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The Future of International Health: Exporting Primary Care Medicine

Over the last few decades, there has been great progress in international health with infant mortality rates declining and average life spans increasing. However, there is a down side to these positive trends. The World Health Organization (WHO) predicts that by the year 2020, there will be more than 690 million people over the age of 65, in contrast with today's 380 million.1 This change will be even more dramatic for poorer nations as more than two thirds of the elderly will be in developing and underdeveloped nations. The increase in the elderly population will cause a major change in the disease patterns of these countries. There will be increasing rates of cancer, kidney failure, eye diseases, diabetes, mental illness and other chronic, degenerative illnesses such as cardiovascular disease. The health care systems of these nations are ill equipped to deal with this transition. Unless steps are taken now, it is becoming more and more clear that this could become tomorrow's health care crisis for the world.

  • What is the future of global health?
  • Why should physicians care about international health?
  • How can medical students become more involved?

STUDENT ORGANIZERS GUIDE
Medical students are in an ideal position to take measures to prevent such a crisis. By working in an international health setting and practicing preventive medicine, medical students can make an impact on the general health of a nation and its people. This Project-in-a-Box will provide the tools necessary to take action: a description of the changing demographics of the world, steps to working abroad, and general information on international health.

This Project-in-a-Box provides information on the topic of primary care and international health and suggests how medical students can become involved in practicing medicine internationally. It also gives tips for medical students to better educate themselves and their medical school community on issues relevant to international health.

Educate Yourself and Your Peers
The following are events or activities that medical students can do to prepare themselves for an international health experience:

  1. Read about current international health issues in medical journals. A great start would be the annual World Health Report. Check out the reference section of this project-in-a-box for the bibliography information on the 1997 and 1998 World Health Reports.
  2. Learn a foreign language, such as Spanish or Hindi, that may be helpful to an international experience. Learning another language or simply reading about another culture can greatly improve physician-patient interactions.
  3. Invite speakers to discuss their international experiences. Local physicians and fourth-year medical students are great resources for this. International health organizations, listed in the resource section of this Project-in-a-Box, may also be able to suggest local speakers.
  4. Raise funds or collect medical equipment for underdeveloped countries: REMEDY, Child Family Health International, and American Medical Resources Foundation are a few of the many programs that are involved with donating medical equipment to needy hospitals overseas.
  5. Take an international health course or encourage your school to offer one.
  6. Try to volunteer at an "international health clinic" - many urban communities have clinics set up specifically for minority and immigrant patients who do not have access to other forms of health care and/or they do not speak English. This type of clinic can be a great place to volunteer because of the culturally diverse patient population.

Serve Internationally

  1. Medical students should plan to serve internationally during the summer after the first year of medical school and/or as an elective during the fourth year of medical school. Traditionally, students opt to go abroad during their fourth year because they find that they can better utilize the clinical knowledge they gained during their third year of medical school. However, there are benefits to an earlier international experience. If a medical student decides to go after his or her first year of medical school, he or she will probably get to observe and even perform medical procedures that he or she wouldn't normally observe or perform until the third year of school.
  2. Identify a source of funding. Volunteering as a medical student in a foreign country can be expensive. However, it doesn't have to be. Students can raise the money by asking for donations from community groups such as churches, clubs, companies, and individual citizens. Various organizations are also willing to pay for a portion, if not all, of the expenses. Check out AMSA's guide entitled, Creative Funding for International Electives. Another great resource for funding information is the International Healthcare Opportunities Clearinghouse webpage. The resource section of this Project-in-a-Box also lists several organizations that you can contact for funding.
  3. Before leaving, medical students make sure that they are medically insured and have received all the appropriate vaccination shots. The Centers for Disease Control and Prevention (CDC) has an online guide, Health Information for International Travel, to determine which vaccinations are needed for the country you will be traveling to.

Online Resources for Medical Students Interested in International Health Opportunities

Part 1: The World Is Changing
The world is undergoing a dramatic change in demographics. In 1997, the global average life expectancy at birth reached 68 years,1 while in 1955, the average was only 48 years. People are living longer than ever before because of preventive health measures and improved medical technology. The international health community has played a major role in improving the global average life expectancy by providing health care to many underdeveloped communities, improving sanitation, and immunizing most of the world's children against the six major diseases of childhood - tuberculosis, measles, poliomyelitis, diphtheria, pertussis, and neonatal tetanus. During the past 50 years, global infant mortality has been reduced by half. As a result, it is expected that by the year 2025, there will be 800 million people over the age of 65, with two thirds of them in developing countries.2

The number of people aged over 65 will rise from 390 million in 1997 to 800 million in 2025 - from 6.6 percent of the population to 10 percent (World Health Report, 1997).

Part 2: Implications for Physicians and Primary Care Medicine
The shift in global demographics brings with it a shift in global health. With the increase in the number of elderly people, there will be an increase in the number of diseases typically found in the elderly. Chronic diseases such as cancer, circulatory diseases, mental disorders, and respiratory conditions, strike later in life. As people live longer lives, health professionals around the world will see more elderly patients and more cases of chronic disease. This will become especially difficult for developing and underdeveloped nations to handle because they lack resources in the area of health care and health care for the elderly. These nations will face a "double burden" in that they will continue to suffer the negative effects of chronic disease in addition to infectious disease.

The increase in patients with chronic disease also is due to the lifestyle changes taking hold in these underdeveloped nations. Tobacco, alcohol, bad diets, and violence have been spreading from the Western world to the underdeveloped world and have created havoc wherever they go. Marketing campaigns heavily target underdeveloped countries to promote and sell their tobacco and alcohol products. In a recent study, it was found that annual tobacco-related deaths exceeded two million, and by the year 2025, that number is projected to approach 10 million - with the majority of deaths occurring in underdeveloped nations.

The international health community predicts that the problem with chronic disease cases in the elderly could become so bad that by the year 2025, money could be diverted from already tenuous primary care and preventive programs to programs addressing this problem.3 This, in turn, could reverse the positive trends made by preventive health measures, such as the infant mortality rate, and cause increased death in both the elderly and young populations.

How can these nations prevent such a health crisis? The solution lies with medical students, the next generation of physicians. The international community will need their expertise in primary care medicine because many of these chronic diseases are without cures. The emphasis will be on prevention. As the 1997 World Health Report states, "If the majority of chronic diseases cannot as yet be cured, the emphasis must be on preventing their premature onset, delaying their development in later life, reducing the suffering that they cause, and providing the supportive social environment to care for those disabled by them." In short, medical students must ensure that individuals are healthy now so that they will remain so tomorrow. Physicians and medical students will have to approach patients in the international setting in much the same way as they approach patient's at home. They must begin to counsel international patients on matters such as diet, alcohol and drug use, safe sex practices, and decreasing exposure to environmental hazards.

"Chronic diseases, with a few exceptions, have not so far lent themselves so easily to cure. They are less open to community action. They do not spread from person to person. Every case of chronic disease represents a burden borne by one individual who, depending on circumstances, may or may not have access to treatment or support" (World Health Report, 1997).

Why Should U.S. Physicians Care about International Health?
There are two reasons why international health should be an important issue for American physicians and physician-students. The first reason is because international health affects American health. Because viruses are not immune to borders, a virus found in Asia can easily travel to America and result in a serious health epidemic for this country. The second reason invokes the sense of social responsibility that comes with the health care profession and its status in society. Medicine is about helping others in need; often the people who need the most help are overseas.

Future physicians must realize that infectious disease is not necessarily a "foreign problem," it is something that affects the health and economy of this country. Recently, the United States witnessed an outbreak of Lyme disease, hanta virus, and cryptosporidium, and the re-emergence of diseases that were thought to be under control, such as malaria and tuberculosis.4 For example, In 1993 the organism cryptosporidium parvum caused the largest water-borne disease outbreak in the United States. The outbreak led to 403,000 cases of infection with 44,000 health care visits and 4,400 hospitalizations in Milwaukee, Wisconsin.4

The return of infectious diseases to America is a result of the increase in international travel and trade, changes in the environment, such as deforestation and urbanization, and the increase in drug-resistant infections due to the use of antibiotics.6 The CDC reports that in the U.S., one third of all patients infected with tuberculosis, are foreign-born individuals. Furthermore, they are more likely to be resistant to the common tuberculosis treatments.

The huge financial burdens of infectious diseases are another reason for U.S. concern. Annually, the U.S. spends $120 billion dollars in treatment costs for infectious diseases. Their prevention, on the other hand, can be extremely cost effective. The eradication of smallpox in 1977 cost a total of $32 million dollars: an amount that is returned to the United States every 26 days. It is also calculated that every dollar spent on the vaccine against measles, mumps, and rubella saves $21.

The toll of infectious disease on the U.S. health and finances should mobilize physicians into action, but it is important to remember the pressing issue at hand - the need of underdeveloped nations and its citizens for medical assistance. The bottom line to the debate over "Why U.S. physicians should care about international health?" comes down to the basic spirit for humanitarianism and kindness that physicians carry.

U.S. physicians and medical students who practice medicine internationally are rewarded by their experiences because they get practical training in the area of cultural competency. When these doctors and students return to the United States, they are much more effective at treating their minority patients. The United States is also rewarded by these returning health professionals because many of them, according to a recent study at Tulane Medical School, become committed to serving in underserved communities in the United States.

"In 1995, The U.S. spent 1 percent of its gross national product on foreign aid - the lowest percentage among industrialized nations. Surprisingly, a recent survey indicates that Americans believe that the country should spend 15 percent of the federal budget on foreign aid (an amount 15 times greater than is actually spent)."

- America's Vital Interest in Global Health5

A recent study at Tulane Medical School found that students who had participated in overseas experiences were four times more likely than traditional medical students to work with an underserved community in the United States.6

Why Should Medical Students Care About International Health?
Medical student may be wondering why they should consider an international rotation. Here are a few reasons to consider:

  • Students can make a difference in the community you work with.
  • Students can learn the skills to work with a diverse population of patients (a skill that is becoming increasingly important in the U.S.)
  • Students can gain exposure to many rare diseases, not often found in the U.S.
  • Students can improve your history taking and physical examination skills.
  • Students can learn more about another country.
  • Students can gain a great sense of accomplishment and fulfillment from the work they do.

Culturally Sensitive Medicine
When traveling to another country, many students are almost immediately struck by the new sights, sounds, and smells. Medical student will continue to experience the new culture, language, and people inside the doors of the clinic. How medical students choose to deal with these differences will shape the quality of their work with their patients, and make them a better physician when they return home to the culturally diverse, United States. Here are a few tips to being learning how to become culturally sensitive:

  • Understand and respect the culture of the patients being treated. Different cultures carry with them different belief systems. These belief systems tend to impact their views on medicine, physicians, and medical treatments. For example, many Asians rely on Chinese traditional medicine for cures to long term ailments, while Western medicine is relied upon for cures to acute illnesses.8 In some other cultures, people tend to keep illnesses to themselves, and delay seeking medical assistance.
  • Recognize that family may be very important to your patients. For many cultures, such as Africans, Asians, and Hispanics, family is an important institution, which becomes even more important during times of illness. Immediate and extended family may play a critical role in medical decision making as well as in the financial and emotional support of the patient.
  • Speak to the patient, not to the translator. Learning a foreign language can be a big plus to the experience abroad. However, if a medical student needs to use a translator to communicate with patients, it is important to maintain eye contact with the patient and speak directly to him or her - not the translator. But remember that in some cultures, it is very disrespectful to look in the eyes of another person.
  • Avoid Stereotypes - Not everyone from an ethnic group or religious creed practices or believes in the same things. In other words, don't assume that all Asian patients go to an acupuncturist every week or that all Hispanic patients use herbal medicine.

ADDITIONAL RESOURCES

Programs and Organizations with International Volunteer Opportunities
For an even more extensive list, check out AMSA's international health web page.

AMSA Publications on International Health

Contact: AMSA Resource Center
(703) 620-6600, ext. 217
maryjo_l@amsa.org
Online Catalog

International Health Organizations and Public Health Resources

Funding Resources

    Academy for Educational Development
    National Security Education Program - Graduate Fellowships
    Scholarships for language study in less commonly studied countries/regions. May be combined with medical electives.
    Contact: AED/ NSEP Program
    1875 Connecticut Ave, NW, Ste 900, Washington, DC 20009-1202
    (202) 884-8285 or nsep@aed.org
     
    Rotary Foundation
    Scholarship for graduate study in any field in international country. Requires a 1-year commitment.
    Contact: Rotary Foundation
    1600 Ridge Ave, Evanston, IL 60201
    (312) 328-0100
     
    American Bureau for Medical Advancement in China /
    Warner-Lambert Clerkship Award
    Contact: Julia C. Grammer, Associate Director
    The American Bureau for Medical Advancement in China
    2 East 103rd Street, NY, NY 10029
     
    American Medical Women's Association
    Pays up to $1200 for 4th-year students who spend 4-12 months serving the underserved abroad.
    Contact: AMWA (703) 838-0500
     
    MAP International
    Pays 75 percent of travel costs for 4th-year students and residents. The fellowship is primarily for Christian missionaries, but MAP sometimes funds non-missionary trips.
    Contact: MAP
    2200 Glynco Parkway, PO Box 215000
    Brunswick, GA, 31521-5000
    (912) 265-6010
     
    Minority International Research Training Grants
    Offers grants to minorities in the sciences to do research or training abroad.
    Contact: Division of International Training and Research
    Fogarty International Center
    NIH, Building 31, Room B2c39
    31 Center Dr. MSC2220, Bethesda, MD 20892-2220
    (301) 496-1653

International Health Organizations: What Are They and What Do They Do?
There are many international health organizations that work towards the goal of improving international health. Below is a list of three types of international health organizations.8

Multilateral Aid Agency: A collective body, representing (such as World Health Organization) many countries, working on global matters. Tasks include refugee care, setting global health targets, advising and aiding individual governments, food supplies, etc.
 
Bilateral Government Aid: An organization that represents (US Agency for one country. Functions International Development) include assisting foreign nations and funding NGO's (non-government organizations).
 
Non-Government Organization: A private organization committed to (Doctor's without Borders) the issue of international health. Tasks vary depending on the focus of the group. Examples include emergency relief, family planning, vaccinations, etc. Their programs are usually smaller than government programs and typically work independently of local health programs.

REFERENCES

  1. The World Health Report 1997. Conquering Suffering, Enriching Humanity. World Health Forum, 1997.>
  2. The World Health Report 1998. Life in the 21st Century-A Vision for All. World Health Forum, 1998.
  3. "As Children Survive: Dilemmas of Aging in the Developing World." Society and Scientific Medicine 28, no. 1 (1989): 59-67
  4. Hughes, J.M., and Tenover, F.C. "Infectious Disease Challenges of the 1990s." Infectious Medicine; 13(9): 798-799.
  5. America's Vital Interest in Global Health: Protecting Our People, Enhancing Our Economy, and Advancing Our International Interests. Washington, D.C.: Board on International Health, Institute of Medicine, 1997.
  6. Chiller, T.M., De Mieri, P., and Cohen, I. "International Health Training: The Tulane Experience." Infectious Disease in Clinical North America 9, no. 2 (1995): 439-443.
  7. Johnstone, P. "Work in a Developing Country." BMJ, 311: 113-5.
  8. Levy, R., and Hawks, J. "Multicultural Medicine and Pharmacy Management." Drug Benefit Trends 7, no. 3(1996): 27-30.

Disease Trends

Smallpox - declared eradicated in 1980 after a 13-year fight against the disease
Plague - has declined in the last 40 years due to insecticides and antibiotics; cyclical epidemics still occur
Cholera - still endemic in some 80 countries
Chagas - found mostly in the Americas from Mexico to Argentina; should be eliminated by 2010
Leprosy - should be eliminated as a public health problem by the year 2000 as a result of a multi-drug therapy promoted in the early 1980s
Measles - still kills almost 1 million children annually; targeted to be eliminated by the year 2000
Hepatitis B - 75% of world's population lives in areas where there are high levels of infection. 2 billion people have evidence of past or current infection, and 350 million are chronic carriers of the virus
   
   
 
 
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