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The Future of International Health:
Exporting Primary Care Medicine
Over the last few decades, there has been great progress in
international health with infant mortality rates declining and
average life spans increasing. However, there is a down side
to these positive trends. The World Health Organization (WHO)
predicts that by the year 2020, there will be more than 690 million
people over the age of 65, in contrast with today's 380 million.1 This change will be even more dramatic for
poorer nations as more than two thirds of the elderly will be
in developing and underdeveloped nations. The increase in the
elderly population will cause a major change in the disease patterns
of these countries. There will be increasing rates of cancer,
kidney failure, eye diseases, diabetes, mental illness and other
chronic, degenerative illnesses such as cardiovascular disease.
The health care systems of these nations are ill equipped to
deal with this transition. Unless steps are taken now, it is
becoming more and more clear that this could become tomorrow's
health care crisis for the world.
- What is
the future of global health?
- Why should
physicians care about international health?
- How can
medical students become more involved?
STUDENT ORGANIZERS GUIDE
Medical students are in an ideal position to take measures to
prevent such a crisis. By working in an international health
setting and practicing preventive medicine, medical students
can make an impact on the general health of a nation and its
people. This Project-in-a-Box will provide the tools necessary
to take action: a description of the changing demographics of
the world, steps to working abroad, and general information on
international health.
This Project-in-a-Box provides information on the topic of
primary care and international health and suggests how medical
students can become involved in practicing medicine internationally.
It also gives tips for medical students to better educate themselves
and their medical school community on issues relevant to international
health.
Educate Yourself and Your
Peers
The following are events or activities that medical students
can do to prepare themselves for an international health experience:
- Read about current international health issues in medical
journals. A great start would be the annual World Health Report.
Check out the reference section of this project-in-a-box for
the bibliography information on the 1997 and 1998 World Health
Reports.
- Learn a foreign language, such as Spanish or Hindi, that
may be helpful to an international experience. Learning another
language or simply reading about another culture can greatly
improve physician-patient interactions.
- Invite speakers to discuss their international experiences.
Local physicians and fourth-year medical students are great resources
for this. International health organizations, listed in the resource
section of this Project-in-a-Box, may also be able to suggest
local speakers.
- Raise funds or collect medical equipment for underdeveloped
countries: REMEDY <http://gasnet.med.yale.edu/~remedy/>,
Child Family Health International <www.cfhi.org>,
and American Medical Resources Foundation <www.amrf.com>
are a few of the many programs that are involved with donating
medical equipment to needy hospitals overseas.
- Take an international health course or encourage your school
to offer one.
- Try to volunteer at an "international health clinic"
- many urban communities have clinics set up specifically for
minority and immigrant patients who do not have access to other
forms of health care and/or they do not speak English. This type
of clinic can be a great place to volunteer because of the culturally
diverse patient population.
Serve Internationally
- Medical students should plan to serve internationally during
the summer after the first year of medical school and/or as an
elective during the fourth year of medical school. Traditionally,
students opt to go abroad during their fourth year because they
find that they can better utilize the clinical knowledge they
gained during their third year of medical school. However, there
are benefits to an earlier international experience. If a medical
student decides to go after his or her first year of medical
school, he or she will probably get to observe and even perform
medical procedures that he or she wouldn't normally observe or
perform until the third year of school.
- Identify a source of funding. Volunteering as a medical student
in a foreign country can be expensive. However, it doesn't have
to be. Students can raise the money by asking for donations from
community groups such as churches, clubs, companies, and individual
citizens. Various organizations are also willing to pay for a
portion, if not all, of the expenses. Check out the guide entitled,
Creative Funding for International Electives, found on
the AMSA web page. <www.amsa.org/programs/ih/creative.htm>.
Another great resource for funding information is the International
Healthcare Opportunities Clearinghouse webpage <library.ummed.edu/ihoc/funding.html>.
The resource section of this Project-in-a-Box also lists several
organizations that you can contact for funding.
- Before leaving, medical students make sure that they are
medically insured and have received all the appropriate vaccination
shots. The Centers for Disease Control and Prevention (CDC) has
an online guide, Health Information for International Travel,
to determine which vaccinations are needed for the country you
will be traveling to. <www.cdc.gov/travel/yellowbk/home.htm>
Online Resources for Medical
Students Interested in International Health Opportunities
- Global Health Network
- <www.pitt.edu/HOME/GHNet/l>
-
- AMSA's International Health Resources
- <http://dev.www.amsa.org/global/ih/ihres.cfm>
-
- International Health Action Group
- <http://www.amsa.org/global/ih/>
-
- International Healthcare Opportunities Clearinghouse
- <http://library.ummed.edu/ihic>
-
- World Health Organization
- <www.who.org>
-
- Center for International Health Information
- <www.cihi.com>
Part 1: The World Is Changing
The world is undergoing a dramatic change in demographics. In
1997, the global average life expectancy at birth reached 68
years,1 while in 1955, the average was
only 48 years. People are living longer than ever before because
of preventive health measures and improved medical technology.
The international health community has played a major role in
improving the global average life expectancy by providing health
care to many underdeveloped communities, improving sanitation,
and immunizing most of the world's children against the six major
diseases of childhood - tuberculosis, measles, poliomyelitis,
diphtheria, pertussis, and neonatal tetanus. During the past
50 years, global infant mortality has been reduced by half. As
a result, it is expected that by the year 2025, there will be
800 million people over the age of 65, with two thirds of them
in developing countries.2
The number of people aged over 65 will rise from 390 million
in 1997 to 800 million in 2025 - from 6.6 percent of the population
to 10 percent (World Health Report, 1997).
Part 2: Implications for
Physicians and Primary Care Medicine
The shift in global demographics brings with it a shift in global
health. With the increase in the number of elderly people, there
will be an increase in the number of diseases typically found
in the elderly. Chronic diseases such as cancer, circulatory
diseases, mental disorders, and respiratory conditions, strike
later in life. As people live longer lives, health professionals
around the world will see more elderly patients and more cases
of chronic disease. This will become especially difficult for
developing and underdeveloped nations to handle because they
lack resources in the area of health care and health care for
the elderly. These nations will face a "double burden"
in that they will continue to suffer the negative effects of
chronic disease in addition to infectious disease.
The increase in patients with chronic disease also is due
to the lifestyle changes taking hold in these underdeveloped
nations. Tobacco, alcohol, bad diets, and violence have been
spreading from the Western world to the underdeveloped world
and have created havoc wherever they go. Marketing campaigns
heavily target underdeveloped countries to promote and sell their
tobacco and alcohol products. In a recent study, it was found
that annual tobacco-related deaths exceeded two million, and
by the year 2025, that number is projected to approach 10 million
- with the majority of deaths occurring in underdeveloped nations.
The international health community predicts that the problem
with chronic disease cases in the elderly could become so bad
that by the year 2025, money could be diverted from already tenuous
primary care and preventive programs to programs addressing this
problem.3 This, in turn, could reverse
the positive trends made by preventive health measures, such
as the infant mortality rate, and cause increased death in both
the elderly and young populations.
How can these nations prevent such a health crisis? The solution
lies with medical students, the next generation of physicians.
The international community will need their expertise in primary
care medicine because many of these chronic diseases are without
cures. The emphasis will be on prevention. As the 1997 World
Health Report states, "If the majority of chronic diseases
cannot as yet be cured, the emphasis must be on preventing their
premature onset, delaying their development in later life, reducing
the suffering that they cause, and providing the supportive social
environment to care for those disabled by them." In short,
medical students must ensure that individuals are healthy now
so that they will remain so tomorrow. Physicians and medical
students will have to approach patients in the international
setting in much the same way as they approach patient's at home.
They must begin to counsel international patients on matters
such as diet, alcohol and drug use, safe sex practices, and decreasing
exposure to environmental hazards.
"Chronic diseases, with a few exceptions, have not so
far lent themselves so easily to cure. They are less open to
community action. They do not spread from person to person. Every
case of chronic disease represents a burden borne by one individual
who, depending on circumstances, may or may not have access to
treatment or support" (World Health Report, 1997).
Why Should U.S. Physicians
Care about International Health?
There are two reasons why international health should be an important
issue for American physicians and physician-students. The first
reason is because international health affects American health.
Because viruses are not immune to borders, a virus found in Asia
can easily travel to America and result in a serious health epidemic
for this country. The second reason invokes the sense of social
responsibility that comes with the health care profession and
its status in society. Medicine is about helping others in need;
often the people who need the most help are overseas.
Future physicians must realize that infectious disease is
not necessarily a "foreign problem," it is something
that affects the health and economy of this country. Recently,
the United States witnessed an outbreak of Lyme disease, hanta
virus, and cryptosporidium, and the re-emergence of diseases
that were thought to be under control, such as malaria and tuberculosis.4 For example, In 1993 the organism cryptosporidium
parvum caused the largest water-borne disease outbreak in the
United States. The outbreak led to 403,000 cases of infection
with 44,000 health care visits and 4,400 hospitalizations in
Milwaukee, Wisconsin.4
The return of infectious diseases to America is a result of
the increase in international travel and trade, changes in the
environment, such as deforestation and urbanization, and the
increase in drug-resistant infections due to the use of antibiotics.6 The CDC reports that in the U.S., one third
of all patients infected with tuberculosis, are foreign-born
individuals. Furthermore, they are more likely to be resistant
to the common tuberculosis treatments.
The huge financial burdens of infectious diseases are another
reason for U.S. concern. Annually, the U.S. spends $120 billion
dollars in treatment costs for infectious diseases. Their prevention,
on the other hand, can be extremely cost effective. The eradication
of smallpox in 1977 cost a total of $32 million dollars: an amount
that is returned to the United States every 26 days. It is also
calculated that every dollar spent on the vaccine against measles,
mumps, and rubella saves $21.
The toll of infectious disease on the U.S. health and finances
should mobilize physicians into action, but it is important to
remember the pressing issue at hand - the need of underdeveloped
nations and its citizens for medical assistance. The bottom line
to the debate over "Why U.S. physicians should care about
international health?" comes down to the basic spirit for
humanitarianism and kindness that physicians carry.
U.S. physicians and medical students who practice medicine
internationally are rewarded by their experiences because they
get practical training in the area of cultural competency. When
these doctors and students return to the United States, they
are much more effective at treating their minority patients.
The United States is also rewarded by these returning health
professionals because many of them, according to a recent study
at Tulane Medical School, become committed to serving in underserved
communities in the United States.
"In 1995, The U.S. spent 1 percent of its gross
national product on foreign aid - the lowest percentage among
industrialized nations. Surprisingly, a recent survey indicates
that Americans believe that the country should spend 15 percent
of the federal budget on foreign aid (an amount 15 times greater
than is actually spent)."
- America's Vital Interest in Global Health5
A recent study at Tulane Medical School found that students
who had participated in overseas experiences were four times
more likely than traditional medical students to work with an
underserved community in the United States.6
Why Should Medical Students
Care About International Health?
Medical student may be wondering why they should consider an
international rotation. Here are a few reasons to consider:
- Students can make a difference in the community you work
with.
- Students can learn the skills to work with a diverse population
of patients (a skill that is becoming increasingly important
in the U.S.)
- Students can gain exposure to many rare diseases, not often
found in the U.S.
- Students can improve your history taking and physical examination
skills.
- Students can learn more about another country.
- Students can gain a great sense of accomplishment and fulfillment
from the work they do.
Culturally Sensitive Medicine
When traveling to another country, many students are almost immediately
struck by the new sights, sounds, and smells. Medical student
will continue to experience the new culture, language, and people
inside the doors of the clinic. How medical students choose to
deal with these differences will shape the quality of their work
with their patients, and make them a better physician when they
return home to the culturally diverse, United States. Here are
a few tips to being learning how to become culturally sensitive:
- Understand and respect the culture of the patients being
treated. Different cultures carry with them different belief
systems. These belief systems tend to impact their views on medicine,
physicians, and medical treatments. For example, many Asians
rely on Chinese traditional medicine for cures to long term ailments,
while Western medicine is relied upon for cures to acute illnesses.8 In some other cultures, people tend to keep
illnesses to themselves, and delay seeking medical assistance.
- Recognize that family may be very important to your patients.
For many cultures, such as Africans, Asians, and Hispanics, family
is an important institution, which becomes even more important
during times of illness. Immediate and extended family may play
a critical role in medical decision making as well as in the
financial and emotional support of the patient.
- Speak to the patient, not to the translator. Learning a foreign
language can be a big plus to the experience abroad. However,
if a medical student needs to use a translator to communicate
with patients, it is important to maintain eye contact with the
patient and speak directly to him or her - not the translator.
But remember that in some cultures, it is very disrespectful
to look in the eyes of another person.
- Avoid Stereotypes - Not everyone from an ethnic group or
religious creed practices or believes in the same things. In
other words, don't assume that all Asian patients go to an acupuncturist
every week or that all Hispanic patients use herbal medicine.
ADDITIONAL RESOURCES
Programs and Organizations
with International Volunteer Opportunities
For an even more extensive list, check out AMSA's international
health web page at <www.amsa.org/programs/ih/ihopps/ihopps.htm>
- Doctors Without Borders
- 6 East 39th Street, 8th floor, NY, NY 10016
- (212) 679-6800
- www.dwb.org
-
- International Medical Volunteers
- P.O. Box 205, Woodville, MA 01784
- (508) 435-7377
- www.imva.org
-
- Project Hope
- Dr. Robert Crone, Senior Vice President
- Medical Operations
- Millwood, VA 22646
- (540) 837-2100
- www.projecthope.org
-
- Amigos de las Americas
- 5618 Star Lane, Houston, TX 77057
- (800) 231-7796
- www.amigoslink.org
-
- Interaction
- 1717 Massachusetts Avenue NW, Suite 801, Washington, DC 20036
- (202) 667-8227
- www.interaction.org
-
AMSA Publications on International
Health
- Contact: AMSA Resource Center
- (703) 620-6600, ext. 217
- maryjo_l@amsa.org
- Online Catalog
International Health Organizations
and Public Health Resources
- World Health Organization (regional office for the
Americas)
- 525, 23rd Street, NW, Washington, D.C. 20037
- (202) 974-3000
- www.who.org
-
- Centers for Disease Control
- 1600 Clifton Rd, NE, Atlanta, GA 30333
- (404) 639-3311
- www.cdc.org
-
- Child Family Health International
- 2149 Lyon Street, #5, San Francisco, CA 94115
- (415) 206-1905
- www.cfhi.org
-
- National Council for International Health
- 1701 K Street, NW, Washington DC, 20006
- (202) 833-5900
- www.ncih.org
-
Funding Resources
- Academy for Educational Development
- National Security Education Program - Graduate Fellowships
- Scholarships for language study in less commonly studied
countries/regions. May be combined with medical electives.
- Contact: AED/ NSEP Program
- 1875 Connecticut Ave, NW, Ste 900, Washington, DC 20009-1202
- (202) 884-8285 or nsep@aed.org
-
- Rotary Foundation
- Scholarship for graduate study in any field in international
country. Requires a 1-year commitment.
- Contact: Rotary Foundation
- 1600 Ridge Ave, Evanston, IL 60201
- (312) 328-0100
-
- American Bureau for Medical Advancement in China /
Warner-Lambert Clerkship Award
- Contact: Julia C. Grammer, Associate Director
- The American Bureau for Medical Advancement in China
- 2 East 103rd Street, NY, NY 10029
-
- American Medical Women's Association
- Pays up to $1200 for 4th-year students who spend 4-12 months
serving the underserved abroad.
- Contact: AMWA (703) 838-0500
-
- MAP International
- Pays 75 percent of travel costs for 4th-year students and
residents. The fellowship is primarily for Christian missionaries,
but MAP sometimes funds non-missionary trips.
- Contact: MAP
- 2200 Glynco Parkway, PO Box 215000
- Brunswick, GA, 31521-5000
- (912) 265-6010
-
- Minority International Research Training Grants
- Offers grants to minorities in the sciences to do research
or training abroad.
- Contact: Division of International Training and Research
- Fogarty International Center
- NIH, Building 31, Room B2c39
- 31 Center Dr. MSC2220, Bethesda, MD 20892-2220
- (301) 496-1653
International Health Organizations:
What Are They and What Do They Do?
There are many international health organizations that work towards
the goal of improving international health. Below is a list of
three types of international health organizations.8
- Multilateral Aid Agency: A collective body, representing
(such as World Health Organization) many countries, working on
global matters. Tasks include refugee care, setting global health
targets, advising and aiding individual governments, food supplies,
etc.
-
- Bilateral Government Aid: An organization that represents
(US Agency for one country. Functions International Development)
include assisting foreign nations and funding NGO's (non-government
organizations).
-
- Non-Government Organization: A private organization
committed to (Doctor's without Borders) the issue of international
health. Tasks vary depending on the focus of the group. Examples
include emergency relief, family planning, vaccinations, etc.
Their programs are usually smaller than government programs and
typically work independently of local health programs.
REFERENCES
- The World Health Report 1997. Conquering
Suffering, Enriching Humanity. World
Health Forum, 1997.>
- The World Health Report 1998. Life in
the 21st Century-A Vision for All.
World Health Forum, 1998.
- "As Children Survive: Dilemmas of Aging
in the Developing World." Society and Scientific Medicine
28, no. 1 (1989): 59-67
- Hughes, J.M., and Tenover, F.C. "Infectious
Disease Challenges of the 1990s." Infectious Medicine;
13(9): 798-799.
- America's Vital Interest in Global Health:
Protecting Our People, Enhancing Our Economy, and Advancing Our
International Interests. Washington,
D.C.: Board on International Health, Institute of Medicine, 1997.
- Chiller, T.M., De Mieri, P., and Cohen, I.
"International Health Training: The Tulane Experience."
Infectious Disease in Clinical North America 9, no. 2
(1995): 439-443.
- Johnstone, P. "Work in a Developing
Country." BMJ, 311: 113-5.
- Levy, R., and Hawks, J. "Multicultural
Medicine and Pharmacy Management." Drug Benefit Trends
7, no. 3(1996): 27-30.
Disease Trends
- Smallpox - declared eradicated in 1980 after a 13-year
fight against the disease
- Plague - has declined in the last 40 years due to
insecticides and antibiotics; cyclical epidemics still occur
- Cholera - still endemic in some 80 countries
- Chagas - found mostly in the Americas from Mexico
to Argentina; should be eliminated by 2010
- Leprosy - should be eliminated as a public health
problem by the year 2000 as a result of a multi-drug therapy
promoted in the early 1980s
- Measles - still kills almost 1 million children annually;
targeted to be eliminated by the year 2000
- Hepatitis B - 75% of world's population lives in areas
where there are high levels of infection. 2 billion people have
evidence of past or current infection, and 350 million are chronic
carriers of the virus
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