Is there a need to train doctors in international public health? Some would argue that countries like the UK have enough public health challenges without its doctors worrying about the state of the world outside. Rebecca Hope opens the debate.

2005 was a remarkable year for global health with issues of development and health in the headlines throughout the year. This was in part due to the Make Poverty History campaign, but also sadly due to health emergencies like the tsunami, the earthquake in Pakistan and avian flu outbreaks. There has, though, in recent years been a surge of interest in global health by professionals and students in countries like the UK. Medical journals increasingly feature articles on issues relevant to the developing world, such The Lancet’s Global Health articles collection . Global health issues are finding more place in the undergraduate nursing, nutrition and medical curricula and medical students can now do BSc’s in International Health. A new F2 programme in international public health begins this year for junior doctors in North Central London Foundation School.

Health professionals working overseas is not a new phenomenon, but could the increasing awareness of the health challenges in low-income countries inspire more people to take on humanitarian work? And has this contributed to the increase in courses and training in international health? This article asks the question why health professionals in the West should be interested in global health and how is it possible to combine your interest with UK training?

Read on for the perspectives of nurse and midwife and the new Director of Medact, Marion Birch for her views and advice.

Medact is a UK charity which challenges barriers to access to health caused by conflict, poverty and the environment. Its Director, Marion Birch is a nurse and midwife who has also worked at the London Hospital of Tropical Diseases. She worked overseas in humanitarian assistance and public health for 15 years in Sudan, Mozambique, Sri Lanka and Angola.

Alma Mata asked whether there is a need for health professionals to work overseas. Shouldn’t they concern themselves with the health care here in the UK?

Marion emphasised the importance of health professionals working as advocates for global health here in the UK as well as taking direct action by working overseas in relief work:

‘The two areas complement each other, there are those who take the decision to do something overseas, but equally important is having a career in this country. As a health professional working in a developed country like the UK which is part of the G8, there is a lot of lobbying, discussion and influence to done, which impacts on global health problems.’

Health professionals going to work overseas should be adequately prepared and trained, but they will also learn new skills that can be applied back in the UK , said Marion who has worked in health training, water, sanitation and waste disposal, support to community organisations and post-conflict health sector rehabilitation:

‘With the rise in non-communicable diseases in economically poorer countries, and communicable diseases such as bird flu and SARS that do not respect borders, health professionals are likely to be using and developing similar skills wherever they work. Climate change is also likely to contribute to a rise in communicable diseases in moderate climates.

There are also non-clinical skills such as encouraging the participation of civil society in their own health care, which have been integral to the work of the development and aid community, which are now being applied to a greater degree in the UK. There is much more scope for two-way learning and discussion between health professionals working in different settings.'

2005 has seen the Make Poverty History campaign as well as Live 8, coinciding with the hosting of the G8 summit. Has this helped create awareness and concern among UK health professionals for the international health problems facing the world today?

'Make Poverty History aimed to address a range of issues around poverty alleviation that are some of the underlying causes of poor health. It is in the nature of large campaigns that messages run the risk of getting simplified. I think it has made more people generally aware that some G8 government policies are harmful for health in developing countries.; that developing countries contribute hugely to health care in the UK with no financial compensation for their training, and that unfair World Trade Organisation trading rules impoverish communities with adverse effects for their assistance that has its own conditionalitites also does not maximise its potential, as in the case of funds that are given for the purchase of particular brands of drugs only.'

What is effective lobbying and how can health professionals get involved?

'It’s essential to attempt to encourage government policies that are beneficial for health in developing countries, and to stop policies that contribute to ill health. However it is essential that this is not just Europe talking about people far away. It is essential that we listen to the Ministries of Health and civil society in these countries and that there is an equal discussion. It can help a lot if working overseas and lobbying in the UK are coordinated.

Evidence gathered about the state of health in developing countries could be used to support lobbying here and help build links between regions. There is a lot of useful information in the ‘grey material’ produced by non-governmental organisations and others. Health professionals working overseas can potentially contribute to the evidence base for global health.'

Marion Birch is the new Director of Medact. For more information about Medact’s current work, including on issues of the ‘brain drain’ of health workers from the developing world, and the impact of the war in Iraq on health, see their website: http://www.medact.org.

An NGO perspective: the value of UK volunteers overseas

We spoke to Dr Raul Pardinaz-Soliz, Development Awareness Officer at Skillshare International, a non-governmental organisation which supports its partner organisations in Africa and Asia through capacity building and the placement of international volunteers. Raul said,

‘Local health professionals have a deeper understanding of the impact of medical decisions made, taking into account social and cultural factors and indigenous knowledge. Health professionals who work overseas need a clear understanding of what they will be doing, and understand that they may have more to learn than to give.

Skillshare International encourages South to South volunteering. Health professionals working in similar settings with the same resources have often similar experience and have therefore more skills and knowledge to exchange, that health professionals from richer countries often don't have. The limited time frame makes it easier for volunteers to work in rural, low-paid settings. For local doctors, long periods working in remote, rural settings can impact on their families' income and makes it more difficult to return to the city and progress in their career.'

Working overseas: a clinician’s perspective

For those who will choose to work in other specialities in the NHS or in general practice, NHS links is one new way to combine clinical work with international health.

NHS Links

NHS Links is a network of health professionals across the United Kingdom that was set up in collaboration with THET (the Tropical and Health Education Trust). The network was established by doctors and health professionals involved in health links between NHS trusts and health centres in low-income countries.

Alma Mata spoke to Dr John Sloan, an Accident and Emergency Consultant and the Coordinator of OPT IN (Overseas Partnering and Training Initiative: http://www.optin.uk.net) which has developed a number of capacity building projects through partnerships with hospitals in Bangladesh, Uganda and Swaziland.

Why should UK health professionals, working in the NHS be interested in international health (IH)?

I see the main reason as training and experience. With MMC [Modernising Medical Careers, the new doctors’ career structure], experience is the thing that our trainees will lose. Periods of work overseas can address this. When a doctor works in the less developed world, the basic clinical experience is far broader than what is possible for many in the UK. For instance, UK obstetrics and gynaecology trainees may see one or two eclamptics and no septic abortions. In Uganda they see these every week. They learn how to do Caesarean sections in extreme conditions, often 3-4 emergency sections per day. They see many vesico-vaginal repairs. The story is the same in general surgery and orthopaedics where extremely late presentations, gross pathology and masses of severe trauma are common. In radiology the images are those that would be seen rarely here, for example Pneumocystis Carinii pneumonia associated with HIV fills the wards. In medicine, the severe anaemia of malaria, the complications of HIV and the compromises that shortage of drugs force are all rare here. In paediatrics there are severely malnourished babies and children, tetanus is common and severe dehydration is a daily occurrence. I could go on and include the labs, but the medical and nursing value of links has to start with this basic clinical experience.

Most recently NHS Trusts have begun to express a sense of corporate responsibility to repay in kind some of the nations who have sourced many of our present NHS staff.

How, in your opinion, is the best way to combine interests in IH and the UK training?

There are many ways, but short term projects, closely supervised with clear objectives are a good starting point. This is why institutional links are so good. Within the framework of an institutional link, individual projects can be small, but the accumulated impact can be impressive.

At Specialist Registrar level it is harder as the training regulations mean that the trainee either takes time “out of programme” or goes with a consultant trainer with the approval of the training committee. In this case an attachment overseas can, in theory at least, count towards consultant training.

In a nutshell what does NHS Links offer to those working in the UK and in their partner hospitals?

For those in the UK the opportunity to broader their own horizons immensely while contributing in a very worthwhile way. For partner hospitals, the opportunity to help UK staff learn new aspects of medicine, and the opportunity to gain support and training for new service developments. And for both, a tremendous sense of global partnership.


John Sloan
Coordinator, OPT-IN
http://www.optin.uk.net.

Conclusion

In today’s globalising world, doctors increasingly find it impossible to practice medicine in isolation from global public health issues, such as conflict, migration and infectious diseases, including HIV. More than ever, the world needs well-informed advocates for the health of the poorest. The dissemination of international health research is vital to tackle the ‘10/90’ gap where, currently, only 10% of the $70 billion invested each year in health research is directed at 90% of the world’s health problems. It seems there are many routes into global health work, indeed the best thing you can do, if you are practising in a high-income country like the UK, may be to be active in research and advocacy to work towards correcting global health inequalities. For those of you who choose to work overseas through an NGO or schemes like NHS Links, be prepared to ‘learn more than you give.’ The skills you can gain from overseas work can aid your personal and professional development, without having to step off traditional career pathways.

Rebecca Hope