The Journal of Pediatrics
Volume 160, Issue 1 , Pages 1-2.e1, January 2012

Brief Overview of United States Involvement in Global Health Training since World War II

  • Bonita Stanton, MD

      Affiliations

    • Department of Pediatrics, Wayne State University School of Medicine, Children’s Hospital of Michigan, Detroit, MI
    • ,
  • Jonathan Castillo, MD, MPH

      Affiliations

    • Division of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Article Outline

PEPFAR, US President's Emergency Plan for AIDS Relief, USAID, US Agency for International Developement

 

The past decade has witnessed a surge of interest in and critical analysis of the involvement of the United States in the training of health professionals from developing countries. Furthermore, since the year 2000, approximately one-quarter of US medical school graduates have participated in an international elective.1 Accompanying this increase in exchanges and collaborations is a growing dialogue about the implications, both positive and negative, to such partnerships, particularly their effect on the developing country partner.2, 3 To inform both continued expansion of international training partnerships and discussions about the safeguards of the interests of the participating nations, institutions, and individuals, an examination of the rich history of the US in these endeavors is useful.

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US Involvement in Training of International Medical Graduates 

The US has a long history of international collaboration in medical training. Modern efforts in US global collaboration might reasonably be construed as corresponding with reconstruction after World War II. The Congressional US Foreign Assistance Act of 1961 reorganized US foreign assistance programs, separating military and non-military aid. President John F. Kennedy created the US Agency for International Development (USAID) to implement development assistance programs in the areas authorized by Congress in the Foreign Assistance Act of 1961. USAID was the federal agency primarily responsible for administering civilian foreign aid or “…to extend a helping hand to those people overseas struggling to make a better life, recover from a disaster or striving to live in a free and democratic country.”4

Of the many activities undertaken in the early years of its existence, USAID was concerned with the training of physicians and medical personnel in developing countries. Frequently, this training occurred onsite in the home country, although short-term training courses in the US and Canada were also common.5 Regardless of the site of this training, a high priority was placed on strengthening relationships between the US and the developing countries. Many of these training efforts were informed by (and subsequently served to inform the later development of) domestic programs focusing on disadvantaged and minority groups in the US.6, 7 In addition to USAID, other international and national organizations began bringing foreign medical graduates to the US to train for varying periods. To illustrate, from April 1970 to November 1971, the US Maternal Child Health Services International Activities Office hosted 45 long-term (6 weeks-2 years) participants and 31 short-term participants from Africa, Australia, South America, Europe, and Asia. Throughout the 1970s, an increasing number of foreign medical graduates came to the US for training. Such training opportunities were designed and perceived to be of benefit to developing countries; foreign students coming to the US benefited from scientific studies and research not available to them in their own countries.5

Although the programs were originally designed with the expectation that these individuals would return home with their increased knowledge and exposure, this was, increasingly, not the case. By the 1970s, foreign medical graduates accounted for one-third (18 333) of all residents and interns in the US (59 900). With time, most foreign medical graduates coming as medical residents to train in the US remained in the US. Concerns began to emerge about this practice. Specifically, questions were raised as to whether the importation of foreign medical graduates deprived US medical graduates of residency slots.8 From 1981 to 2001, the total number of foreign medical graduates increased by 97%; foreign medical graduates represented 24% of all physicians in the US. India and the Philippines provided the greatest proportion of foreign medical graduates each year from 1981 to 2001, 20% and 11%, respectively, in 2001.9

The new millennium witnessed increased concern about the dependence of the US and other industrialized nations on the importation of highly educated and talented individuals from emerging economies. Questions were raised about the ethics of taking physicians from countries where their numbers were already very limited to practice in settings with much higher ratios. For example, although the psychiatrist-per-population ratio in Great Britain was noted to be 27-fold greater than that of India, Great Britain was described as seeking to recruit additional specialists from India.10 Likewise, in the US, there were 51 surgeons per 100 000 persons, compared with 0.5 surgeons per 100 000 persons in West Africa.11 In 2006, the Association of American Medical Colleges issued a report urging an increase of 30% in the numbers of medical students graduating from US allopathic medical schools from 2002 to 2012. The report expressed the dual concerns that: “There are large numbers of Americans who aspire to attend US medical schools but have been unable to gain admission due in part to limited capacity. Many are so committed that they are willing to pay high tuitions at schools with varying standards and leave the US for several years to reach their goal; There is growing international concern that English-speaking countries may be draining valuable human resources from less-developed countries.”3

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US Medical Graduate Participation in Training Abroad 

During the 1980s and 1990s, a growing number of US medical students and residents began to express interest in an international educational experience. Despite the increases in their numbers, there was little published information about such electives during residency and an absence of broad educational guidelines. A study conducted in 1990 revealed that of US medical students participating in overseas electives, only 15% received any preparatory training.12 A survey conducted in 1995 found that 25% of pediatric residencies in Canada and the US offered international rotations, most of which were unilateral exchanges arranged by residents.13

In the next decade, the situation began to change rapidly. A survey conducted in pediatric residency programs in 2006 found that 70% included an international health option. The most common activities are lectures in international health and elective rotations. More than two-thirds of pediatric residents without such experiences reported desiring a formal international rotation.14 Despite the widespread nature of such programs, there was (and remains) little description in the literature of the reciprocity of such programs from the perspective of the international host country. Scarce is a literature describing what benefits are derived, either by the institution itself or by reciprocal programs (eg, residents or faculty from the host country travelling for electives in the US). Similarly, there is little description of the duration of the relationship between the developed and developing country sites. The American Academy of Pediatrics has published guidelines for residents and residency programs from the US, but, to date, has not published such guidelines or expectations for the international host programs.14

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The New Millennium: An Emphasis on Bilateral Benefit 

The last 5 years have witnessed a new, clearer articulation of mutual or bilateral benefit from such arrangements. Agencies such as the National Institutes of Health’s Fogarty International Center15 and the Bill and Melinda Gates Foundation16 focus on sustainable, bilateral collaborations. As an example of the US commitment to bilateral benefit, in 2010, the US President’s Emergency Plan for AIDS Relief (PEPFAR) collaborated with the National Institutes of Health to invite proposals from sub-Saharan African institutions receiving PEPFAR support and their partners to develop or expand models of medical education and research in sub-Saharan Africa. The initiative, the Medical Education Partnership, in which the funding went to the sub-Saharan institutions, supported PEPFAR’s goal to increase the number of new health care workers in sub-Saharan Africa by 140 000 and to strengthen the local (African) medical education systems and build clinical and research capacity in Africa as a retention strategy for the new cadre of health workers.17

In a similar fashion, efforts are underway to develop global standards for residency training that could—and should—be conducted anywhere in the world. One such initiative is the Global Pediatric Education Consortium. Beginning in 2008, representatives from >20 national and international pediatric societies from across Asia, Africa, Europe, and the Americas are engaged in “…creating common standards for training, assessment, professional development, and physician accreditation for general pediatrics as one way of promoting improvement in the quality of medical care provided to infants, children, adolescents, and young adults worldwide.” The group’s mission is to develop “…common training curriculum for general pediatrics that can be incorporated into any training environment, regardless of geographical and/or political boundaries.”18

Likewise, the Accreditation Council for Graduate Medical Education-International is a non-governmental organization responsible for the accreditation of international Graduate Medical Education programs outside the US to “…improve health care by assessing and advancing the quality of resident physicians’ education through accreditation to benefit the public, protect the interests of residents, and improve the quality of teaching, learning, research, and professional practice.” Currently 15 specialties (including pediatrics) can be accredited. Participation in accreditation is completely voluntary.19

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Conclusion 

The US medical profession has enjoyed a long and evolving relationship between medical professionals and institutions in developing, transitional, and/or post-conflict countries. Current initiatives are marked by articulation of the need for bilateral benefit and explicit recognition of the importance of international distributive justice.

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References 

  1. Drain PK, Primack A, Hunt D, Fawzi WW, Holmes KK, Gardner P. Global health in medical education: a call for more training and opportunities. Acad Med. 2007;82:226–230
  2. Ahmad OB. Managing medical migration from poor countries. BMJ. 2005;331:43–45
  3. Association of American Medical Colleges (AAMC). AAMC Statement on the physician workforce–June 2006. Available at www.aamc.org/download/55458/data/workforceposition.pdf. Accessed May 14, 2011.
  4. United States Agency for International Development (USAID). About USAID. Available at http://www.usaid.gov/about_usaid. Accessed May 15, 2011.
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  10. Patel V. Recruiting doctors from poor countries: the great brain robbery?. BMJ. 2003;327:926–928
  11. Adebonojo SA, Mabagunje OA, Pezzella AT. Residency training in the United States. W Afr J Med. 2003;22:79–87
  12. Heck JE, Wedemeyer D. A survey of American medical schools to assess their preparation of students for overseas practice. Acad Med. 1991;66:78–81
  13. Torjesen K, Mandalakas A, Kahn R, Duncan B. International child health electives for pediatric residents. Arch Pediatr Adolesc Med. 1999;153:1297–1302
  14. Kamat D, Armstrong R. Global child health: an essential component of residency training. J Pediatr. 2006;149:735–736
  15. Fogarty International Center, National Institutes of Health. Available at www.fic.nih.gov/programs/pages/framework.aspx. Accessed May 12, 2011.
  16. Bill and Melinda Gates Foundation. Framework for Global Health. Developing Successful Global Health Alliances. Available at www.gatesfoundation.org/global-health/documents-globalhealthalliances.pdf. Accessed May 12, 2011.
  17. Fogarty International Center, National Institutes of Health. Medical Education Partnership Initiative (MEPI). Available at http://www.fic.nih.gov/programs/pages/medical-education-africa.aspx. Accessed May 15, 2011.
  18. Global Pediatric Education Consortium. Training ahd Sustaining a Global Pediatric Workforce–Our Mission. Available at http://globalpediatrics.org/ourmission.html. Accessed May 15, 2011.
  19. Accreditation Council for Graduate Medical Education International. Advanced Specialty Program. Available at http://www.acgme-i.org/web/index.html. Accessed May 19, 2011.

PII: S0022-3476(11)00730-X

doi:10.1016/j.jpeds.2011.07.034

The Journal of Pediatrics
Volume 160, Issue 1 , Pages 1-2.e1, January 2012

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