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Global Health Program Director's Guide: Chapter 3

Chapter Authors: Tania Condurache, MD, MSc, Heather Lukolyo, MD, MHS & Jennifer Watts, MD, MPH

Key Points

enlightenedGH emphasizes the health of all people, both internationally and locally. 

enlightenedLocal GH topics encourage trainees to “think globally, act locally” in the care of underserved children and migrant populations. 

enlightenedUnique competencies are required for pediatricians to care for local global pediatric populations, including refugees, immigrants, internationally adopted children, and victims of human trafficking. Competency-based objectives for local GH training programs are offered in this chapter.

enlightenedChallenges inherent to the development of community partnerships need to be mindfully considered and discussed with institutions, partners, and trainees. 

 

The term “global health” is intentionally not “international health,” because the field emphasizes the health of all, regardless of location or ethnicity. Many of the educational objectives and practical learning that are met through GH experiences — such as an appreciation for social determinants of health, a preventive focus, and engagement with vulnerable populations — can be met through immersive experiences in underserved communities domestically. It is notable that:

  • The overall health of the U.S. population continues to rank low on many measures compared with 29 other developed countries, including infant mortality rates.13,14
  • One in five U.S. children lives in poverty.15
  • Ethnic minority children have higher rates of many chronic illnesses (asthma, obesity, developmental delay) and hospitalization than their white counterparts, even after controlling for socioeconomic characteristics, including poverty and parental education.16,17

Additionally, there are unique health considerations for migrant populations (travelers, adoptees, refugees, immigrants, and victims of human trafficking), summarized in Table 5.

 

 

Given the magnitude of health disparities in the United States and the health-related implications of human migration, it is apparent that pediatricians must be carefully trained to provide comprehensive, coordinated, culturally and linguistically effective care for diverse U.S. pediatric populations.18,27,28 To do so, many residency programs offer domestic or “local global” experiences,29 loosely defined here as a 1- to 6-week community/field elective with clinical and nonclinical components, with an emphasis on topics such as public health, socioeconomic and political sciences, medical sciences, and health management. A local GH elective should be designed to equip pediatric trainees with the tools, resources, knowledge, and ethical conduct needed to identify and address causes of suboptimal health outcomes for underserved populations and improve health equity in U.S. communities. 

“My career goal is to work in primary care with underserved populations. The global health opportunities allow us to learn about caring for patients in resource-poor settings, both nationally and internationally, so we feel more comfortable in practice when confronted with various scenarios. It is valuable to experience medical practice outside the walls of Children's to see how patients are cared for elsewhere and also expand our knowledge on how to improve care in other settings.”

- Anonymous trainee

Opportunities to consider for local GH field experiences include but are not limited to the following:

  • Clinical experiences: federally qualified health center clinics, public health department sites, specialty clinics serving underserved populations, travel clinics, international adoption centers, child abuse centers, foster care clinics, Native American Reservation clinics, rural underserved clinics
  • Community site visits: organizations working with refugees, immigrants, and underserved populations, including Family Health Clinics, refugee resettlement agencies, Job and Family Services offices
  • Guided visits: shelters, family drug court, food banks, substance abuse and recovery programs
  • Home visits: accompany case workers assigned to refugee families
  • Shadowing of clinical interpreters
  • Tutoring: English as a Second Language (ESL) classes, training sessions for refugees on U.S. health care, exercise and nutrition classes
  • Poverty simulation: trainees use specific tools to travel by public transportation to a patient’s neighborhood and assess the environment, available grocery options, quality of green spaces, etc.

An example of a 1-week local GH elective schedule provided by Cincinnati Children’s Hospital Medical Center and Children’s Mercy Kansas City is in Appendix D.

Challenges of Local Engagement

Challenges to effective local engagement need to be mindfully addressed by institutions, community partners, GH educators, and trainees, as definite harm can be done with unethical, non-sustained, and/or paternalistic pursuits with community partners, both locally and internationally.30 These real and perceived barriers can include but are not limited to:

  • Process-related issues (need for permits, bureaucratic barriers, etc)
  • Lack of time/infrastructure/funding to support community partnerships
  • Skepticism from community partners
  • Trainee misperception of lesser importance/glamor/meaning/value of local engagement compared with international engagement
  • Trainee misperception that local projects are more difficult to complete.

The process of developing and sustaining a mutually beneficial, ethically sound community partnership is outside of the scope of this chapter, but such partnerships are a fundamental foundation for successful trainee community engagement.

The author team offers local GH competency-based objectives for integration into pediatric training programs (Table 6) to be paired with GH objectives that were previously described in Chapter 2. Notably, there are some areas of overlap between the objectives provided in Chapter 2 and those in Table 6. This is intentional, but the author team opted to highlight the local GH objectives in this chapter as a separate entity to assist programs that are creating this specific arm of their GH training infrastructure.

Competency-based Objectives for Resident Participants in Local Global Health Electives

 

 

Citation: St Clair N, Abdul-Mumin A, Banker S, Condurache T, Crouse H, Helphinstine J, Kazembe P, Lukolyo H, Marton S, McQuilkin P, Pitt M, Rus M, Russ C, Schubert C, Schutze G, Steenhoff A, Uwemedimo O, Watts J, Butteris S. Global health in pediatric education: an implementation guide for program directors. American Board of Pediatrics Global Health Task Force Publication, in collaboration with the American Academy of Pediatrics Section on International Child Health and the Association of Pediatric Program Directors Global Health Learning Community. September, 2018. abp.org/ghpdguidehome