Community & Global Health - Developing Goals & Objectives

A basic understanding of the global burden of disease is an essential part of a modern medical education. This knowledge is crucial for participating in discussions of priority setting, healthcare rationing and funding for health and health-related research. A basic understanding of the global burden on disease would include:

• Knowledge of the major causes of morbidity and mortality around the world, and how the risk of disease varies by region
• Familiarity with major public health efforts to reduce disparities in global health (i.e. Millennium Development Goals, Global Fund to Fight AIDS, Tuberculosis and Malaria, PEPFAR, etc.)
• Ability to skillfully discuss priority setting, healthcare rationing and funding for health and health-related research

Social, economic, and environmental factors are important determinants of health. Healthcare providers should understand how these conditions affect health in order to recognize disease risk factors in their patients and to contribute to improving public health. It is also important to realize that health is more than simply the absence of disease. Critical elements to this include:

• Understanding how social and economic conditions such as poverty, education, literacy, conflict, distribution of wealth, and life styles affect health and access to health care
• Understanding key areas for action to impact social determinants
• Understanding the relationship between access to clean water, sanitation, food and air quality on individual and population health
• Describe the relationship between environmental degradation and human health

Globalization is profoundly changing disease patterns and the availability of healthcare workers worldwide.  Besides the direct effects of diseases, a healthcare system’s ability to meet its’ population’s health needs is now being affected by the migration of both healthcare workers and patients, global agreements, and international institutions.  Key concepts include:

• Understand how global trends in healthcare practice, commerce and culture, multinational agreements and multinational organizations contribute to the quality and availability of health and healthcare locally and internationally
• Understand the implicit and explicit roles of major multinational organizations such as UNICEF, UNAIDS, the Global Fund or efforts such as the President’s Emergency Plan for AIDS Relief in providing healthcare in low-income settings
• Understand the relationship between large pharmaceutical companies and the provision, pricing and distribution of essential medicines globally
• Understand positive and negative consequences of international grants and loans on the long-term planning, stability and healthcare system sovereignty of low and middle-income nations
• Understand how large-scale donors such as the Gates Foundation shape healthcare and global health policies and practices
• Understand the role of the World Trade Organization, advocacy bodies, legal and trade agreements in terms of improving or limiting access to essential medicines across countries or regions
• Understand how travel and trade contribute to the spread of communicable and chronic diseases
• Understand and describe general trends and influences in the global availability and movement of healthcare workers
• Understand the professional, socio-political and economic forces that contribute to healthcare professional exodus from low-resource areas including active recruitment of health personnel, compensation, lack of career opportunities or funding locally, occupational health, and quality of life
• Understand “medical tourism” and the motivations, goals, risks, benefits and ethics behind short-term medical interventions by health professionals from developed countries  in developing countries or patients traveling for medical procedures
• Understand the emerging trend of community-based training of healthcare professionals, and how this approach is affecting traditional medical education and the health workforce crisis

Health care needs and resources markedly differ between high- and low-resource settings, yet much medical training occurs in high-resource settings. To effectively care for patients across a range of settings, healthcare providers working in low-resource settings should:

• Understand the barriers to recruitment, training and retention of competent human resources in underserved areas, such as rural and inner-city communities, and Native American reservations and low-income countries
• Be familiar with the concept of an essential medicines list and its’ role in ensuring access to standardized, effective treatments
• Understand a successful community or village health worker model for providing care
• Be familiar with the concept of traditional healers and examples of how they have or have not been successfully integrated into healthcare teams
• Understand the affect of distance and inadequate infrastructure on the delivery of health care
• Understand the barriers to evidence-based medicine including appropriate prevention and treatment programs
• Understand the advantages and disadvantages of short-term international medical trips (humanitarian missions, medical missions, etc.) on the local community and health system (including the relationship with local providers, sustainability of services, medical tourism, identification of community needs, relationship with local and state governments)
• Understand the ethical issues involved in allowing trainees to practice or assist in settings where they may be perceived and treated as physicians, even by local healthcare providers
• Understand how an aid or research organization’s goals, ideologies and policies may affect local health care services
• Understand how to assess the health care and public health needs of communities and make evidence-based decisions about resource allocation and the delivery of population health services
• Develop the ability to adapt clinical skills and practice in a resource-constrained setting
• Understand the role of syndromic management and clinical algorithms for treatment of common illnesses
• Identify clinical interventions and integrated strategies that have been demonstrated to substantially improve individual and/or population health in low-resource settings – immunizations, essential drugs, maternal child health programs, etc
• Identify cost-effective uses of resources based on international evidence and the needs of the patient population – HIV prevention, cervical cancer screening
• Understand the importance of developing a culturally relevant and effective medical education program for the local community

The appropriate management of patients necessitates taking into consideration perspectives and risks posed by international travel or foreign birth. Relevant key elements include:

• Health risks posed by international travel or foreign birth
• The ability to take an appropriate travel history
• Awareness of how cultural context influences perceptions of health and disease
• The ability to elicit individual health concerns in a culturally sensitive manner when caring for patients
• Familiarity with issues that arise when communicating with patients and families using a translator
• The basic health issues faced by refugees and displaced persons including an overview of international human rights laws

Basic health precautions for traveling in resource-poor settings: water and food safety, personal safety including road traffic accidents, vector-born illness prevention, protecting against environmental exposure and be able to locate information on pre-travel medical preparations.

Human rights impact both individual and population health. Health also is an essential element of economic and social development. To effectively advocate for patients’ and communities’ health based on an understanding of the relationship between human rights, social and economic development and health, the following elements are critical:

• Understand the organizations and agreements that address human rights in healthcare and medical research – The World Health Organization’s role in linking health and human rights, the Universal Declaration of Human Rights, International Ethical Guidelines for Biomedical Research Involving Human Subjects (2002), Declaration of Helsinki (2008)
• Understand the relationship between health and social/economic development