Global Health Matters International EducatorStudents and faculty in health professions are increasingly going abroad to learn about public health issues and learning new ways of care to improve global health.

By Cathy Yarbrough

Women in the rural, tribal communities south of Mysore, India, often walk long distances each morning to obtain their families’ daily supply of clean water for drinking, cooking, and cleaning. After filling their large pots with water from the distant well, the women balance the containers on the tops of their heads for the long walk home.

Melissa White visited one of these communities while she was an undergraduate student participating in the University of Minnesota (UM) Global Future Physician Seminar in India. Prior to White’s visit, a charitygroup drilled a well in one of the communities to improve sanitation and provide the local residents with a ready supply of clean water. But the women continued their long walks to obtain water at the distant well.

“Because the women walked together to the well, it was an opportunity for them to talk and socialize. They didn’t want to give that up,” says White, now a first-year medical student at UM. For White, the women’s boycott of the new well so that they could continue their group walks illustrates the non-medical influences on people’s health. “The women likely have been walking together to the well for generations,” she adds.

Public health, or “global health,” as many refer to the discipline when it involves healthcare issues around the world, is fast becoming internationalized. As the world becomes more diverse, health professions are recognizing that their students’ patients will come from all over the world—not just born and raised in their own communities. Also, as travel is more frequent, illness and disease can move faster across borders than in the past, and so public health has become a global issue. Many higher education institutions are taking the lead to prepare their students with a firsthand education in global health in various international healthcare settings. And for students, learning about global health issues in communities abroad will also help them in their future practice in the United States with people from diverse cultures.

Learning Social and Cultural Determinants of Health

UM’s seminar in India is designed to “help premed and prehealth students to learn about the social and cultural context of health and medicine,” says Tricia Todd, MPH, assistant director of the UM Health Careers Center. “Understanding the context of health is essential to being a global health professional today,” she adds.

Todd, who cofounded the UM seminar in India in 2012, uses the term “prehealth” to describe undergraduates who are considering careers in nursing, public health, or one of the other nonmedical health professions.

When Todd and her UM colleagues review undergraduate students’ applications to participate in the annual global health seminar in India, they give first preference to UM students who have taken the university’s Future Physician series of three courses on medicine in the twenty-first century, life and work of today’s physicians, and 35 hours of volunteer experiences in the field. Todd considers the seminar in India as the fourth course in the Future Physician series. Participation in the India seminar is limited to 26 students.

The seminar, which occurs over two weeks during the university’s winter break, is based at the Vivekananda Institute of Indian Studies (VIIS), and includes classes as well as field visits to tribal and rural areas of the Mysore district. In addition to two UM physicians, the students’ instructors are eight Indian doctors. During the seminar, the students learn about the cultural and environmental context of health and medicine by visiting ancient temples, schools, rural development projects, and water resource utilization projects.

While in India, the UM students visited two hospitals, one government-operated, and the other private. “The two different hospitals illustrated the huge disparities in the Indian health system. It was eye-opening,” says Rachel Lee, now a first-year UM medical student. “At the public government-run hospital, hundreds of people were waiting to be admitted to the wards. That was not the case at the private hospital whose facilities were nicer than what you often see in the U.S.”

At the beginning or end of each day, the students and their instructors met for what Todd describes as a “debrief and reflection,” to discuss their observations about the health challenges specific to Mysore and India’s rapidly developing economy. The students and faculty members also compare health care in India and the United States.

In addition to improving their understanding of the cultural and social determinants of health, the seminar helps the students “to be clearer about what they want to do in their careers,” says Todd. “When the students return from India, we see many who decide to go into medicine and some who decide not to. And, that’s okay.

“Some students who had wanted to be physicians decide to go into other fields such as public health policy, in which they believe that they could have a broader impact,” she adds. Other students, such as White and Lee, are even more committed to medicine but now want to specialize in primary care for underserved populations.

“Coursework introduces students to new ideas,” says Todd. “Experiential programs help them learn at a deeper level.”

Working in Ghana: “They Don’t Need To Be Saved”

Students who participate in one of the University of Utah’s overseas experiential programs in global health quickly learn that their role is not to “fix” another country’s health problems, but to help the people there build the capacity to improve their own lives and create sustainable, positive changes in their communities.

“We’re not going into these countries to save the people there,” says Stephen Alder, PhD, codirector of the University of Utah’s Global Health Initiative (GHI), which has forged collaborative community development partnerships in Ghana, Peru, Armenia, and India.

“The people in those countries don’t need to be saved. What they need is partnerships, and so do we,” he points out.

U of U’s international partnerships provide opportunities for the university’s graduate and undergraduate students in public health, medicine, and other disciplines to learn firsthand about global health, conduct public health research, and participate in the university’s service mission, adds Alder, who also is chief of the Division of Public Health and professor of Family and Preventative Medicine at the University of Utah as well as president of the Association of Accredited Public Health Programs.

Alder also is a member of the Association of Schools and Programs of Public Health (ASPPH) task force on “Framing the Future: The Second 100 Years of Public Education for Public Health.” Not surprisingly, the task force’s recommendations for the undergraduate and graduate degree programs call attention to the value of international learning experiences such as the University of Utah’s Global Health Initiative. Unlike their predecessors, future public health professionals must be knowledgeable about the health and healthcare of communities and countries outside their geographical borders.

In 2014 University of Utah students participated in GHI’s community development partnership projects in Ghana, Peru, and Armenia. (GHI’s new program in India will begin in 2015.) The students were selected based on their applications. Prior to leaving the United States, they attended orientation sessions about the countries that they would be visiting and their in-country project activities. The University of Utah faculty member who is the project’s leader accompanied the students. When they returned, the students earned course credits for their work in the GHI program.

For many students, participating in these three-week summer programs can be transformative, says Alder. “I’ve not seen a single experience impact a student’s career as much as these experiential programs do. The students’ perspectives about the world change,” he explains. “They often reconsider their career plans and think more about how they can do the most good, rather than how they can earn the most money.”

The oldest and most active GHI partnership is the Ghana-Utah Connection (GhUC), which began more than 10 years ago in the West African country’s rural Barekuma area. Home to about 2,500 villagers, Barekuma is located about 15 miles outside Kumasi, Ghana’s second largest city. Like many other rural villages in Ghana, Barekuma was burdened with malaria and other communicable diseases as well as inadequate sanitation, contaminated water, and poverty.

In Ghana, GHI created a partnership model that emphasizes collaboration with leaders and members of the Barekuma community as well as local government officials and the country’s own experts in medicine and public health. GHI’s partners in Ghana include faculty and students at the country’s Kwame Nkrumah University of Science and Technology (KNUST), the KNUST School of Medical Sciences, and Komfo Anokye Teaching Hospital, all in Kumasi.

GHI’s partnerships are decidedly nonpaternalistic. “We are guests in these communities. It’s not our voice, but the community’s voice that guides us in identifying what needs to be addressed,” says Alder.

To determine the Barekuma community’s voice, University of Utah faculty and students assessed the local population’s health needs through surveys of community members and leaders. By talking directly with the community, they also compiled an inventory of available public health resources. The results of the needs assessment survey and inventory were discussed with Barekuma tribal chief Nana Joseph Tabiri, the tribal elders, and other community leaders. Together they decide GHI’s priority projects.

In partnership with GHI, the Barekuma community has obtained the following:

  • Funding and building materials to construct two K–9 schools.
  • A community bathroom facility and sewer system so that villagers no longer use an open pit covered with boards as their toilet.
  • A community-based medical clinic that emphasizes early detection and treatment of diseases.
  • Healthy Families Initiative, a program based on Ghana’s plan for health care that places community health nurses in local clinics.
  • An economic development grant that enabled villagers to form a cooperative and obtain a loan from a local bank to purchase and cultivate an empty five-acre plot of land. The cooperative now has a revenue-generating grove of 400 orange trees.

Because the partnership is designed to foster community-level self-reliance, villagers, not GHI faculty and staff, constructed the schools, bathroom, and clinics and planted the orange grove. “Our philosophy has been that we don’t go take charge of a system or a program, but we offer support as a partner, mentor, and sometimes a technical adviser,” Alder says. “However, we also go there to learn.”

While in Ghana, University of Utah faculty and students conduct community-based research on such topics as the micronutrients in mothers’ diet, hygiene education among school-age children, and the prevalence of diseases ranging from high blood pressure to malaria. Brynn Fowler, a student in the MPH. degree program at the University of Utah, says she was surprised by how much she enjoyed the research. “There is a significant amount of work that goes into the research process and that can provide its share of challenges, but I found it to be such a rewarding and exciting process. It was really a transformative experience to get to go into a country with a research question and spend three weeks investigating it,” she says.

Fowler, who is now analyzing data from the Ghana study, also discovered the role of culture in determining people’s views of health and disease. “When you go into a country like Ghana and see how rampant the health concerns such as malaria are, it is easy to assume that it represents a significant health burden,” Fowler says. “Upon talking to residents of rural communities, we learned that they tend to see an issue such as malaria like we in the U.S. see the common cold—a part of normal life. All in all, the state of public health in any country is a multifaceted issue that is influenced on multiple levels.”

Alder also sees the similarities between the people of Ghana and Utah. For example, the rural areas of both Utah and Ghana have relatively few physicians, hospitals, and clinics. As a result, the people who live in both areas may not seek health care until serious disease complications develop. In collaboration with its Ghanaian partners, the KNUST School of Medicine and Komfo Anokye Teaching Hospital in Kumasi, GHI trained a group of Barekuma residents to serve as community health workers. Because they have been trained to recognize the early signs and symptoms of commonly occurring disorders in the population, the community health workers can help and encourage their fellow residents to seek health care before serious disease complications develop.

Based on the success of the community health workers program in Barekuma, Alder says that the University of Utah’s Division of Public Health is helping to develop a similar program for the rural areas of Utah. However, in the Utah program, the community health workers are referred to as health coaches, and they focus on issues important to the United States, such as nutrition.

Over the past 10 years, the University of Utah’s activities in Ghana have increased. Alder and his colleagues are helping to guide the design of academic and administrative programming at the country’s new Ensign College of Public Health, located on the outskirts of Kpong. Alder serves as a member of Ensign’s Board of Directors.

Teaching Team-Based Health Care

Overseas experiential learning programs in global health traditionally have not combined students from different disciplines—such as nursing, dentistry, pharmacy, and medicine—into the same study abroad project.

In 2014 the University of Maryland-Baltimore (UMB) campus launched what may be the first university-based program to support short-term interprofessional experiential projects in global health that bring together students from different professional schools. In addition to a faculty member, each funded project included two students from different schools. UMB’s professional schools are medicine, nursing, dentistry, pharmacy, law, and social work.

“We have to prepare students to function in their specific professions as well as interprofessionally,” says Jody Olsen, PhD, director of UMB’s Center for Global Education Initiatives.

Each faculty-student project in 2014 was funded by a $10,000 UMB grant to help cover transportation and related expenses. The nine funded projects, which were selected through peer competition, were conducted in China, Gambia, Kenya, Malawi, the Philippines, Rwanda, and Zambia. A total of 10 faculty members and 35 students participated.

Topics of their research projects, which were based on the faculty members’ ongoing health studies, ranged from “Examining Palliative Care in China” to “Malaria Prevention in School-Aged Children in Rural Malawi.” Headed by a School of Nursing faculty member, the research project in China involved three students from the Schools of Social Work and Medicine. The three students who participated in the Malawi project were enrolled in the Schools of Medicine, Pharmacy, and Law. Their project leader was a School of Medicine faculty member.

The faculty-staff IPE grants program in global health, which UMB will renew in 2015, reflects UMB President Jay A. Perman, MD’s support of IPE in the health professions. A pediatric gastroenterologist, Perman practices and teaches team-based health care to students each week at a pediatric clinic at UMB. His students are in medicine, pharmacy, nursing, dentistry, social work, and law.

With Perman’s support, Olsen and UMB colleagues sponsored an October 2013 roundtable discussion of key IPE global health competencies in didactic and experiential learning in the health professions. The 42 global health leaders invited to that meeting also discussed how the key IPE global health competencies should be incorporated into students’ education to prepare students for multidisciplinary collaborations as global health professionals.

The one-day meeting, “Global Health Inter-professional Council Roundtable,” will be summarized in a paper coauthored by Olsen and scheduled for publication in the December 2014 edition of the Journal of Law, Medicine & Ethics.

Cathy Yarbrough is a freelance writer in San Diego, California.