Opinion
VIEWPOINT
Parminder S. Suchdev, MD, MPH Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children’s Healthcare of Atlanta, Atlanta, Georgia; and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia. Robert F. Breiman, MD Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia; and Emory Global Health Institute, Atlanta, Georgia. Barbara J. Stoll, MD Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and Children’s Healthcare of Atlanta, Atlanta, Georgia.
Global Child Health A Call to Collaborative Action for Academic Health Centers DespitesubstantialprogresstowardachievingtheMillennium Development Goals of maternal and child survival, challengespersist,includingtacklingfactorsbeyondsurvival suchasimprovingqualityoflifeandlong-termphysicaland cognitive development. The web of health determinants haveevolvedandincludefoodsecurity,climatechange,urbanization, and noncommunicable diseases. These 21st century realities underscore an urgent need to engage a widearrayofdisciplinestocatalyzenewwaystoimplement sustainable solutions for the health of the planet.1 TheInstituteofMedicinesupportsincreasedUSinvestmentinglobalhealth(GH)throughsustainablepartnerships to scale up existing interventions, generate and share knowledge,andbuildhumanandinstitutionalcapacity.2 In 2009,PresidentObamaintroducedtheunprecedentedUS GlobalHealthInitiative,whichrepackageda$63billionglobal health commitment toward the health of women, newborns, and children in low-income countries. In fragmented health systems with silos and barriers, academic health centers (AHCs) are uniquely positioned to foster interdisciplinary collaborations between multiple academic disciplines, government, industry, and community, which drive transformation from the “bench to bedside to population.”3 The case for GH engagement builds on the classical tripartite missions of patient care, education, and research. The important role of AHCs in achieving each of these missions is described below and summarized in the Box.
Benefits for Patient Care
Corresponding Author: Parminder S. Suchdev, MD, MPH, Departments of Pediatrics and Global Health, Emory University, 1760 Haygood Dr, Atlanta, GA 30322 (psuchde @emory.edu).
Hands-on experience caring for children from resourcepoor settings improves patient care at home. Trainees rotating abroad demonstrate sophisticated physical examination and cost-effective problem-solving skills and are more likely to select career paths in primary care and work in underserved communities.4 Opportunities for clinical work overseas are often short-term. Lack of standardized credentialing, clinical duties, language expectations, and funding mechanisms may raise ethical challenges, which should be addressed by predeparture training. Longer-term placements are optimal, such as the Global Health Service Partnership with the US Peace Corps, which recently deployed its first cohort of physicians and nurses to spend 1 year in Africa. Academic health centers should establish best-practice guidelines for patient care in low-resource settings and standards for bidirectional clinical exchanges and training, which include adequate oversight, appropriate mentorship, and well-defined safety and security plans (Box). While GH focuses on reducing inequities in the developing world, significant disparities in disease bur-
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den and access to health care also exist in the United States, often in proximity to AHCs. Many American cities have large numbers of immigrants, refugees, and international adoptees with specialized health needs as well as underrepresented minorities who often face poverty and health disparities. Thus, GH is also local health.
Benefits for Education and Training Morethan2400medicalschoolsworldwidetrainapproximately1millionnewphysiciansandhealthprofessionalsannually,yethealthcareworkershortagesandimbalancesremain major challenges that require novel approaches to postgraduate medical education.5 Global health is an increasingly valued dimension of American medical education,largelyinresponsetodemandsfromtrainees.Increasingnumbersofmedicalstudentsparticipateininternational health experiences and pediatric residency training programs are increasingly implementing GH curricula, tracks, and fellowships. Eight of the 10 top children’s hospitals ranked by US News and World Report in 2012 have formal GH training programs. By enhancing the knowledge base andclinicalacumenoftrainees,theseprogramsstrengthen recruitment and expand career choices. The Pediatric Education Group of the Association of Pediatric Program Directors was formed in 2012 to coordinate GH education of pediatric residents. Standardized GH curricula have been developed, aligned with the Accreditation Council for Graduate Medical Education competencies.6 Components include didactics in various topics of global child health, domestic and international field experiences, a scholarly project, and mentorship.6 With increasing global connectivity, mobile technology and distance learning can enhance exchanges between AHC classrooms and the field. The benefits of GH education are bidirectional and scaled-up investments in medical universities in lowresource settings are needed. For example, the NIH Fogarty Center–funded Medical Education Partnership Initiative, which supports 13 medical schools in 12 African countries, aims to improve medical education models, increase the number of health workers, and build clinical and research capacity by retaining physicians and faculty. Academic health centers should play a visible role in establishing best practices for such mutually beneficial GH partnerships (Box).
Benefits for Research Research led by AHCs could benefit local health and GH by addressing diseases of low-resource settings, understanding their social and economic determinants, and designing innovative, effective intervenJAMA Pediatrics November 2014 Volume 168, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
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Opinion Viewpoint
Box. Recommendations for Collaboration Among US Academic Health Centers Working to Improve Global Child Health Patient care: 1. Develop best-practice guidelines for global health work. 2. Establish long-term partnerships for bidirectional clinical exchange. Education and training: 3. Develop and adopt standardized competency-based curricula in global child health with committed faculty. 4. Incorporate innovative technologies for global health training including mobile technology and distance learning. 5. Establish well-defined global health career paths. Research: 6. Invest in international transdisciplinary and multidisciplinary research partnerships. 7. Focus global health research in areas of program evaluation and implementation science. Advocacy: 8. Develop global health organizational structures that cross institutional boundaries and include strong monitoring and evaluation. 9. Work collaboratively with other universities to implement international partnerships. 10. Develop a cadre of leaders in global health through sustainable partnerships.
tions to address factors that cause and sustain disparities in maternal and child health. Moreover, AHCs can work collaboratively with scientists in low-resource settings to tackle emerging challenges in science and medicine, including improving prevention strategies, characterizing etiologies of priority diseases, developing low-cost technologies to improve diagnosis, developing new therapeutics and vaccines, and advancing implementation science (Box). Academic health centers should view building local research capacity as an important objective. Promotion processes for faculty in US AHCs should deemphasize lead authorship for collaborative interARTICLE INFORMATION Published Online: September 15, 2014. doi:10.1001/jamapediatrics.2014.1566. Conflict of Interest Disclosures: None reported. REFERENCES 1. Horton R, Beaglehole R, Bonita R, Raeburn J, McKee M, Wall S. From public to planetary health: a manifesto. Lancet. 2014;383(9920):847. 2. Medicine Io. The US Commitment to Global Health: Recommendations for the Public and Private Sectors. Washington, DC: National Academy Press; 2009.
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national research, recognizing the substantive contributions of local coinvestigators. Furthermore, mentoring local scientists to design, implement, and serve as principal investigators on studies should be rewarded. Global health research presents opportunities for nontraditional grant funding. The expansion of foundations committed to GH has transformed the research landscape. The Bill and Melinda Gates Foundation awarded $3.4 billion in grants in 2012 and more than $30 billion since inception, primarily to support global development and health. Likewise, the UK Wellcome Trust invested nearly $700 million during the past 5 years on health research in developing countries. The return on investments for maternal and child health interventions is substantial (eg, $1 invested in childhood nutrition generates $138 in improved health and increased productivity).7 Multidisciplinary teams within AHCs often convened by universitywide global health institutes can respond to complex needs and attract new donors (Box).
Advocacy: A Manifesto for Action Academic health center leadership and collaboration in GH will help ensure a just, safe, and healthy world for children. In 2009, North American universities formed the Consortium of Universities for Global Health to define a shared vision of the role of universities in GH. The Consortium of Unversities for Global Health membership includes GH leaders from nearly 100 universities working to develop long-term partnerships between universities in resourcerich and resource-poor countries. As the Consortium of Universities for Global Health continues to evolve, a focus on maternal and child health will be critical. To effectively engage in GH, AHCs must address significant challenges including lack of organizational structures and sustainable funding, competing agendas, limited time, and the complexity of maintaining international partnerships. To avoid duplication of effort, universities should work more collaboratively to promote joint partnerships with international institutions (Box). Investments in infrastructure, monitoring and evaluation, long-term partnerships, and committed faculty in the United States and abroad are keys to developing sustainable GH programs. The benefits to trainees, faculty, and academic institutions—but most importantly, to mothers and children worldwide—are well worth the challenge.
3. Dzau VJ, Ackerly DC, Sutton-Wallace P, et al. The role of academic health science systems in the transformation of medicine. Lancet. 2010;375 (9718):949-953. 4. Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on US and Canadian medical students and residents: a literature review. Acad Med. 2003;78(3):342-347. 5. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming
education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756): 1923-1958. 6. Suchdev PS, Shah A, Derby KS, et al. A proposed model curriculum in global child health for pediatric residents. Acad Pediatr. 2012;12(3):229-237. 7. Hoddinott J, Rosegrant M, Torero M. Investments to Reduce Hunger and Undernutrition. Washington, DC: International Food Policy Research Institute; 2012.
JAMA Pediatrics November 2014 Volume 168, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
jamapediatrics.com
VIEWPOINT
Parminder S. Suchdev, MD, MPH Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children’s Healthcare of Atlanta, Atlanta, Georgia; and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia. Robert F. Breiman, MD Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia; and Emory Global Health Institute, Atlanta, Georgia. Barbara J. Stoll, MD Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and Children’s Healthcare of Atlanta, Atlanta, Georgia.
Global Child Health A Call to Collaborative Action for Academic Health Centers DespitesubstantialprogresstowardachievingtheMillennium Development Goals of maternal and child survival, challengespersist,includingtacklingfactorsbeyondsurvival suchasimprovingqualityoflifeandlong-termphysicaland cognitive development. The web of health determinants haveevolvedandincludefoodsecurity,climatechange,urbanization, and noncommunicable diseases. These 21st century realities underscore an urgent need to engage a widearrayofdisciplinestocatalyzenewwaystoimplement sustainable solutions for the health of the planet.1 TheInstituteofMedicinesupportsincreasedUSinvestmentinglobalhealth(GH)throughsustainablepartnerships to scale up existing interventions, generate and share knowledge,andbuildhumanandinstitutionalcapacity.2 In 2009,PresidentObamaintroducedtheunprecedentedUS GlobalHealthInitiative,whichrepackageda$63billionglobal health commitment toward the health of women, newborns, and children in low-income countries. In fragmented health systems with silos and barriers, academic health centers (AHCs) are uniquely positioned to foster interdisciplinary collaborations between multiple academic disciplines, government, industry, and community, which drive transformation from the “bench to bedside to population.”3 The case for GH engagement builds on the classical tripartite missions of patient care, education, and research. The important role of AHCs in achieving each of these missions is described below and summarized in the Box.
Benefits for Patient Care
Corresponding Author: Parminder S. Suchdev, MD, MPH, Departments of Pediatrics and Global Health, Emory University, 1760 Haygood Dr, Atlanta, GA 30322 (psuchde @emory.edu).
Hands-on experience caring for children from resourcepoor settings improves patient care at home. Trainees rotating abroad demonstrate sophisticated physical examination and cost-effective problem-solving skills and are more likely to select career paths in primary care and work in underserved communities.4 Opportunities for clinical work overseas are often short-term. Lack of standardized credentialing, clinical duties, language expectations, and funding mechanisms may raise ethical challenges, which should be addressed by predeparture training. Longer-term placements are optimal, such as the Global Health Service Partnership with the US Peace Corps, which recently deployed its first cohort of physicians and nurses to spend 1 year in Africa. Academic health centers should establish best-practice guidelines for patient care in low-resource settings and standards for bidirectional clinical exchanges and training, which include adequate oversight, appropriate mentorship, and well-defined safety and security plans (Box). While GH focuses on reducing inequities in the developing world, significant disparities in disease bur-
jamapediatrics.com
den and access to health care also exist in the United States, often in proximity to AHCs. Many American cities have large numbers of immigrants, refugees, and international adoptees with specialized health needs as well as underrepresented minorities who often face poverty and health disparities. Thus, GH is also local health.
Benefits for Education and Training Morethan2400medicalschoolsworldwidetrainapproximately1millionnewphysiciansandhealthprofessionalsannually,yethealthcareworkershortagesandimbalancesremain major challenges that require novel approaches to postgraduate medical education.5 Global health is an increasingly valued dimension of American medical education,largelyinresponsetodemandsfromtrainees.Increasingnumbersofmedicalstudentsparticipateininternational health experiences and pediatric residency training programs are increasingly implementing GH curricula, tracks, and fellowships. Eight of the 10 top children’s hospitals ranked by US News and World Report in 2012 have formal GH training programs. By enhancing the knowledge base andclinicalacumenoftrainees,theseprogramsstrengthen recruitment and expand career choices. The Pediatric Education Group of the Association of Pediatric Program Directors was formed in 2012 to coordinate GH education of pediatric residents. Standardized GH curricula have been developed, aligned with the Accreditation Council for Graduate Medical Education competencies.6 Components include didactics in various topics of global child health, domestic and international field experiences, a scholarly project, and mentorship.6 With increasing global connectivity, mobile technology and distance learning can enhance exchanges between AHC classrooms and the field. The benefits of GH education are bidirectional and scaled-up investments in medical universities in lowresource settings are needed. For example, the NIH Fogarty Center–funded Medical Education Partnership Initiative, which supports 13 medical schools in 12 African countries, aims to improve medical education models, increase the number of health workers, and build clinical and research capacity by retaining physicians and faculty. Academic health centers should play a visible role in establishing best practices for such mutually beneficial GH partnerships (Box).
Benefits for Research Research led by AHCs could benefit local health and GH by addressing diseases of low-resource settings, understanding their social and economic determinants, and designing innovative, effective intervenJAMA Pediatrics November 2014 Volume 168, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
983
Opinion Viewpoint
Box. Recommendations for Collaboration Among US Academic Health Centers Working to Improve Global Child Health Patient care: 1. Develop best-practice guidelines for global health work. 2. Establish long-term partnerships for bidirectional clinical exchange. Education and training: 3. Develop and adopt standardized competency-based curricula in global child health with committed faculty. 4. Incorporate innovative technologies for global health training including mobile technology and distance learning. 5. Establish well-defined global health career paths. Research: 6. Invest in international transdisciplinary and multidisciplinary research partnerships. 7. Focus global health research in areas of program evaluation and implementation science. Advocacy: 8. Develop global health organizational structures that cross institutional boundaries and include strong monitoring and evaluation. 9. Work collaboratively with other universities to implement international partnerships. 10. Develop a cadre of leaders in global health through sustainable partnerships.
tions to address factors that cause and sustain disparities in maternal and child health. Moreover, AHCs can work collaboratively with scientists in low-resource settings to tackle emerging challenges in science and medicine, including improving prevention strategies, characterizing etiologies of priority diseases, developing low-cost technologies to improve diagnosis, developing new therapeutics and vaccines, and advancing implementation science (Box). Academic health centers should view building local research capacity as an important objective. Promotion processes for faculty in US AHCs should deemphasize lead authorship for collaborative interARTICLE INFORMATION Published Online: September 15, 2014. doi:10.1001/jamapediatrics.2014.1566. Conflict of Interest Disclosures: None reported. REFERENCES 1. Horton R, Beaglehole R, Bonita R, Raeburn J, McKee M, Wall S. From public to planetary health: a manifesto. Lancet. 2014;383(9920):847. 2. Medicine Io. The US Commitment to Global Health: Recommendations for the Public and Private Sectors. Washington, DC: National Academy Press; 2009.
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national research, recognizing the substantive contributions of local coinvestigators. Furthermore, mentoring local scientists to design, implement, and serve as principal investigators on studies should be rewarded. Global health research presents opportunities for nontraditional grant funding. The expansion of foundations committed to GH has transformed the research landscape. The Bill and Melinda Gates Foundation awarded $3.4 billion in grants in 2012 and more than $30 billion since inception, primarily to support global development and health. Likewise, the UK Wellcome Trust invested nearly $700 million during the past 5 years on health research in developing countries. The return on investments for maternal and child health interventions is substantial (eg, $1 invested in childhood nutrition generates $138 in improved health and increased productivity).7 Multidisciplinary teams within AHCs often convened by universitywide global health institutes can respond to complex needs and attract new donors (Box).
Advocacy: A Manifesto for Action Academic health center leadership and collaboration in GH will help ensure a just, safe, and healthy world for children. In 2009, North American universities formed the Consortium of Universities for Global Health to define a shared vision of the role of universities in GH. The Consortium of Unversities for Global Health membership includes GH leaders from nearly 100 universities working to develop long-term partnerships between universities in resourcerich and resource-poor countries. As the Consortium of Universities for Global Health continues to evolve, a focus on maternal and child health will be critical. To effectively engage in GH, AHCs must address significant challenges including lack of organizational structures and sustainable funding, competing agendas, limited time, and the complexity of maintaining international partnerships. To avoid duplication of effort, universities should work more collaboratively to promote joint partnerships with international institutions (Box). Investments in infrastructure, monitoring and evaluation, long-term partnerships, and committed faculty in the United States and abroad are keys to developing sustainable GH programs. The benefits to trainees, faculty, and academic institutions—but most importantly, to mothers and children worldwide—are well worth the challenge.
3. Dzau VJ, Ackerly DC, Sutton-Wallace P, et al. The role of academic health science systems in the transformation of medicine. Lancet. 2010;375 (9718):949-953. 4. Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on US and Canadian medical students and residents: a literature review. Acad Med. 2003;78(3):342-347. 5. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming
education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756): 1923-1958. 6. Suchdev PS, Shah A, Derby KS, et al. A proposed model curriculum in global child health for pediatric residents. Acad Pediatr. 2012;12(3):229-237. 7. Hoddinott J, Rosegrant M, Torero M. Investments to Reduce Hunger and Undernutrition. Washington, DC: International Food Policy Research Institute; 2012.
JAMA Pediatrics November 2014 Volume 168, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
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