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October 2, 2002

Toward a More Global Medical Education

Author Affiliations

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JAMA. 2002;288(13):1651. doi:10.1001/jama.288.13.1651-JMS1002-5-1

The humanitarian and economic development crises wrought by disease in low- and middle-income countries (LMICs) have garnered increased attention in the past decade. At the same time, increasing numbers of US medical students have become involved in international clinical, research, and public health projects.1 In 2001, 20% of graduating US medical students had completed an international clinical elective, compared to 13.5% in 1991 and 8.6% in 1985.2 However, few formal programs and dependable funding sources for global health training are available to young physicians and medical students.1

The importance of fostering global health solutions stems from the grave and far-reaching consequences of disease in LMICs. Communicable diseases such as HIV/AIDS, tuberculosis (TB), and malaria currently account for 300 million illnesses and 5 million deaths per year, predominantly in LMICs.3 In addition, chronic diseases, such as cardiovascular disease and diabetes, cause death at an earlier age in LMICs than in established market economies, negatively affecting working-age populations.4 Aside from its medical impact, this increased disease burden has enormous political and economic consequences. According to a recent WHO study, better health care, indicated by lower rates of infant mortality, correlates with a higher rate of growth of per capita GDP.5

For these reasons, international and domestic groups are mounting larger efforts to ameliorate the health problems of LMICs. The WHO's Global Fund to Fight AIDS, TB, and Malaria has received $2 billion in commitments from public and private sector sources and has already pledged $616 million to 40 countries.6 In addition, many US leaders now agree that one important way to prevent terrorism is to foster stable democracies through sustained interventions such as increased access to effective health care.7 The federal government has accordingly increased its commitment to global health aid, specifically to fight the HIV/AIDS epidemic in sub-Saharan Africa.8

Expanded programs to improve health care in other countries will require more physicians trained in global health. At present, however, few medical schools offer global health training as part of their curriculum and these programs and students receive little financial support. In 1993 only 35 of 120 US medical schools offered training in global health, with 19 schools offering training during third and fourth years.1 Most global health programs rely on internal institutional support, with no program reporting more than 30% of its funding coming from outside sources.1

The few formal, funded programs that exist have reported a potential to change attitudes and to direct career choices of students and young physicians. The federally funded International Health Fellowship Program provides students with advanced preparation prior to departure for international clinical electives, placement at host sites, and a stipend to defray travel costs. Haq et al9 reported that this experience had a significant positive impact on student awareness of cultural and socioeconomic factors in patient care in both domestic and international settings. More than 90% of the participants intended to spend some time abroad during their careers.1,10 Similar programs for residents at Duke and Yale suggest that participants were more likely than non-participants to choose jobs in public health, or to work with disadvantaged populations. 10,11

Given the growing US commitment to improving health care in other countries, governmental and nongovernmental agencies will need to expand existing programs and create new ones to encourage physicians to pursue leadership roles in global health. Previous efforts to develop leaders in other medical fields have been successful and can serve as models. For example, a majority of medical students who have participated in the fully funded Medical Scientist Training Program go on to obtain faculty-level positions in biomedical research while maintaining active roles in patient care.12 Formal programs providing global health training and financial support could likewise enable talented individuals to pursue careers in global health.

Heck  JEWedemeyer  D International health education in US medical schools: trends in curriculum focus, student interest, and funding sources. Fam Med. 1995;27636- 640
Association of American Medical Colleges, Medical student graduation questionnaire.  Washington, DC AAMC1985, 1991, 2001;
Not Available, WHO Information Office Fact Sheet. Available at: http://www.who.int/inf-fs/en/back001.html. Accessed August 12, 2002.
Murray  CJLLopez  AD Mortality by cause for eight regions of the world: global burden of disease study. Lancet. 1997;3491269- 1276Article
Not Available, Report of the WHO Commission on Macroeconomics and Health. Available at: http://www3.who.int/whosis/cmh/cmh_report/e/htm/021-029/021-029.html. Accessed September 11, 2002.
World Health Organization, Global Fund to Fight AIDS, Tuberculosis, and Malaria. Available at: http://www.who.int/global_fund/en. Accessed August 12, 2002.
Not Available, Building countries, feeling generous. The Economist. June29 2002;
Stolberg  SG Congress awakens to AIDS with a convert's zeal. New York Times. May12 2002;sect 1:1
Haq  CRothenberg  DGjerde  C  et al.  New world views; preparing physicians in training for global health work. Fam Med. 2000;32566- 572
Gupta  ARWells  CKHorwitz  RI  et al.  The international health program: the fifteen-year experience with Yale's University's internal medicine residency program. Am J Trop Med Hyg. 1999;621019- 1023
Miller  WCCorey  GRLalligner  GJDurack  DT International health and internal medicine residency training: the Duke University health experience. Am J Med. 1995;99291- 297Article
Bradford  WDAnthony  DChu  CPizzo  SV Career characteristics of graduates of medical scientist training program, 1970-1990. Acad Med. 1996;71484- 487Article