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

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

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  1. Global Health in US Medical Education: A Focus on Israel and Palestine David McRay, MD Director of Maternal-Child Health John Peter Smith Hospital Family Medicine Residency Fort Worth, TX Texas Tech University Health Sciences Center September 28, 2012

  2. 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

  3. What is global health? • 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”

  4. What is global health? • 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”

  5. 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

  6. Why is global health education important and popular? • 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

  7. Why is global health education important and popular? • 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

  8. 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%

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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)

  14. 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

  15. 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

  16. 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

  17. 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)

  18. JPS FMR Global Health Sites Russia Haiti Palestine Thailand Mexico India Ghana Uganda

  19. 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/)

  20. 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

  21. 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

  22. oPT (Palestine) • “West Bank” and Gaza • Population – 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 four • 50% rely on donor food for some of daily food need • Unemployment – 27% in WB, 40% in Gaza • Health (UNICEF, 2007) • Infant mortality – 25.3 • Under 5 mortality – 28.2 • Stunting – 10% • Maternal mortality – 11

  23. Qalqilya Nablus Ramallah Bethlehem Hebron

  24. 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

  25. 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

  26. Qalqilya – West Bank

  27. Qalqilya Hospital

  28. Qalqilya Hospital - OR

  29. Qalqilya Hospital - ER

  30. Qalqilya – Separation Wall

  31. 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

  32. Princess Aliya Hospital - Hebron

  33. Princess Aliya Hospital - Hebron

  34. 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

  35. Al Makassed Hospital - Jerusalem

  36. Al Makassed Hospital - Ethics

  37. 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

  38. Augusta Victoria Hospital - Jerusalem

  39. Augusta Victoria Hospital - Ethics

  40. 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

  41. An Najah University Faculty of Medicine

  42. 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

  43. UNRWA Health Centers

  44. 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