Global Health in US Medical Education: A Focus on Israel and Palestine

Global Health in

US Medical Education: A Focus on Israel and Palestine

David McRay, MDDirector of Maternal-Child HealthJohn Peter Smith Hospital Family Medicine ResidencyFort Worth, TX

Texas Tech University Health Sciences CenterSeptember 28, 2012

What is global health?

• Am J Public Health 2006; 96:67-72• Global Health

• Attempt to understand and reduce health disparities at home and abroad

• Working collaboratively with other communities and countries to improve community health locally and globally

• Learning about health issues that transcend geographic borders and commonly present a greater burden to disadvantaged populations


• How is it different from “international health”?• Houpt, et al. Acad Med 2007; 82(3): 222-5• “Global health” stresses “the global

commonality of health issues that transcend national borders, class, race, ethnicity, income, or culture.”

• Disease patterns vary geographically but the factors that foster disease onset are often the same.

• Rise of NCDs highlights our “sameness”


• How is it different from “international health”?• Director General of the World Health

Organization:• “In the past, desperate conditions on another

continent might cynically be written out of one’s memory. The process of globalization has made such an option impossible. The separation between domestic and international health problems is no longer useful.”

• Speech in New York, NY – April 19, 2001

• “Global” emphasizes “sameness”• “International” emphasizes “differences”

Why is global health education important and popular?

• Fam Med 2011; 43(1):21-28• Expansion of global travel and trade• Risk of rapid transmission and spread of

infectious diseases (e.g. HIV, Avian flu, H1N1)

• Common and increasing burden of NCDs• Increasing immigration


• Acad Med 2009; 84:320-325• Increasing travel and migration has led

to a “globalization” of disease• Physicians must understand:

• Global burden and epidemiology of disease

• Disparities and inequities in global health systems

• Importance of cross-cultural sensitivities


• United States• 40 million residents who were born

abroad • 13% of US population

• 1,161,000 people immigrate to the US annually• 25% of US population growth

• 60 million US residents travel abroad annually• Increasing number to “developing” or

majority-world countries

Why is global health education increasing in the US?• ACGME annual report• US medical students are increasingly

interested in volunteering and global health electives• 2007 – 26.3%• 2011 – 30.5%

• Seeking experiences in cultural awareness and cultural competence• 2007 – 47.2%• 2011 – 69.1%

Why is global health education increasing in the US?

• ACGME annual report• US medical students with experiences in a

“free clinic” for an underserved population• 2011 – 70.8%• This question was not asked in prior years

• US medical students perception of their education in:• Health care systems – 2011 – 37.1% “inadequate”• Global health issues – 2011 – 38.1% “inadequate”

• Down from 43.3% in 2007

Why is global health education increasing in the US?

• Since 2000, 23.1% of all US medical students have participated in international training annually• Fam Med 2011; 43(1):21-28

• More than 25% of US medical school graduates enter residency training with some international health experience• Acad Med 2009; 84: 320-325 – Drain, et al

• Nearly all medical schools have incorporated some form of global health teaching into their curricula

Global Health Education in Family Medicine

• 300 of 450 FM residency programs offer exposure to global health• Some have GH electives without didactics or faculty

support• Some have formal programs with international travel

with faculty mentors (like JPS)• 90 programs are listed in the AAFP directory

• www.aafp.org/international/residencies

• AAFP Global Health Workshop

Global Health Education in Pediatrics

• Pediatrics 2011; 128(4): e959-965• 2010 publication of a 2007 survey of pediatric

residency graduates• 59% - global health training was available• 21% - participated• 22% - global health training was essential or

very important in selecting a residency• 30% - definitely/very likely to work/volunteer

in a “developing” country after residency

What is global health education/training?

• Acad Med 2007; 82(3): 222-5• Three domains of competency in global health

education: recommendations for all medical students – Houpt, et al• Global burden of disease• Traveler’s medicine• Immigrant health

• But, no standardized curriculum exists for medical schools or residencies (Drain, et al)

Strategies to meet global health interest of medical students

• Drain, et al. Academic Medicine 2007; 82 (3): 226-30• Integrate global health topics into core medical

curricula• Offer courses on global public health and tropical

medicine• Offer various elective courses, e.g. medical

anthropology, international development and health, or health and human rights

• Establish a global health pathway or track to recognize international experiences and training

• Offer combined degree programs (e.g. MD/MPH) in global health

Strategies to meet global health interest of medical students

• Drain, et al. Academic Medicine 2007; 82 (3): 226-30• Provide academic, logistic, and financial support for

international rotations• Establish a global health administrator or office

within the medical school• Form international partnerships with developing-

country institutions• Create more scholarships and financial support for

international exchanges• Make an international clinical rotation a routine part

of medical education

What do graduates DO with global health training?

• Long-term (career) work in majority world country

• Short-term volunteer• “missionary medicine”

• Consultants• Educators• WHO, UN, etc.• Travel medicine• Refugee care• Underserved populations in US• Better citizens – locally and globally

John Peter Smith Hospital Family Medicine Residency

• Strong interest in international travel and health among residents

• Provision made for international electives• Faculty participation in international trips• Development of rural/international track• Change of focus/name to “global health”• Development of global health fellowship

(P4 program)

JPS FMR Global Health Sites

HaitiPalestine

Thailand

Russia

Mexico

Ghana India

Uganda

John Peter Smith Hospital Family Medicine Residency

• Current options:• Thailand – 2-4 weeks• Haiti – 7-10 days• Palestine – 4 weeks• Russia – 1-2 weeks• Mexico (El Paso, TX) – 1 week• Ghana – 4 weeks• Uganda – 3-4 weeks• Others – Ethiopia, Papa New Guinea• [India]• Institute for International Medicine

(http://www.inmed.us/)

JPS Global Health Elective to Palestine

• Origins• 1969 or 1972• 2000• 2004• 2009

• Goals• Improve understanding of health systems

(“systems-based care” – ACGME)• Introduction to the humanitarian and health care

consequences of military occupation and oppression

JPS Global Health Elective to Palestine

• Structure• One month• 6-7 family medicine residents and/or medical students• Visits to hospitals and clinics throughout the West Bank

(and briefly in Israel – Beer Sheva and Jerusalem)• Lectures and conversations

• Expectations• Introductory historical/political reading• Lancet series on health care in Palestine• Participation in lectures and small group conversations• Write two essays• Make a presentation to peers after return

oPT (Palestine)

“West Bank” and GazaPopulation – 3.9 million (1.4 million in Gaza –

360 sq km, twice the size of Washington D.C.)Poverty – 67% in WB, 88% in Gaza

Less than 2.7 USD/day for a family of four50% rely on donor food for some of daily food need

Unemployment – 27% in WB, 40% in GazaHealth (UNICEF, 2007)

Infant mortality – 25.3Under 5 mortality – 28.2Stunting – 10%Maternal mortality – 11

Qalqilya

Nablus

Ramallah

Bethlehem

Hebron

Juzoor Foundation for Health and Social Development• Juzoor – “Roots” in Arabic• Palestinian NGO -founded in 1996

• Improve the health and well-being of Palestinian families

• Promote health as a basic human right• Focus

• Impact health and social policies• Provide continuing professional

education/development• Empower communities

Juzoor Foundation for Health and Social Development• Opportunities through Juzoor

• Qalqilya Hospital - UNRWA• Princess Aliya Hospital in Hebron – MOH• Al-Makassed Hospital in Jerusalem – NGO – Islamic

Charitable Society• Augusta Victoria Hospital in Jerusalem – NGO –

Lutheran World Federation• An Najah University Medical School - Nablus• Refugee Camps – outpatient clinics• Other formal educational experiences

• Meetings with MOH official• ALSO course in Jericho and Bethlehem• Ethics education

Qalqilya – West Bank

Qalqilya Hospital

Qalqilya Hospital - OR

Qalqilya Hospital - ER

Qalqilya – Separation Wall

Princess Aliya Hospital - Hebron

Al Makassed Hospital - Jerusalem

Al Makassed Hospital - Ethics

Juzoor Foundation for Health and Social Development

• Opportunities through Juzoor• Qalqilya Hospital - UNRWA• Princess Aliya Hospital in Hebron – MOH• Al-Makassed Hospital in Jerusalem – NGO – Islamic




Augusta Victoria Hospital - Jerusalem

Augusta Victoria Hospital - Ethics

An Najah University Faculty of Medicine

UNRWA Health Centers

ALSO - Jericho

Ethics Education Workshop

oPT (Palestine)

• Palestinian Medical Relief Society• Grassroots, community-based,

non-profit• 1979 – group of Palestinian

doctors and health professionals – to supplement the decayed and inadequate health infrastructure

• Many national health programs focusing on the needs of the most vulnerable (women, children, disabled, and poor in rural villages, refugee camps, and urban centers)

• 26 primary care clinics• 8 mobile clinics• Emergency centers• Laboratories, pharmacies,

school-based clinics• School of Community

Health

oPT (Palestine)

Holy Family Hospital in Bethlehem – NGO – Sovereign Order of Malta Leading obstetric and

neonatal facility in Palestine >3000 deliveries per year Almost 50,000 deliveries

since reopening in 1989 18 bed NICU Operated by standards of

the Royal College of Obstetrics and Gynecology

Outcomes comparable to institutions in US and UK

ACGME Competencies

Patient CareOutpatient clinics, inpatient wards, ED, hospice,

mobile clinicsCommon medical problems, as well as illnesses

related to the patients’ circumstances – trauma, infection, malnutrition, etc.

Medical KnowledgeAcross the life cyclesEnd-of-life care, mobile (Bedouin and Palestinian),

traumaCommunity Health

Community health assessment, use of resources, development of specific programs to meet needs, health education

ACGME Competencies

Practice-based Learning and ImprovementInterpersonal and Communication Skills

Across cultural/ethnic/linguistic/socioeconomic barriers with patients, families, and other healthcare providers

ProfessionalismChallenges – people groups, political situations,

historical contexts, cultural interactionsConsider issues of fairness and justiceTest ability to respond with sensitivity and integrityDidactic exercises to strengthen/test ability to

identify and discuss core ethical issues

ACGME CompetenciesSystems-based Practice

Introduced to complex, new systems of careIsrael

National healthcare systemRegional primary care-based systemCentral leadership role of family physiciansConsiderations of cost and advocacy

PalestineFour components of the system

• Ministry of Health of the PA• NGOs• UNRWA• Private

Evaluate the effectiveness of primary care and role of family physicians

Plans and Questions – Sept 2008

• First trip in March, 2009• Start small – one or two residents, one or two

medical students• Housing – limited options in Beer Sheva• Funding

• Travel costs• Eventually need funds to reimburse BGU Department of

Family Medicine for time spent teaching• How to recruit medical students?

• March 2009 – 2 JPS residents and 1 student• March 2010 – 6 JPS residents• March 2011 - 1 JPS resident and 5 students• March 2012 – 3 JPS residents, 2 students, 1 PT• Increasing opportunities for clinical

involvement• Ethics curriculum• Advanced Life Support in Obstetrics• Develop family medicine curriculum at Al

Quds University Medical School in Jerusalem• Family Medicine residency at An-Najah

National University in Nablus

Update

JPSHFamily MedicineGlobal Health Elective in Israel and Palestine

Expansion - 2012

Resources for Global Health

American Academy of Family Physicians

AAFP – Center for International Health Initiatives

AAFP – Global Health Workshop

Global Health Education Consortium

Thank you

Questions?

Global Health in US Medical Education: A Focus on Israel and Palestine

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