Medical students, medical schools and international health

Many groups aim to deliver targeted contributions to foreign clinics and hospitals, often in the form of basic medical supplies and infrastructure. If hospitals or clinics identify items in short supply, students can deliver these personally during their elective terms. Recent contributions include birthing kits for women in Vietnam and Madagascar (Wake Up!, University of Newcastle), medical equipment for Lady Willington Hospital in northern India (TIME, University of Queensland), and efforts to equip a health care centre for orphans in Chiboba, Zambia (Victorian Students Aid project, University of Melbourne).

Other groups raise funds to support existing health care systems. HOPE (Griffith University) has supported the construction of a medical centre in Ghana (Box 3). Other organisations address determinants of poverty; for example, SANTE (James Cook University) has delivered pens, pencils and books to schools in Papua New Guinea.

Although student groups are aware of their limited capacity to transform the root causes of poor health and the negative effects of globalisation, they believe their efforts can make a meaningful contribution.

Clearly, student organisations must remain mindful of any potential negative effects of their activities, and develop processes to ensure that donations are appropriate and delivered effectively.6 We believe it is vital to work in partnership with existing health care structures, to avoid creating parallel health systems and to respect local autonomy.

Student organisations can also have particular difficulty sustaining long-term relationships. For example, MSAP has provided medical equipment to the Queen Elizabeth Hospital in Malawi for only 4 of the past 6 years, owing to year-to-year variation in the availability of elective students. This experience underpins the importance of SIHOs’ committing to a small and achievable number of partner hospitals.

Student organisations have achieved great success in the university and broader community. SIHOs enhance community awareness by helping students, other health care workers, and the general public to engage with global health inequality. They also focus students’ attention upon the broader social, political and economic contexts of disease. In the past year, Ignite (Monash University) held a photo exhibition promoting international health awareness, and Insight (University of Adelaide) has held forums on HIV/AIDS and Women’s Health in the Middle East. MSAP holds an annual project launch, with invited keynote speakers (Box 4).

Medical students develop personal and professional skills as they lead their organisations. Fundraising projects develop skills in advocacy and persuasion. Students learn to chair meetings, work as a team and manage finances. Others use creative skills through marketing and publicity. We believe that skills learned by students will equip them to serve the poor throughout their careers, whether overseas or locally. Already, alumni of MSAP have worked as medical volunteers in Papua New Guinea, Burma, Malawi and East Timor.

The three most prominent functions of medical schools are teaching, research and clinical service.7 A fourth concern — social justice — often receives less attention. In 1995, the World Health Organization emphasised the importance of “social accountability” in medical schools, citing an “obligation to direct . . . education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve”. 8 Some authors argue that, when a society confers resources and privileges on medical schools, they must in turn serve the greater social good.9,10

Medical schools have a moral duty to prepare doctors who can care for Australia’s disadvantaged populations. As the world becomes more interdependent and aware of global health inequalities,11 wealthy nations such as Australia arguably also have a moral duty to consider the interests of their poorer regional neighbours.12

A curriculum that emphasises international health will facilitate teaching on many issues that are relevant to Australian medical practice. Houpt and colleagues have argued that medical schools must identify certain domains of international health competency that can be taught to all students.13 These include knowledge of the global burden of disease, travel medicine and immigrant health. Cross-cultural health and refugee health are highly relevant to caring for Australia’s immigrant community. International health also provides an excellent vehicle for promoting general principles of social justice. Schools may also develop additional elective subjects for students with a particular interest in global health. Teaching on public health, tropical medicine, anthropology, and human rights could also be expanded.14 Some important diseases, such as avian influenza and multidrug-resistant tuberculosis, require an understanding of public health principles at a global level. For these reasons, a former WHO Director-General has argued that “the separation between domestic and international health problems is no longer useful”.15

Students are increasingly seeking input into the design of curricula. Some authors have argued that medical schools “must listen to [medical students’] views as the consumers and purchasers of medical education”.13 A number of medical students training in Australia will return to low- and middle-income countries, and need to understand the diversity of health care settings. Further, many Australian students are keen to work in international settings during their early careers. Consequently, there is an increased demand for teaching of international health. Where medical schools endorse these approaches, they help students learn cross-cultural medicine, encourage idealism3 and inform students’ future careers.4

Medical schools in Sweden, the UK and the Netherlands have built international health into their curricula.12 In the United States, a consortium of 70 medical schools16 has appraised teaching of international health nationwide, and developed teaching modules to better promote a global health agenda. Medact, a UK group, has also developed communal curricular resources for global health teaching.12

In 2003, the Medical Deans of Australia and New Zealand identified a need to collaborate in regards to standards for electives in developing countries.17 However, the task remains incomplete. There is a great potential for this body to oversee guidelines that support Australia’s medical schools in providing integrated international health curricula. James Cook University illustrates how this might be done. Its offers a subject entirely devoted to international public health (Professor Craig Veitch, Professor of Rural Health, James Cook University, personal communication). James Cook University also maintains links with hospitals in East Timor, Papua New Guinea and Fiji, and provides scholarships for students on overseas electives.

There are many practical ways in which universities can support existing elective programs. Firstly, universities must ensure that they adequately prepare students before they leave and provide appropriate debriefing on return. Many universities provide administrative staff to support elective terms. Other valuable approaches by faculties across Australia include funding scholarships, subsidising vaccines or HIV starter packs, cataloguing previous students’ experiences, and recommending worthwhile destinations. Sydney University’s Hoc Mãi initiative with Vietnam exemplifies a sustainable program operated by a medical faculty to support students during their medical electives and build international cooperation.18

Autonomy and diversity are the great strengths of student groups, yet SIHOs can also learn a great deal from faculty staff with experience in international health. Academics can act as mentors for student leaders, and provide valuable advice about how to run the organisations well. Many student groups invite faculty members to speak at events, and draw on the university community for advice and financial support. It is important, however, that student organisations are not subsumed by faculty programs.

There is considerable scope for medical schools and postgraduate training programs to work together to stream students into careers in international health.19 With expanding graduate numbers in coming years, there is opportunity to develop innovative training pathways. Further research is also required to evaluate student interest and identify what particular skills are required for students and junior doctors to serve overseas long term.