Peter Nicholas Kazembe, MBChB, FRCPC
Associate Professor, Baylor College of Medicine
Executive Director, Baylor College of Medicine Children’s Foundation Malawi

I am glad to see this long overdue comprehensive guide for pediatric global health program directors and other interested stakeholders in international health. In this age of the “Global Village,” none in our profession can be insulated from the health issues that affect those who reside in mostly resource-poor environments.

I write from the perspective of one who has been at the head of an African, U.S. university-affiliated institution that has been host to dozens of international scholars, mostly from North American universities, for both short-term as well as longer-term global health attachments. I have also hosted elective students from United Kingdom and European universities and so can draw some contrasts.

Over the years, what has become clear is the importance of pre-departure briefing for the trainees so that expectations are realistic and managed. It is informative that the one GH attaché that we had to prematurely send back home to the United States during a period of more than 20 years was one who made his own arrangement for an elective placement. This is obviously something that has to be avoided.

In the pre-departure course it is important that the potential attachés are sensitized to some of the challenging and sometimes ethical issues they may face, including the frustration of dealing with critically ill children whose lives would otherwise have been saved by access to equipment that would have been available in the home institution. A good example of this is the lack of mechanical ventilation possibilities in neonates and infants. Or they may sometimes be expected or asked to perform beyond their capability or training (after all, being a doctor in a resource-limited environment is supposed to be an indication that you are able to be a “jack of all trades” in medical care). Dealing with the death of multiple children during the course of one shift is not something that can be effectively taught in a lecture, but it is certainly an issue that time should be spent on, especially in sites where the neonatal and child mortality rates may be high, as is the case in most of the popular international placement facilities.

Based only on a foreign application letter for placement, those of us at international sites are not in a position to assess a candidate’s suitability for an elective placement. We depend on the home institutions to make the necessary evaluation for suitability of the placement, with special attention paid to an individual’s cultural sensitivity and not just their enthusiasm to work in an international setting or clinical acumen. The much talked about “cultural shock” cannot always be predicted by the global health program director, but they are better placed than the host institution’s director to “sieve out” the ones least likely to cope in a new environment that is often less organized or supportive.

It is important that the short-term global health electives or attachment should be planned in such a way that there is visible mutuality of benefit for all three parties: the individual GH scholar, the home institution, and the host institution. The benefit to the individual and the home institution are easier to see in terms of exposure to a wide range and numbers of pathologies, polishing of clinical skills, and exposure to different cultures. For the home institution, a global health track in pediatrics is a good selling point for the faculty to attract applicants, and the diversity of the international exposure of their trainees certainly enriches the curriculum. As for the host institution, there are also educational benefits where the visiting scholars are expected to present at journal club, participate in the training of medical students, give opinions on how differently particular cases could have been handled in their more-resourced institution, or even assist in developing job aids for nurses and paramedics. In addition, the more senior resident attachés also contribute to the clinical care of patients. Some short-term scholars have asked in advance what small items they can bring from the United States for use in the clinic where they would be working -- this can be anything from stickers for children to transcutaneous oxygen monitors. Some European university programs have actually established a small fund for students on electives overseas to utilize to buy something for their host institution. All are designed to make a contribution to the functioning of the host facility.

The ideal collaborative set-up would of course be a bidirectional partnership arrangement whereby scholars from the host institution also go to the United States. This is usually not possible, partly because of financial constraints but also more importantly because of stringent U.S. regulations regarding who is allowed to manage patients in the United States. A close surrogate could be an “educational tour” as opposed to a clinical one, for clinicians from a host institution to gain an appreciation of what it is possible to achieve with “state of the art” resources at the elective scholar’s home institution. Such an arrangement of course can only be a reasonable expectation if there is a long-term memorandum of understanding (MOU) between the two institutions for developing each other’s capacities. An MOU is essential to avoid unnecessary misunderstanding, as it clearly sets out each party’s responsibilities and encourages accountability from all parties involved.

From our experience with short-term GH scholars, four to six weeks seems to be the most popular elective duration, and four weeks are the minimum for meaningful interaction and benefit for both sides; the longer, the better for the host institution. It takes time to get people acclimated to the new work and social environment, especially for those who have not previously traveled outside the United States. The scholars often need to use translators if they are left with a patient on their own (it’s not always possible to have a supervisor all the time); it can take time to get comfortable with each other; it might take a week at least to understand the clinic flow and also to understand the various documentation that may be needed for patient management.

In the environment in which we work, most of the health care is managed by paramedics and clinical officers (the equivalent of a physician assistant in the United States). It is important that the scholars give them due respect. There are a lot of very competent and experienced clinicians among them; however, there is sometimes a tendency for them to have the perception that they are looked down upon by visiting scholars, and the scholars need to be sensitive about this perception. It can lead to a less fruitful stay. Another issue that is sometimes sensitive can be the form of address, which can so easily lead to people taking offense. Some people don’t like being referred to by their first name and prefer the surname; scholars should be counseled to learn how the people they are working with wish to be addressed, and this of course works both ways.

Visiting scholars need to be aware that the local clinic staff may not be familiar with some of the North American terminology, I have in mind basic titles like resident and fellow. Under the British system, there are no residents; these are registrars and the fellow is a very senior academic, often one who has completed specialty training. This clarification is particularly important to ensure that the local staff expectations are in line with the individual’s stage in training to reduce the chance that they will be asked or expected to perform procedures that may be beyond their capability.

Of course, a good number of these points I raise are covered to various extents in the chapters of this document, which is a very useful resource for those coordinating and managing the expanding specialty of Global Health in Pediatric Education. I would like to congratulate and thank the leadership of the American Board of Pediatrics Global Health Task Force, the Association of Pediatric Program Directors Global Health Learning Community, and the American Academy of Pediatrics Section on International Child Health for developing this useful resource.