS Relief (PEPFAR) and a recent commitment to increased support for malaria control.

This increased funding and support is targeted primarily at improving global health by increasing access to health commodities (ie, those related to identification [diagnostics], treatment [drugs], and prevention [condoms, bednets, etc]) and implementing the corresponding intervention programs. To be successful in this area, a wide range of disciplines must come together. The initial stages of developing new commodities require a command of the basic science background in the etiology, pathogenesis, and natural history of bacterial, viral, and parasitic diseases.[11] In approaching health product discovery and manufacturing, high throughput screening methodologies, formulation, quality control, and quality assurance are all issues to be considered.[11] From an access and program design perspective, economic analysis, epidemiologic impact, social anthropology, and trade issues play an important role. More macrotopics, such as analysis of health systems, developmental economics, demographics, and financing mechanisms, also affect the structure of various programs, particularly at the national level.

However, although this multidisciplinary approach to addressing global health issues is well recognized, the opportunity in North America to gain such a comprehensive education remains fragmented. Indeed, the educational shift in the United States to address such issues is on a marked decline.[10] No single school of medicine or public health offers an all-encompassing curriculum in which students can acquire a set of skills that are applicable to real-world global health practice. Simply stated, we have committed financially and politically to address the issue, but our own in-country capacity for comprehensive training is woefully inadequate. Some schools offer very little in any of these areas, whereas others specialize in some of the areas. Of the 33 accredited schools of public health, only 8 have departments devoted to infectious and/or tropical diseases, and only one of these 8 has emerged in the last 30 years.[12,13] Postgraduate medical training no longer offers a tropical disease residency but rather as fragmented research opportunities during infectious disease subspecialty training.[10] Most medical schools still do not provide strong, formal programs promoting overseas training in developing countries. Within these few existing infectious disease programs, only a handful of skills (primarily epidemiology in public health schools and clinical assessment/pathology in medical schools) are offered- leaving the remaining skills to be acquired elsewhere in a piecewise fashion.

As highlighted in a new report from the Institute of Medicine (IOM), the state of global health is necessitating a fundamental shift in training, education, and research in the United States.[14] To further advance this concept, we propose that to adequately prepare our healthcare professionals, a centralized institute of learning should be established whose primary focus would be to improve our capacity to respond to global health issues, as outlined above. Specifically, its objectives would be 3-fold.

Advancing knowledge and training in appropriate technology: The term appropriate technology refers to "health technology, which is developed, produced, delivered and monitored in a comprehensive framework that takes into account the systems, the individuals, and the community.[11]" Included among appropriate technology are new control tools, such as bednets, preventive drugs, and vaccines as well as health assessment instruments used in disease surveillance, mathematical modeling, and cost-effectiveness studies.[11] As a collective, these tools can offer maximum impact in the control of infectious diseases in developing countries.

Training of current and future healthcare professionals: As we have argued, although the interdisciplinary nature of disease is well recognized, the specific training of interdisciplinary global health scientists is lacking. Using 2 main areas of study, technology delivery and healthcare delivery, a training system could be established. Such training would delve into the various disciplines comprising each of these 2 areas. For example, technology delivery would focus on many of the issues relative to appropriate technology. Healthcare delivery would look more at the programmatic issues (design and implementation within a health system) that include economics, sociology, anthropology, and political science. Increasing the training capacity is a key component to improving our healthcare labor workforce response to such global health issues, and should be augmented in our formal education system.

Service to the global health community: A component that is devoted to balancing the research and training components is essential. Facilitating service activities (short-, medium-, and long-term assignments) can provide an opportunity to practice in the real world of global health and include a local capacity training component that is equally important in terms of creating sustainable, self-reliant programs at country level. Additionally, it has been noted that in many countries the healthcare workplace supply is short of demand.[15] Ironically, much of this is due to the emigration of healthcare workers to other countries that offer better opportunities. However, it is these very countries from which they are emigrating that have the greatest need. Not only does a service component reinforce training, promote practical application of skills, and bridge the human resource gap, but it also provides a concrete commitment to our responsibility in improving the health of the world.

As stated elsewhere, "no school exists that can comprehensively address global health problems at the molecular, clinical, epidemiologic, public health practice, development, and policy level.[10]" The impact of such neglect may only be truly realized in the coming years as the ability of the United States to respond to global health issues becomes increasingly tested. With a 3-pronged approach focusing on research, training and service allow us to better prepare future healthcare professionals in becoming global health leaders. Two clear areas where we could have a significant impact are altering the sobering statistic, indicating that (1) only 10% of expenditures on research and development globally are devoted to health issues comprising 90% of disease burden, and (2) between 1975 and 1999, only 1% of the nearly 1400 new drugs developed were devoted to tropical diseases.[16,17] If the IOM is correct in stating that "America has a vital and direct state in the health of people around the globe . . . derive[d] from both America's long and enduring tradition of humanitarian concern and compelling reasons of enlightened self-interest,[18]" then it is imperative to match this concern with proper education of our health professionals.

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