The why, where, and how of global health teaching

Medical students the world over are getting more involved in global issues. The demand for teaching is there, but will medical schools respond?

Global events seem to be impinging more and more on our daily lives. Terrorism, war in far off places, economic crashes causing stock market jitters—it is not a happy list. Many commentators argued that the events of 11 September gave a wake up call to the developed world, and the United States in particular, that there was a world “out there” full of poverty, injustice, and violence, which we couldnt divorce ourselves from. We needed to educate ourselves about the rest of world and particularly what was happening in poor countries.

We certainly do. But among medical students at least this process was already happening well before the events of 9/11—and it wasnt just because we need to understand why billions live on the margins of destitution. Many students simply wanted to know more about the fascinating range of cultures and societies that exist in the world around them, with which they are experiencing greater interaction.

In the health sector this interest has also arisen because, as the Director-General of the World Health Organization, Gro Harlem Brundtland, has noted: “The distinction between domestic and international health problems is no longer useful.”¹ Developments in global trade and travel shift people, goods—and microbes—across greater distances and at faster speeds than ever before. Despite what are often ridiculous and unfair controls on immigration, Western societies have become increasingly multicultural as migrants, asylum seekers, and victims of torture come knocking on our doors. Doctors and other health professionals therefore need to know more about the world in general (and not just the patterns of disease elsewhere) to understand the physical and mental conditions they are being presented with on an increasing basis.

These are some of the good clinical reasons why global health issues should be on the medical curriculum. But there are others. As noted elsewhere, the ability to appreciate diversity, challenge prejudice, analyse change and the forces that shape society, and to be able to function in a range of circumstances, are important skills for any professional to learn.²

Big issues, small world
NASA

Ideally, these should be part of the present medical curriculum, whether in public health or elsewhere. Evidence shows, however, that they are not always there. Surveys suggest in depth teaching of international health issue in medical schools is rare.³ For example, among 70 medical schools in developed countries, 61% claimed to be teaching international health, but only 26% listed it as a separate curriculum item.⁴ And given that diversity, prejudice, and change are present in every society, however influenced by the outside world they are, you would think that teaching about these issues would be commonplace in training for a professional life that involves such a high degree of human interaction. But in my experience this is not the case, including in public health curriculums, which are often dominated by discussion of statistics and which sometimes do not reflect the huge and fascinating role that social and economic forces have in shaping the wellbeing of the British population.

Medact has been involved in a number of surveys, both in the United Kingdom and abroad, which suggest that demand for teaching about global health issues related to war, poverty, and infectious disease is high among medical students.⁵ Hundreds come to the annual conferences of the Medical Students International Network and hundreds more get involved in MedSIN projects that tackle British as well as global health issues. So I have a theory: given that many of these issues should and could already be part of medical curriculums, this vigorous activity represents not only a demand for teaching about the rest of the world, but also a demand for a revitalising of curriculums in general, to put students more in touch with both this society and the world around them.

Theories aside, there is already much work being done to bring international health issues into medical curriculums, whether as elements in the core curriculum, as special study modules or intercalated BSc courses. At Bristol and Imperial College, global health is in the core in the form of international health days in the public health curriculum.⁷ Special study modules exist at University College London, Birmingham, and elsewhere (see www.ihmec.org). The new International Health and Medical Education Centre (IHMEC) at UCL has set up an intercalated BSc on international health issues which is proving popular with students and which covers issues related to poverty, human rights, globalisation, maternal and child health, and infectious diseases. Leeds is also about to start a similar course. IHMEC has also launched a structured elective scheme, which has been piloted in Tanzania and looks likely to be extended to Zambia. Other countries such as the United States, Canada, the Netherlands, and Sweden also offer models of integrating global health issues into the curriculum.^{2 8} In many of these countries medical students associated with the International Federation of Medical Students Associations (IFMSA) are leading the way in pressing for more coverage of global health issues (see box).

Teaching materials are also available. Medact has recently produced a global health studies teaching pack covering a range of health issues related to socioeconomic development, environmental change and conflict, with a particular emphasis on understanding the livelihoods (rather than simply the health, narrowly defined) of poor people in the developing world.⁹ Others have produced similar educational tools on health human rights and war and public health.^{10 11}

Given the increasing importance of optional modules and intercalated courses in medical curriculums, the future looks hopeful for teaching on global health issues. MedSIN, together with Medact, has just launched a campaign to get global health teaching into all medical schools in the United Kingdom in some form or other by September 2005. But putting this type of teaching into core curriculums is also crucial, and the examples of where this is already being done have to be gathered together and evaluated in order to convince the General Medical Council, when it next decides to offer guidelines on medical teaching, that global health should be an indispensable part of student training. The demand for global health teaching is in our view already present, some educational materials are also available, but the supply of teachers is the uncertain variable at the moment. Resolving this problem needs leadership and commitment from the GMC, and also from public health and other departments across the United Kingdom.

MORRIS CARPENTER/PANOS
The effects of war and poverty: A British nurse working for the humanitarian agency Merlin, measures a malnourished baby in Afghanistan

Medact is an organisation of health professionals undertaking education, advocacy, and research on the health impacts of conflict, environmental degradation, and poverty.

1. Brundtland GH. Speech at United Nations Associations Global Leadership Awards. New York, USA; April 19, 2001. www.medact.org/tbx/docs/Bateman%20-%20Bringing%20global%20issues%20to%20medical%20teaching.doc (accessed 11 Jun 2002).
2. Bateman C, Baker T, Hoornenborg E, Ericsson U. Bringing global issues to medical teaching. Lancet 2001;358:1539-42.
3. Heck JE, Wedemeyer D. A survey of American medical schools to assess their preparation of students for overseas practice. Acad Med 1991;66:78-81.
4. Bandaranayake DR. International health teaching: a survey of 100 medical schools in developed countries. Med Educ 1993;27:360-2.
5. Peel Berlin A, Piachaud J, James E. Medical students should be taught to appraise evidence on global health issues. BMJ 1996;312:907-8.
6. Edwards RE, Rowson M, Piachaud J. Teaching international health issues to medical students. Med Educ 2001;35:807-8.