International EM

Preparing for a Global Health Experience

While global health interventions can have a tremendous impact for relatively low investment when done the right way, they also can have negative unintended consequences. Prepare carefully so your rotation is helpful to patients and communities.

In the past several years, medical student and resident participation in international rotations has dramatically increased.1 Many benefits to participating in international rotations have been described.23 Students who have traveled to other countries reported increased cultural and interpersonal competence and improvement in medical knowledge.4 Global health allows the trainee to experience health care through a completely different resource and cultural paradigm and can lead to introspection and critical assessment of clinical practice back home. International medical experiences can also help the student learn about pathologies not commonly seen in the U.S. such as some tropical diseases and advanced stages of diseases not treated because of lack of resources.

Beyond the cultural and clinical learning, many medical trainees seek global health experiences as an opportunity to help very needy populations. After all, there are tremendous needs in low and middle income countries that, depending on the specific setting, range from medical expertise in a given area (eg, emergency, medicine) to common medications, electricity, or even running water. This marked difference in resources creates the perception that it takes very little to have a positive impact in places that lack so much. And while global health interventions can have a tremendous impact compared to relatively low investment when done the right way,5 unfortunately, often global health interventions can have negative unintended consequences for both the trainee and the host community.6

Common reasons for negative experiences for the trainee include lack of preparation and contingency planning (ie, preparing for when things do not go as planned). And common reasons for projects that are ineffective or have a negative impact include lack of knowledge of and buy-in from the local population and a lack of emphasis on sustainability.

How do we avoid these negative consequences?
We asked three global health experts:

Dr. Abigail Hankin-Wei, director of the first emergency medicine residency in Mozambique
Abigail Hankin-Wei.jpg


Dr. Hiren Patel, Global Health Fellowship director at the Massachusetts General Hospital in Boston
Hiren Patel.png


Dr. Anna Yaffee, International Section Chair in the Department of Emergency Medicine at Emory University
Anna Yaffee.png
These experts offer tips on how to choose and prepare for a global health experience to increase the chances of having a positive impact and lower the risk of unintended consequences for the trainee and the host community.

Types of Global Health Experiences
Before delving into preparing for a global health experience, it is important to consider a few types of experiences one can pursue:

  • Remote participation: Dr. Hankin-Wei recommended that trainees look for opportunities to work on international health projects remotely before traveling abroad. The expansion of the internet in the developing world has made it possible for trainees to support international projects from Trainees can help with activities such as literature reviews, data analysis, administrative tasks, and proposal and report writing for research or capacity building projects. U.S.-based trainees can also help with teaching activities and journal clubs via video conferencing. One advantage of this global health experience is that it may fit more easily with training schedules, as trainees can stay involved over time without interrupting their studies. Remote activities could be stand-alone experiences, or a way to prepare for a planned trip. For example, Dr. Hankin-Wei has had U.S. residents collaborate with residents in Mozambique on journal articles and newsletters before visiting Mozambique, which likely contributed to their overall experience while in country.
  • Medical Missions: During medical missions, the medical trainee travels for a short period of time to help an organization providing medical care on a temporary basis. Trip duration is usually in the order of days or weeks. Dr. Yaffee developed her passion for international work after volunteering in Tanzania. She cautioned that mission trips are not the “epitome of global health,” but the experience did teach her about the importance of cultural exchange in medicine and affirmed her interest in this field. For students who have never had international experience before, mission trips may be a formative starting point.
  • Clinical Rotations: During international medical rotations, trainees participate in medical care under the supervision of local or international physicians. Rotation duration is an important consideration. Dr. Patel recommends dedicating at least four weeks given the steep learning curve for the trainee in a new environment before she can be effective in her role.
  • Research or Development Projects: Research and capacity building or development projects allow the trainee to look at the health care system in the host country from a broader perspective. Participation in these activities usually requires longer term commitment, at least in the order of months given the need to become familiar with the host community to achieve the project’s results.

Choosing a Global Health Experience
Finding one's first global health experience can feel like a daunting task. The best place to start is usually global health faculty in the student or resident’s program. If there are no global health faculty in one’s program, one can look online for faculty and organizations working in a country and project of one’s interest. Cold-emailing may be an uncomfortable but sometimes necessary part of this process. Dr. Patel recommends global health committees and conferences through different potential organizations (eg, EMRA, ACEP, SAEM) to make global health connections.

Often, trainees will run into multiple global health experiences they could pursue. How should they choose? Personal interest in a specific country or culture, connection to an existing project via a faculty member, and previous language skills or experiences are all common reasons to choose one specific experience. These are other factors that trainees should consider:

  • Timing: Will the experience be available during the trainee’s elective time?
  • Safety: Will the experience take place in a country and province safe enough for travel? Will the student be staying in a safe place? Are there severe health risks to the trainee (eg, ebola)?
  • Sponsoring organization and local contact: Is the organization reputable and dependable? Will there be a local contact that can be easily reachable in case of emergency and to help guide the trainee with any logistical issues.
  • Impact and sustainability: Does the program seem to listen to and uphold the host community’s values? Is the program sustainable? What are the risks of negative unintended consequences to the host community from the program?
  • Cost and Funding: What will be the cost of travel and room and board? Are there scholarships available?

Dr. Yaffee encouraged students to work within the framework of an already well-defined system. She recommended trainees pursue a larger, more established program for their international experiences, particularly for trainees who are only traveling for a short period of time. She added, “no student or resident should be going to a site that has not been vetted by either an institutional faculty member or another institution that is trusted.”

Preparation Before Traveling
Preparation is crucial for the safety of the participant and the success of the experience, as well as minimize any negative impacts on the host community. Figure 1 lists some of the recommended steps when preparing for an international experience. First and foremost, the trainee needs at least two good mentors: one in the U.S. and one in the host site. A global health experience, after all, is a learning experience, and one needs guidance. There is a lot to learn about the host country, healthcare in low resource settings, culture, and language. The pace of work can vary significantly in other countries, which can be a source of frustration for trainees. Frequently students and residents come back from their experiences frustrated because they were not able to finish their projects. Having clear expectations from one’s mentors that are based on the host community’s reality—while remaining flexible—can help the trainee make the most out of the experience. Dr. Yaffee recommends contacting the local staff via apps such as WhatsApp or Skype to start building relationships that will be helpful once the rotation begins.

Not only will the participant find the experience more fruitful with good mentor support and clear guidelines and objectives, but mentorship is paramount for the participant’s safety, as trainees may be completely out of their element in a different country. Before traveling it is important to talk extensively with the local and U.S.-based mentors about the conditions in the host site and how to stay safe. It is important to have the phone numbers of people in country who can be of help 24/7 in case of emergency. Furthermore, Dr. Patel brought up it is important that the trainee recognizes he or she will likely be one of the most affluent people in the community and easily identified as foreign because of her look, language, accent, clothing, or even mannerisms. Extra care should be taken to not flaunt expensive clothing or technology. Not only will this create a barrier when establishing relationships with the local community, but it can make the trainee a target of unwanted attention, harassment, or crime. Thus, it is important that the trainee discuss with local contacts proper attire and how to move around the local community most safely (to and from work, grocery store, pharmacy, etc.). Health insurance and evacuation insurance should also be discussed with your mentors and training program. Other safety considerations include a visit to the travel clinic for vaccinations and prophylactic medications (e.g. malaria) and reading the country profile in the Department of State website for any upcoming political or civil event with potential for turmoil (e.g. upcoming elections).

Learning as much as possible about the local community will not only help with safety but can help the trainee connect with local collaborators, understand local patients, and uphold the values of the community. Dr. Hankin-Wei believes that, in addition to knowing the state of Emergency Medicine in the country, one should be familiar with its history to better understand patients and the systems that are currently in place. One should ask about the social determinants of health of the host population and ask what the main causes of illness and the main barriers in the healthcare system are. Before embarking in a global health experience, ask if community members were involved in the planning and execution of the project/program and what the end goal is. In other words, does the community feel ownership of the program and will they be able to continue it once foreign aid stops? Ask about local manners. Drs. Hankin-Wei and Yaffee recommend learning how to say basic words and phrases in the local language, such as “hello” and “thank you,” to demonstrate respect and interest in the local community.

In addition to the advice above, we asked our interviewees what resources trainees should read before departure. Figure 2 contains their recommendations and other helpful links. Furthermore, our experts encouraged trainees to read about some of the ethical dilemmas frequently experienced during global health experiences, as discussed below.

Ethical Considerations
A common ethical issue trainees run into while working abroad is being asked to work outside their scope of practice.7 Not uncommonly trainees may be asked to peroform tasks and procedures beyond their level of training or without the level of supervision they would usually require. This can happen for many reasons, including lax local regulation, a less hostile malpractice environment, shortages of healthcare personnel, or lack of understanding of the trainees’ level of training by the host medical facility. However, all our interviewees stressed that trainees should practice with the same level of supervision and in a scope of practice as close as possible to what would be expected of them in the US. Obviously, working outside of one’s scope and level of training can cause harm. Just because patients may be seeking care in a low resource setting does not mean they are any less entitled to safe and high-quality care. Our experts recommended trainees to avoid being overconfident. Dr. Yaffee put it succinctly by saying “don’t be a cowboy.” Feeling empowered to say “no” when asked to perform outside of one’s level of training is important before embarking on an international experience.

Other ethical challenges encountered by trainees abroad stem from resource scarcity. All three global health experts indicated that observing patients suffer from potentially preventable causes is a significant stressor for rotating trainees. Consider a hypothetical: a U.S.-based emergency medicine resident is caring for a patient X with new kidney failure in country Y. The resident has cared for similar patients in the U.S. where they have been started on dialysis, feel much better, and go home. However, in country Y, there is only one dialysis clinic, hours away by car and the costs of each treatment is hundreds of times the patient’s family’s daily income. Thus, patient X is not able to receive dialysis, struggles to breath from volume overload, and dies on day five of hospitalization. It can be very upsetting to witness patients suffer or die from conditions one perceives as very treatable back home, even if it is completely beyond one’s resources in a given setting. Another common situation is having to choose who gets treatment when resources are available but limited. Schwartz et al. describe a situation in rural northeast Africa where a hospital had only one oxygen machine that could not be split between patients. The healthcare provider had to make the decision about who received life-saving oxygen and who did not.8 Resource scarcity can result in a myriad of situations like these where the trainee can experience moral injury (or injury to their conscience), feeling guilt and like they could have done more, even though they could not. This is another important reason it is critical to have good supervision, mentorship, and a support system during a global health experience. Each of our experts acknowledged the importance of debriefing, whether that is with a supervisor at the site, or in a group upon returning home. Dr. Patel mentioned that journaling is also frequently a helpful adjunct. Being able to process these experiences is essential to caring for one’s mental health.

 

Trainees witnessing scarcity sometimes want to pay for treatments or some element of a patient’s care. However, Dr. Yaffee and Dr. Patel feel this is not sustainable. Who will pay when the trainee leaves? Other people may hear about the trainee giving financial assistance and come asking for help. Where does the trainee draw the line? If trainees are motivated to make a financial donation, Dr. Patel recommends those donations go to an organization doing work in the area as opposed to individuals.

 

While on the topic of local organizations, it is important to consider any unintended consequences a global health activity can have on those local organizations. For example, a hypothetical medical mission M starts going to town T twice a year for 2 years to provide free medical care and medications. Unfortunately, its funding runs out at the end of year 2, and program M stops. During those 2 years the only medical clinic and the only pharmacy in town T closed because people stopped using their paid services in favor of mission M’s free mission services. In the long-term, mission M left town T worse than it found it—without its only permanent clinic and pharmacy. People from town T must now travel 2 hours by car to seek medical care. Thus, any global health project must have the input of patients, community members, local government, local businesses, and any other stakeholders. Perhaps if Mission M had delivered its services through the local clinic and pharmacy, these local businesses would have become stronger and better able to serve the community when the mission left. While trainees most often will not design global health interventions themselves, they should choose to participate in sustainable programs. Trainees should ask how a specific program is strengthening local capacity, its impact on local organizations, and how it will transition its activities to the local community when it leaves. Programs should leave communities more self-sufficient than they found them.

In contrast to the example above, sometimes local community members distrust foreign programs and do not take advantage of the services provided. For example, during the Ebola epidemic, many people in the affected communities actively avoided healthcare services provided by NGOs because of distrust.9 Dr. Patel highlighted the necessity of understanding what is important to the community one wishes to serve. All three interviewees indicated that it is crucial to obtain “buy-in” from the local community. Dr. Patel emphasized that local professionals are the experts in their system--not the visiting trainee. As Dr. Yaffee stated, “being deferential is important; realize that many times we are going to learn a lot more from places we visit than we are giving back.” Listening and being deferential to the host system will earn you respect and buy-in from the community. An intervention developed without the input and active participation of a local community will often fail because it is either ineffective in the local context or because it fails to gain the community’s interest and trust. A trainee that feels superior to her local coworkers and patients will struggle to gain trust and be effective in her role.

Table 3 lists articles that discuss some of the challenging ethical dilemmas that healthcare workers encounter when doing international work. All of our experts recommended reading papers such as these before embarking on a global health rotation.

Reflection
Our experts think working abroad has made them more resourceful in their practices in the U.S. Dr. Yaffee shared that she has been able to solve problems more creatively, without relying as heavily on as many resources. Dr. Patel mentioned the challenge of switching from treating serious, debilitating illnesses in a low resource area to practicing in an emergency department in the U.S. that welcomes many non-emergent complaints. It can be easy to feel judgmental of patients with low acuity complaints.

However, he states we must not forget each patient deserves the same level of respect. “You can’t be judgmental of people’s vulnerabilities.”

A global health experience can be intense and transformative. To get the most out of it make sure you take pauses and reflect all the way through and especially at the end. Debrief with your mentors and other people who have had similar experiences. How do care and resources compare across countries?

What do you wish you would have known before going? What would you do differently on your next trip? Did you feel your experience had a positive, negative, or neutral impact on the host community? What are some parallels between the social determinants of health affecting your patients in the community you visited vs. your home setting? How will practicing medicine abroad influenced your work in the U.S.? Are there ways you can stay connected with the host community and help from home?

Conclusion
International rotations can have a profound impact on medical trainees. According to our interviewees, the experience will be enhanced by significant preparation, good mentorship, allotting enough time in the host community, debriefing, and staying connected with the individuals at the host site. Some pitfalls to avoid are practicing outside of one’s scope, disregarding the knowledge of the local community, overconfidence, and lack of respect for the local community. Above all, it is important that, as visitors, we make every effort to familiarize ourselves with the host country’s history and medical system and not simply try to impose our own ideals. As Dr. Patel stated, “We have this notion when doing global health work we want to go and make all these changes. We have all these ‘wants’: ‘I want to teach them this, I want to do that,’ without understanding the needs of the community. Instead we must be humble, listen and be thankful to the community for letting us be there, think about unintended consequences of well- meaning actions, and expect to learn much more than we can teach.”

Steps to take to prepare for international rotations

Preparation

  • Experience: Make sure you have discussed the experience at length with both a U.S.-based and a host country mentor. You need both. Make sure you have their cellphone numbers in case of emergency. Here are some questions to ask:
    • What will be my expectations and responsibilities? What will be my role in the team?
    • What are people in the hospital/site like? What languages are spoken? Will I be working through an interpreter?
    • Place of residence and local travel safety?
    • Local emergency contacts?
    • Will evacuation insurance be provided?
    • Expected impact in the local community?
    • Common health conditions and how are they managed differently at the site?
    • Common pitfalls for people who have traveled before?
    • Ask to talk to students/residents who have participated in experience in the past and ask them about:
      • Safety, cost, interaction with local people
      • Were mentors easy to reach? Helpful with questions?
    • Site information and safety: familiarize yourself with the host site
      • Local history, culture, and language, recent political events
      • Water, food, toiletries, medication availability
      • Healthcare system
      • Consider taking UN Security in the field course module
      • Search State Department website for any travel advisories for the country
    • Make a travel clinic appointment:
      • Vaccines, antimalarials, HIV prophylaxis (in case of needlestick if working clinically), bug spray, mosquito net
    • Two weeks before traveling:
      • Get local currency (some banks will exchange for free if requested in advance)
      • A working cellphone can be invaluable when navigating a new location. You can use it to look up information and call for help: find out if your carrier has coverage in host country or get unlocked cell phone and buy international SIM card or local SIM card on arrival. Download offline map in case you get lost in area without reception. Bring a small portable back-up battery. Download dictionary/translation app.
      • Make copies of passport and other important documents in case you lose them
      • If you take medications, make sure you have enough
      • Buy a few nonperishable snacks
      • Buy hygiene items that may be hard to find in host country
      • Share accommodation contact information with family/training program
      • Bring personal protective equipment if working clinically (N95, surgical masks, and goggles, and even gloves may be less readily available in the host site).

 

General Reference Material for Global Health Experiences

Articles About Ethical Issues in Global Health

  • Ethics in Humanitarian Aid Work: Learning From the Narratives of Humanitarian Health Workers
    • Schwartz, L et al, AJOB Primary Research. https://doi.org/10.1080/21507716.2010.505898
  • Challenges in International Medicine: Ethical Dilemmas, Unanticipated Consequences, and Accepting Limitations
    • Iserson, K et al, In Academic Emergency Medicine. https://doi.org/10.1111/j.1553- 2712.2012.01376.x
  • Your Morals Depend on Language
    • Costa, A et al, PLoS ONE. https://doi.org/10.1371/journal.pone.0094842
  • Ethical Challenges and Considerations of Short-Term International Medical Initiatives: An Excursion to Ghana as a Case Study
    • Jesus, J. E. In Annals of Emergency Medicine. https://doi.org/10.1016/j.annemergmed.2009.07.014
  • Ethical dilemmas during international clinical rotations in global health settings: Findings from a training and debriefing program
    • Peluso, M. J et al, Medical Teacher. https://doi.org/10.1080/0142159X.2017.1391374
  • Tackling challenges of global health electives: Resident experiences of a structured and supervised medicine elective within an existing global health partnership1

Interviewees

Abigail Hankin-Wei, MD, MPH
Dr. Hankin-Wei works for Emory University and practices emergency medicine (EM) at Grady Memorial Hospital in Atlanta, Georgia and in Maputo, Mozambique, where she developed and implemented the country’s inaugural EM residency program. She was initially drawn to the field of global emergency medicine after serving as a community health educator in India during medical school.

Hiren Patel, MD, MPH, FACEP
Dr. Patel is the Fellowship Director for the Global Health Innovation and Leadership Fellowship at Massachusetts General Hospital (MGH) where he practices Emergency Medicine. Dr. Patel attributes his interest in pursuing global health to his upbringing in Zambia. His early experiences working at an orphanage there motivated him to seek a career in medicine. Throughout his career, he has led a number of international intiitaives including trauma stabilization efforts in Iraq, sex trafficking abolition work in Delhi, India, and most recently, innovations and systems building in Kenya.

Anna Yaffee, MD, MPH
Dr. Yaffee is the Director of the Global Health and Emergency Medicine Section in the Department of Emergency Medicine at Emory University. She has been a part of many global health initiatives including nurse training in Pakistan, conducting a needs assessment for nursing training in the Kingdom of Eswatini, and performing EM education in Ethiopia. Dr. Yaffee was inspired to pursue global health from a young age after reading the book “The Hot Zone.”


References

  1. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P. Global health training and international clinical rotations during residency: Current status, needs, and opportunities. Acad Med. Published online 2009. doi:10.1097/ACM.0b013e3181970a37
  2. Henry JA, Groen RS, Price RR, et al. The benefits of international rotations to resource-limited settings for U.S. surgery residents. Surg (United States). Published online 2013. doi:10.1016/j.surg.2012.10.018
  3. Lu PM, Park EE, Rabin TL, et al. Impact of global health electives on us medical residents: A systematic review. Ann Glob Heal. Published online 2018. doi:10.29024/aogh.2379
  4. Ibid
  5. Iserson K V., Biros MH, Holliman CJ. Challenges in international medicine: Ethical dilemmas, unanticipated consequences, and accepting limitations. Acad Emerg Med. Published online 2012. doi:10.1111/j.1553-2712.2012.01376.x
  6. Li V. Ethical Dilemmas in Global Clinical Electives. J Glob Health. Published online 2011.
  7. Dell EM, Varpio L, Petrosoniak A, Gajaria A, McMcarthy AE. The ethics and safety of medical student global health electives. Int J Med Educ. Published online 2014. doi:10.5116/ijme.5334.8051
  8. Schwartz L, Sinding C, Hunt M, et al. Ethics in humanitarian aid work: Learning from the narratives of humanitarian health workers. AJOB Prim Res. Published online 2010. doi:10.1080/21507716.2010.505898
  9. Richards P, et al.Trust, and distrust, of Ebola Treatment Centers: A case-study from Sierra Leone. PLoS One. 2019 Dec 2;14(12).

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