Starting an International Health Curriculum at Your School

Linking International and Domestic Health Care:
by Sara Bhargava, 1998

This guide was created with support provided by BHR/PVC, Bureau for Humanitarian Response, US Agency for International Development (USAID), under the terms of Grant No. FAO-A-00-97-00020-00

I. INTRODUCTION

If you would like to start an international health curriculum at your school or improve one that already exists, use this guide to get started. Working for curriculum change at any institution is difficult, but it has been successfully accomplished by medical students just like yourself in other schools. Use this guide and the work of other students and faculty to develop your own systematic plan for initiating or adding to the international health curriculum at your school. International health curricula are becoming more prevalent at US medical schools. Much of the credit for this growth goes to students working as catalysts for curriculum change.

While this guide focuses specifically on setting up an international health curriculum at your school, keep in mind that most students who will be interested in these courses will also want to travel abroad. Therefore, as you work to create an elective to prepare them to study abroad, you should also look toward creating a travel component as part of your course, or at least create a database of international health travel programs already available. More information on the travel component can be found in many of the resources listed at the end of this guide.

II. WHY IS THE STUDY OF INTERNATIONAL HEALTH SO IMPORTANT?

Today, more than ever, society needs physicians who have a sense of responsibility to those in need, particularly those who lack adequate health care coverage. This idea must extend to encompass an awareness of global health needs. There is much to be learned from studies of the global health care system and the interplay between social, political, and economic factors of a society that affect the incidence of disease and the relationship between health care practices and beliefs. With increased interest in primary health care, international health serves as an important model of the efficacy of using primary care medicine where resources are scarce.

Many students and physicians show little or no interest in international health because they fail to see the practical implications and applications. Demonstrating why and how the study of international health and experiences abroad are important to health care in the US will be critical to the creation and success of your international health course. In addition to preparing students for experiences overseas, an international health course would serve as a valuable introduction to the study of community and public health, primary care, health care for the underserved, epidemiology, as well as infectious and tropical diseases. Specific issues to emphasize in demonstrating the connections between international health and US health care include:

• Some subscribe to the myth that the study of international health only focuses on preventing and treating exotic conditions in foreign travelers. However, since any "exotic" disease is only a plane ride away from the US or any other country, working to eradicate these diseases helps us at home as well.
• Foreign strategies for promoting community health and delivering primary health care can provide valuable lessons for addressing some of the United State's most pressing health care and public health problems.
• International experience and training that expose US doctors to diverse cultures can help them broaden their own cultural perspectives and learn to communicate more effectively with the increasingly diverse patient populations they work with in the US. Almost all health care professionals now treat patients whose cultural, religious, and political backgrounds are far different from their own. To provide effective care, it is essential that they understand the differences in health care beliefs, practices, and expectations.
• Learning about and participating in prevention and intervention strategies abroad will keep us healthier by containing the spread of dangerous infectious diseases. International study experiences may allow students to diagnose and treat diseases that are rare in the US but recently on the rise (e.g., malaria, cholera, and tuberculosis). Also, US students may gain experience in diagnosing and treating diseases that have progressed to advanced stages not often seen in the US. Dr. Silver, a strong advocate of medical study abroad, relates the following insights from his experience abroad:

During my two years at the Muhimbili Medical Centre in Dar es Salaam, Tanzania, I saw many patients with diseases common to the West but presenting initially in advanced stages of the disease. I not only learned how to manage these patients but also saw the consequence of late diagnosis of diseases which are so easily managed in early stages and so difficult to deal with later on. The importance of even routine diagnosis and management becomes apparent and I no longer take for granted the well being of patients with ailments we see almost daily in our practices.

• Working in developing countries with limited resources can provide important lessons for working in similar situations in the US, although the problem here is more likely related to resource allocation rather than lack of resources. Doctors may be able to utilize similar strategies in these diverse situations using minimal resources to expand health care coverage to as many people possible. In addition, learning to work in environments with limited diagnostic and therapeutic resources calls for greater reliance on clinical skills and ingenuity regarding treatment options. This carries over to better and more efficient medical practice upon return to the US.

III. PLANNING

Planning is essential to the success of your new international health elective. During the process remember not to reinvent the wheel. Look to other programs and organizations to find out how they have done things and what problems they have encountered along the way that might be avoided. Keep in close contact with your associates in other institutions as you develop your program. The AMSA International Health Action Group (IHAG) and the International Health Medical Education Consortium (IHMEC) run email listserves that may provide a good forum for questions and project updates (see Resources section at the end of this guide for their web sites). Sharing your successes or problems with other programs and vice versa may help you inspire and encourage each other along the way. Necessary phases of any curriculum change plan include:

Assess Need - Before beginning to create a plan for curriculum change, determine exactly what types of programs already exist at your school. Explore programs and courses not only at your medical school, but also in other graduate and undergraduate university departments (see Appendix B for a listing of some of the 1997 and 1998 courses offered). Also look at opportunities offered by extracurricular organizations. Students are your target group, but keep in mind that they will only participate if they are interested in issues of international health. Gauge this interest before you begin. This interest can later be used to demonstrate need to the administration.

Set Priorities- Define your target audience and their specific interests. Are you going to include undergraduates and other graduate students? If so, clinical aspects of the course may need to be modified for each group. Does it make sense to create an interdisciplinary elective? An interdisciplinary approach may provide more resources and attract more student interest.

Define Goals and Objectives - Based on your needs assessment and analysis of resources and barriers, define a goal and realistic objectives. Create a timeline by which to meet each objective. When writing objectives, be specific and realistic. Make your objectives measurable, and direct your statements toward outcomes. Use active words. Always keep sight of your objectives, your target group, the resources you have available, and the barriers which might exist. This will insure that you will be organized in your approach and will appear that way to the faculty, administration, and public whose support you seek to gain.

Develop Program Support - One of your first, most important steps, is to identify classmates and/or other students interested in helping you. This is essential, unless you are the one and only medical student on the planet with an endless amount of free time. Are there student groups, such as local AMSA chapters or international health/medicine interest groups (remember to check in the School of Public Health if your school has one), who might want to take this on as a project?

Examine the process of curriculum change at your school and find out about the organization and composition of the curriculum committee. Which members of the committee are likely to support your plan and help you to develop it further? If your curriculum committee has student members, get to know them, present your ideas, and find out if there is an opportunity for you to serve on the committee.

Contact people in local nursing, physician assistant, dental, and public health programs to try to find other supporters to help you organize the course. These allied health professionals can provide different perspectives to consider and help you tap into a larger pool of resources.

Consider other circumstances or needs specific to your school. Are there local agencies which may be of value to you in the development of your new curriculum? Find national and/or local contacts for the World Health Organization (WHO), Centers for Disease Control (CDC), World Bank, Red Cross, Rotary International, UNICEF, etc. Consider other local resources, such as church missionary groups, practicing physicians with international experience, and other returned international volunteers (e.g., Peace Corps). Faculty that share an interest in international health, community medicine, cultural diversity can serve as your most important resources.

Contact Physicians for Social Responsibility (web site listed in Resources section), AMSA, and IHMEC to find local chapters or local members. Also try posting an introductory flier for Residents at your school. Many of them have international health experience they can share. Residents often have tight schedules but might be able to answer some questions and help point you in the right direction. They may be willing to come share their international health experience with your group.

Identify Resources

• Financial - Will the school fund such a course, and if so, which departments would be most likely to help? Often departments - the office of student affairs, the dean's office, etc. - can provide in-kind donations (e.g., copies, faxes, phone calls, parking passes for guest lecturers) even though they can not provide direct funding. Be diligent in seeking out this kind of support.
• Facilities- What building and room space is available?
• Human Resources -Contact any department that may be remotely interested in international health. Possibilities include, but are not limited to: family medicine, preventive medicine, public health, health policy, epidemiology, sociology, anthropology, biology, medicine, infectious disease, tropical medicine, public policy, maternal and child health. Determine specific people to be contacted in each department.

The Study Abroad Component - While gathering all of this information during the planning stages, start a database of international health opportunities. Those students interested in taking your class will probably also be interested in studying overseas, and making opportunities for overseas travel available (or at least information about them) may help stimulate interest among students as well as post-graduates.

For more ideas on how to go about the planning process for your international health elective, see the case study in Appendix A from the Medical University of South Carolina College of Medicine.

IV. ACTION

Confirm Support and Find a Faculty Advisor - Make sure you have contacted everyone you identified as possible resources and confirm their support. One of your most important supporters will be your faculty advisor. Working with someone "on the inside" will give you a great advantage as you work to gain support from the administration. Take the time to choose this person carefully, and remember that you will be working very closely with them. Look for someone with substantial international health experience. This person should be willing to field questions from the administration as well as the public. Finding an advisor with a secretary or assistant is useful because he/she may be able to help you with scheduling speakers, making copies, booking rooms, etc. Also, the advisor you choose will play a critical role in determining the longevity of your program. When you leave the school, you want to be confident that your advisor is committed to continuing and improving the program.

Establish Administrative Support - Discuss with your dean of students the steps for registering your new course and issuing credit. One possibility is to use a directed reading or independent study classification, which will already have an established course number. It helps to have a syllabus ready, along with any reading or referenced articles to give to your registrar and/or dean. You can obtain sample syllabi for international health courses at other schools (see Appendix B). Plan for students to write a paper at the end of the course covering a topic from the lecture series or an international health experience and its impact on their subsequent education. Such a paper may make the powers that be more willing to grant credit for your elective. Adding a service component to the course, like working in a local agency involved with international health, may help you gain support from the administration. It promotes a good image for the school: students concerned about an issue in their community and doing something about it.

Find Speakers - Ask interested faculty, physicians, or other community members to come and speak at one session each to share their insights about their international health experiences and comment on specific topics from your curriculum plan. You may ask the advisor to be present at all sessions in order to serve as the professor for the course.

Logistics to Consider - Find out if there is a specified time frame for electives at your school. Lunch time generally works well for most students and faculty. If you are bringing in outside speakers, once a week in the early evening often works well for most people. Make sure the lecture location is easily accessible to students and faculty.

Establish Interest and Sign Up Students - Many schools have some kind of activities fair in the fall that provides a good initial opportunity to sign students up for the course. Present the course as an important preparation for anyone interested in doing an overseas clinical elective. Set a limit for the number of students allowed in the course, and create a sign-up deadline in order to increase interest and accelerate commitment.

Arranging some type of hands-on experience, preferably as the service component mentioned earlier, could increase the popularity and success of your course. Students could volunteer at a health care facility that uses interpreters and serves refugees or an otherwise diverse patient population. This will give students a first-hand introduction to the practice of cross-cultural medicine and the language and culture barriers faced by health care providers in the US. It will also emphasize the relevance of international health to health care in the US.

It is okay to start small and expand as interest increases and your program becomes more established. If it makes things easier, the course can at first be organized as a small group discussion session where students take turns researching and presenting material with an occasional guest speaker. The advisor serves as a resource that is present but does not necessarily give "lectures" at each session. This will minimize your need for outside resources and support at first.

V. CONCLUSION

You will inevitably face obstacles along the way as you begin to develop your curriculum. Some people will never see the practical relevance of international health to the practice of health care in the United States. Remember to stay in close touch with your student and faculty contacts at other schools that have already been through the process and can give you suggestions and support. Keep sight of your goals and your timeline, and give yourself credit for small steps. Good luck!

Some topics you may want to include in a basic international health curriculum:

• Demographics: the relationship of age, income, resources, health spending, literacy, etc., to health and disease
• Basic epidemiology (This can also be a way to sneak international health into your school's regular basic science curriculum by encouraging them to use case studies with an international health theme to teach about epidemiology.)
• Overview of health indicators such as infant mortality, incidence, prevalence, quality of life, and comparison of these indices among sites in the US and developing countries
• Cross-cultural health beliefs/practices (may want to break this down into individual areas such as Africa, Latin America, China, India)
• Maternal and infant health
• Immunizations
• Sanitation/water sources
• Basic nutrition/malnutrition
• Essential drugs
• Economics/politics of health care and health systems management
• Primary and community health care
• Health problems specific to developing countries
• Infectious and tropical diseases
• IDS epidemic, other sexually-transmitted diseases
• Malaria prevention, treatment
• Diarrheal diseases/parasites/oral rehydration therapy
• Family planning/population growth
• Effects of government and private sector on health status
• Illness vs. disease
• Varying roles of the physician and other health care workers
• Traditional/alternative medical practices
• Geographic, cultural, environmental factors in disease/mortality occurrence
• Basic statistical, economic, epidemiological planning models
• Appropriate technology/technology transfer
• Ethics of international health

Tom Hall, IHMEC (International Health Medical Education Consortium) member from the University of California at San Francisco, is currently developing an international health bibliography organized into 40 different international health topics and meant to serve as a core reading list for international health curricula. The list is due for final review in late spring 1998, and will hopefully appear on the IHMEC web site soon after that (see Resources section for web address).

The IHMEC Curriculum Committee is starting a project to create a "tremendous International Health Curriculum resource" on their web site and is looking for new members to join the Curriculum Committee and help with this project. Joining IHMEC and its Curriculum Committee is a great way to get yourself and your institution "in the loop" to start your own curriculum. Contact information for IHMEC is listed in the Resources section at the back of this guide.

Organizations/Groups

IHMEC Headquarters (membership inquiries and change of address)
IHMEC Secretariat, c/o Dept of Medicine, Indiana University School of Medicine, M200, Wishard Hospital, 1001 West 10th St, Indianapolis, IN 46202 / Tel: (317) 630-7091 / Fax: 317 656-4230 / Email: info@ihmec.org

The National Council for International Health (NCIH)
1701 K Street, NW, suite 600, Washington, DC 20006-1503
(202) 833-5900; fax (202) 833-0075; email: ncih@ncih.org

Publications
Various publications are available online through AMSA.

The following three publications are available from IHMEC. Write to IHMEC Secretariat, c/o Department of Medicine, Indiana University School of Medicine, M200, Wishard Hospital, 1001 West 10th Street, Indianapolis, IN 46202

1. Preparing for International Health Electives; A Mini-Guide to Resources
2. Foreign Language Study and International Health Work: Selected Resources
3. Creative Funding for International Electives

Other publications:

• Krogh C, Pust R. International Health: A Manual for Advisors and Students, Society of Teachers of Family Medicine, 8880 Ward Parkway, P.O. Box 8729, Kansas City, Missouri, 64114. (800) 274-2237.
• Wotton K, et al. Basic Concepts of International Health Module. 1995, Canadian University Consortium for Health in Development (CUCHID), 170 Laurier Avenue, West, Suite 902, Ottawa, Canada, K1P 5V5. (613) 230-2654.
• Wotton K, Cosway N. Orientation Guide for International Health Electives. 1995. Also available from CUCHID at the above address.

Several publications available from the Intercultural Press provide practical advice about various aspects of cross-cultural encounters. Publications list available from P.O. Box 700, Yarmouth, Maine, 04096.

Web Resources
Most of these sites contain extensive resource lists and links to other important international health sites.

• International Health Medical Education Consortium (IHMEC) contains a list of annotated international health web sites
• The National Council for International Health (NCIH)
• Centers for Disease Control (CDC)
• US State Department (for travel advisories)
• American Society of Tropical Medicine and Hygiene
• Institutional Links, UCLA School of Public Health, Department of Epidemiology
• Web site for the "supercourse" in epidemiology, the internet, and global health for medical and nursing students
• Pan American Health Organization includes country health profiles and technical information on international health topics
• Physicians for Social Responsibility
• National Association of Foreign Student Advisors (NAFSA) contains useful resources for addressing safety issues in study abroad

1. Health Education Personalized!, AMSA and Wayne State University School of Medicine, 1993.
2. Heck, J and Pust, R. "A National Consensus on the Essential International-health Curriculum for Medical Schools," Academic Medicine. 68(8), August 1993, 596-598.
3. Heck, J and Wedemeyer, . "International Health Education in US Medical Schools: Trends in Curriculum Focus, Student Interest, and Funding Sources," Family Medicine. 27(10), Nov-Dec 1995, 636-640.
4. Pust, R and Moher, S. "Medical Education for International Health; The Arizona Experience," Infectious Disease Clinics of North America. 9(2), June 1995, 445-451.
5. "Links: Examining the Relationship Between International and U.S. Health Care," an AMSA/Options international health newsletter. Spring 1998. No.2.

CASE STUDY:
The Development of an International Health Curriculum at Medical University of South Carolina College of Medicine

The following description comes from a poster presentation for the 1998 IHMEC Conference in San Jose, Costa Rica. The poster presenters are:

• Jinlene Chen, Second-year Medical Student at MUSC and AMSA Co-chair
• Carol R. Savage, Ph.D., Assistant Dean for Student Academic Programs at MUSC

This poster presentation describes the efforts and emerging systematic plan to develop an international health curriculum at a conservative, tradition-bound medical school in the southern United States. One presenter is a second-year medical student whose summer experience in Cali, Colombia through an AMSA-sponsored program motivated her to return and work at developing courses in medical Spanish for other MUSC medical students. The other presenter is an assistant dean, who for several years has responded to student requests for international resources for summer experiences and fourth-year clinical electives. The information provided will describe steps in a classic change strategy model used in higher education.

1. Testing Interest Level and Building a Support Base. A twelve-week elective course on Introduction to International Study was offered in fall 1997, which attracted 25 medical students. Committees were formed to explore three areas of interest; fourth-year clinical electives; fundraising to support international travel; and developing a resource file of activities and information related to international experiences.
2. Identify Potential Resources and Persons with Similar Interests. The assistant dean surveyed the Medical University to identify faculty, administrators and others who needed to be filled in on potential plans, or who had similar goals and objectives. Numerous faculty members were identified who had volunteered internationally, or who had good connections with international universities and medical schools. The beginnings of a resource data bank accessible to students was found.
3. Develop a Proposal and Use Volunteer Pilot Efforts to Provide Data. Topics of special importance and interest to medical students were identified, and include: medical Spanish; cultural sensitivity and competency issues in patient care; tropical disease medicine; and a comparison of systems of medical service delivery in other countries. A spring semester elective course will sample some of these topics. A model for an elective curriculum in international health will be developed, using information provided by medical school programs involved in the IHMEC organization, and using our own trial experiences and evaluative comments to refine the model.
4. Implementation and Funding Strategy. The above mentioned activities require minimal additional funding and depend on volunteer efforts from interested students and faculty. As the program develops, a funding source for a part-time program manager, and to secure faculty teaching time will be required. Additionally, funding to support student international travel is important to make international experiences equitable for all. As the International Program is systematically developed, program evaluation data and student interest will be used to convince MUSC administrators, corporate funders and foundations to support the effort. At that time, several years of data and comments from those who participated in elective coursework will be available to support program expansion.

Why Develop a Program in International Health at MUSC?
International health experiences create a powerful impact on the overall professional education and career goals of medical students. In the words of one first-year student who participated in the fall 1997 International Study class, "It is inspirational and educational to hear about how doctors and students donate their time internationally while struggling with medical school classes South Carolina." Another wrote, "Being exposed to many people on campus that are from other countries and have traveled abroad has been wonderful. Their experiences give me great excitement and motivation to go on my own medical adventure."

The Farmer's Almanac provides some compelling information on the "global village". Currently, the earth's population is approximately 5.7 billion people. Population explosion has meant that there is a monthly increase equal to the number of residents of New York City. If we could shrink the earth's population to a village of precisely 100 people, but all of the existing human ratios remained the same, our world would look like this:

• 57 Asians; 21 Europeans; 14 people living in both Americas; 8 Africans
• 70 of the 100 people would be persons of color
• 70 of the 100 would not be Christians
• 50% of the entire world's wealth would be owned by only six people, and all six would be citizens of the United States
• 70 persons would be unable to read
• 50 persons would suffer from malnutrition
• 80 persons would live in substandard housing
• one person would have a college education

There are clear links between pressing health care issues and the needs of underserved populations in the United States, and in second- and third-world countries. As Richard Preston put it in The Hot Zone, "All of the earth's cities are connected by a web of airline routes. The web is a network. Once a virus hits the net, it can shoot anywhere in a day - Paris, Tokyo, New York, Los Angeles, wherever planes fly." The alarming rise of TB in South Carolina, as well as the explosive expansion of infectious disease in this country, increases the importance of prevention through information and positive health teaching. A class member commented, " Studying abroad is a great way to make students more aware of medicine and life in its 'rawest' form, and at the same time, help us appreciate the great facilities we have here in the US."

There are major shortfalls in medical school curricula that address cross cultural and global health issues, as well as deficiencies in the preparation of students for culturally-sensitive community interactions. Another first-year student wrote, "International Medicine allows one to experience clinical medicine, appreciate different cultures, gain personal insight, and become aware of the interconnectedness and beauty of humanity."

To respond to these needs, and because of the increasing requests for assistance from students who wished to plan international volunteer experiences, an Independent Study course in International Study was offered in spring 1997. This course led to the fall 1997 activities described below:

Spring 1997 MDCOR 601 Elective Course
A two-session Independent Study Elective course was offered for medical students in March and April 1997. The purpose of the course was to provide an introduction to international experiences for a group of ten first-year medical students who were planning organized volunteer activities during the summer of 1997. One group of six first-year students participated in a Global Volunteers camp in Tanzania, another student spent the summer in England studying the hospice movement, several students participated in mission trips to Central America, and one student participated in an eight-week AMSA surgery program in Cali, Colombia. These students were given three credits (pass/no pass) for their participation, and were required to keep a journal or photo diary to document their experiences. They were also asked to describe their experiences before other groups of medical students.

Fall 1997 MDCOR 601 Elective Course
The Independent Study Elective Course in International Study was expanded too a twelve-week course, meeting from September to December at 4-5:30 on Tuesday afternoons. A total of twenty-two students enrolled and attended regularly. Each week speakers presented information on international experiences, including individually-designed student trips, student group experiences, and mission trips that included groups of students and faculty members. Several faculty members spoke on their professional and clinical international experiences. Part of each class was devoted to resource sharing and each class provided handouts and information about locating, planning, and funding overseas experiences. These handouts were used to augment the file of resource materials that was made available for students. At the conclusion of the class in December 1997, several students had located and accepted a summer experience, and a group of 20 first-year students was exploring another Global Volunteers African experience. The class was very highly rated by all students, and a wish list of further offerings and activities was developed.

International Follow-up Activities
Susan Jones, from the International Programs Office, spoke to the MDCOR 601 Class, and provided information on the international employee and faculty database that will be useful for students in identifying mentors and contact persons in other countries. Also, it was agreed that the resource file of program information will be located in a filing cabinet in International Programs for easy student access.

The 1998 version of the International Service Learning Opportunities Directory was provided to all first-year medical students. Updated by Dr. Savage and class members, it provides web sites, program information and details related to organizations that offer international volunteer and clinical contacts. This list is also available in the International Student Office.

Dr. Savage and several students joined the International Health Medical Education Consortium (IHMEC), which is a group of faculty, students and medical schools that teach international health. This group provides names and protected clinical elective sites, offers an excellent newsletter and a yearly conference to bring interested participants together to share and develop programs in international health. Over 225 individual faculty members and 40 medical school institutional members have joined this organization. IHMEC will provide valuable assistance in expanding international offerings at MUSC.

Plans for the Future
The positive evaluations and success of the above mentioned classes and activities have identified the need for an organized program of international health activities for medical students at MUSC. In class discussions we have identified topics of special importance and interest to medical students. Medical Spanish, cultural sensitivity and competency issues in patient care, tropical disease medicine, and a comparison of systems of medical service delivery in other countries are topics of particular interest.

We propose a spring semester elective course of approximately eight weeks in duration that would sample some of these topics, and raise the level of participation and information above the "show and tell" introductory nature of the fall course. Several students, including the co-chair of AMSA, are working to develop a model syllabus for medical Spanish that will be tried out in a four-week format. They are identifying volunteer presenters, and student participation activities to be used on a pilot basis. We hope to add some speakers who can address cultural sensitivity and competency in medical practice, a topic of increasing interest in the Charleston area.

A survey of students and faculty will be done to assess interest in International Health topics, including proposed course offerings, volunteer and clinical opportunities abroad. The College of Medicine will be polled, as well as other Colleges of MUSC.

During the spring semester we will develop a model for an elective curriculum in international health, using information provided by medical school programs involved in the IHMEC organization and using our own trial experiences to refine the model. Courses can be offered on an Independent Study basis to medical students, and other students at MUSC using a pass/no pass grade method. There is no additional charge for fully -enrolled students, yet the course is registered on the academic transcript, which provides a good motivation for students.

The above mentioned activities require minimal additional funding, and depend on volunteer efforts from interested students and faculty. Student interest and enrollment in elective courses, and the results of the student/faculty survey will be used to document the need for program expansion.

At that time, a funding source for a part-time program manager, and to secure faculty teaching time will be required. Additionally, funding to support student international travel is important to make international experiences equitable for all. As the International Program is systematically developed, program evaluation data and student interest can be used to convince MUSC administrators, corporate funders, and foundations to support the effort. A pamphlet called Creative Funding for International Health Electives is provided by IHMEC, and contains other useful suggestions to secure funding. All these sources will be creatively tapped for program expansion support, using several years of data and comments from those who participated in elective coursework and activities for documentation of need.

INTERNATIONAL HEALTH COURSES OFFERED IN 1998 (list provided by IHMEC)

1. University of Arizona, July 13-31, 1998. International Health in the Developing World. Open to senior medical students planning a health care elective in a developing country. Case-based clinical orientation by physicians and other health care experts experienced in medical and community health problems of tropical countries. Ron Pust, MD, Department of Family and Community Medicine, University of Arizona College of Medicine, 1501 N. Campbell, AHSC, Tucson, AZ 85724, (520) 626-7962.
2. University of Southern California/Baja California, July 3-24, 1998. International Community Health and Medical Spanish. Program in the Mexican state of Baja California for first-year medical students features classroom study of medical Spanish and guided experiences in community health programs and clinics. Family homestay is arranged for participants. Dennis Mull, MD, MPH, Department of Family Medicine, University of Southern California, 1420 San Pablo Street, PMB-B205, Los Angeles, CA 90033, (213) 342-1313.

INTERNATIONAL HEALTH COURSES OFFERED IN 1997
In addition to those above, some of these 1997 courses may still be operating.

1. Boston University. Six courses offered: Management Methods for International Health, Feb. 6-May 2, Drug Policy Issues for Developing Countries, Feb. 14-28, Health Care in Developing Countries, May 31-Aug. 27, Strengthening Public Hospitals, April 7-25, Setting Tomorrow's Agenda: New Directions for Health Policy in Developing Countries, approximately 3 weeks in September, Financing Health Care in Developing Countries, Sep. 18-Dec. 12. Joseph Anzalone, Center for International Health, Boston University, 80 East Concord Street, Room A310, Boston, MA 02118, (617) 638-5234.
2. Case Western Reserve University, Sept. 2-26. Ninth Annual Course in International Health. Introduction and overview of major infectious disease and related problems of developing countries. Multi-disciplinary approaches to health management such as primary health care and nutrition assessment. Intended primarily for house officers, also open to other health workers with backgrounds in biomedical sciences or clinical medicine. An Advanced Course in Tropical Medicine and Parasitology is provisionally scheduled for Oct. and Nov., to follow the 9th Annual Course. Thomas Daniel, MD, Center for International Health, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4978, (216) 368-6321.
3. University of Connecticut, two courses, Sept. 9-Oct. 4. Workers' Health and Safety and Environmental Health and Developing and Managing Community-Based Rehabilitation Programs. Open to participants from developing countries. Colleen Foster-Bey, Center for International Community Health Studies, Department of Community Medicine, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-6330, (203) 679-1570.
4. Emory University in coordination with the Centers for Disease Control and Prevention, Oct. 7-Nov. 1. International Course in Applied Epidemiology. Emphasizes epidemiologic principles for work in developing countries. Philip Brachman, MD, School of Public Health, Emory University, 1518 Clifton Road, 7th Floor, NE, Atlanta, Georgia 30322, (404) 727-0199.
5. George Washington University, several programs offered on a flexible basis throughout the year, with emphases placed on international health and development and professional skills formation. Rosalia Rodriguez-Garcia, MD, George Washington University Center for International Health, 605 Ross Hall, 2300 Eye Street, NW, Washington, DC 20037, (202) 994-5682.
6. Johns Hopkins University School of Hygiene and Public Health, July 8-Aug. 26. Summer Institute in Tropical Medicine and Public Health. Tropical health and medicine and social and behavioral foundations of primary health care in developing countries. May be applied for credit for the Johns Hopkins MPH program. Heather Roth, Coordinator, Johns Hopkins School of Hygiene and Public Health, 615 N. Wolfe Street, Department of International Health, Room 5521, Baltimore, MD 21205, (410) 614-3959.
7. Johns Hopkins/University of Maryland, April-May 1997. Tropical Medicine and International Health. Lectures, seminars, site visits and laboratory demonstrations covering major diseases of the developing world. Clinically-oriented, intended principally for fourth-year medical students, the course is also appropriate for health professionals such as nurses. Draws upon resources of two institutions. Clive Shiff, MD, Johns Hopkins Hospital, Division of Infectious Diseases, 1159 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205, (410) 955-1263.
8. Tulane University, Aug.-Dec.1997. Diploma Course in Clinical Tropical Medicine and Traveler's Health. Lecture/laboratory coursework in tropical medicine with emphasis on practical applications for diagnosis. Participants may also rotate through traveler's health and infectious diseases clinics. Richard A. Oberhelman, MD, Tulane University School of Public Health and Tropical Medicine, Department of Tropical Medicine, 1501 Canal Street, 5th Floor, New Orleans, LA 70112, (504) 588-5199.
9. Uniformed Services University of the Health Sciences, Feb. -May 1997. Clinical Tropical Medicine and Traveler's Health. Comprehensive coverage of principles and practice of clinical tropical medicine and traveler's health. Course format includes lectures, laboratories, seminars, and participation in a traveler's clinic. Captain Larry Laughlin, Department of Preventive Medicine and Biometrics, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4799, (301) 295-3732.
10. West Virginia University, July 1-Aug. 29. Clinical Tropical Medicine and Parasitology. Lecture and laboratory multidisciplinary approach to clinic training in tropical medicine and public health. A limited number of two-month overseas field opportunities are available to course participants. Nancy Sanders, International Health Program, Robert C. Byrd Health Sciences Center, P.O. Box 9164, West Virginia University, Morgantown, WV 26506-9164, (304) 293-5916.

There are additional International Health courses coordinated by North American schools in developing countries. Contact IHMEC for a list of these courses.

AMSA would like to thank the following reviewers: Audrey Bernfield, M.D., Cynthia Haq, M.D., Molly Martin, Kavita Patel, Ronald E. Pust, M.D., Carol R. Savage, Ph.D., Arthur W. Silver, M.D., Carl Taylor, M.D., Kate Tulenko, Pninit Varol, Donald Wedemeyer, M.D., Calvin Wilson, M.D., Judy Zerzan