Case history

H. Rosling (Stockholm, Sweden)

This paper reviews how the development of research on global health problems is medical schools in Europe is resulting in new courses in global medicine in the undergraduate training. In the Nordic countries international health is emerging as a discipline in many medical schools. It is defined as a study of global variations in health status, with focus on interdisciplinary studies of health determinants, health systems, disease causes, clinical management and control of diseases among poor population groups in low and middle-income countries.

International health constitutes a revision and widening of the old concept of tropical medicine, that focused on specific parasitic disease that have been or become exotic to high income countries. International health encompasses a widened concept of global health. The research and teaching focus on the wide variety of both infectious and other diseases as well as how to organise health systems in countries with scarce resources. Infectious diseases do remain a central part, but nutrition, child health and maternal and reproductive health are as important. Another branch that has grown out of 'tropical medicine' is 'travel medicine' covering the needed for people from high income countries who for different reasons visit other parts of the world. It includes prevention and management of infectious diseases, traffic accidents, sexual transmitted diseases and other conditions for which such travellers are at risk to acquire. Another subdiscipline emerging form tropical medicine is migration and refugee medicine that range from studies of infections diseases to post-traumatic stress syndromes. International health is in different ways encompassing all these aspects. Another tendency is that well-established disciplines establish 'international' subdisciplines, such as international child health and international maternal health. International health may in fact in some schools be regarded as a subdiscipline of public heath.

International health in undergraduate training

Undergraduate study of the teaching in international health in 100 medical schools in 'developed countries' revealed that the teaching about global health problems is very limited in undergraduate education (1). The teaching in Swedish medical schools on global health problems has up to recently mainly been done in extra-curriculum evening courses that have not formed part of the regular educational programmes. About 10-15 % of students have attended these courses that have been named international medicine or medicine in developing countries. A general reform of the medical education in 1994 gave the possibility to offer education in international health to more students. This reform introduced 5-weeks periods for optional courses in the 2nd, 4th and 5th year. The departments were invited to offer course modules of 1-5 weeks and budgets were allocated based on the number of students choosing each course. Starting in the 2nd semester of 1994 a course on global medicine was offered in these optional programmes at Uppsala University and it became the course that attracted the greatest number of students. Later the same course was offered at Karolinska Institute, the medical school in Stockholm, where it also became the most popular optional course among the students. In the 1st semester of 1997 almost half of the students at these two medical faculties take the optional course in global medicine.

The course in global medicine

The aim of the course is to teach how socio-economic, cultural and environmental factors determine the health of nations and how the global burden of disease and the demographic patterns vary between and within countries. A review of the disease transition during socio-economic development from infectious diseases and malnutrition to various forms of chronic diseases in adults is also taught. Students learn to use different sources of global health and demographic indicators in problem based learning sessions, where they analyse the health profiles of different countries. The long over-due division of nations in developing and industrialised is replaced by a new taxonomy reflecting the continuum of health status of the nations of the world as determined by general economic development and degree of equity in life conditions and access to health services in each country. Global variations in health policy and health service systems, modern as well as traditional, and the aims and activities of various international health organisations are reviewed. Teaching about food security and humanitarian assistance ends the first three weeks of the course. Cultural dimensions of health are covered in relation to reproductive health and food culture.

The last two weeks of teaching of the students from the Karolinska Institute is given by the Medical Colleges in Blantyr, Malawi or Trivandrum, India. Students pay the travel themselves, but may get additional study loans to cover part of the ticket costs. The Karolinska Institute pays the tuition from its core budget and gives students a small support for board and lodging only. During these two weeks the students are taught about cost-effectiveness and come to admire the clinical skills of the teachers in India and Africa, that have access to very few of the costly diagnostic techniques used in Sweden. They also have practical training sessions in health centres and are surprised how much health can be improved with very few resources if the primary health care strategy is optimally applied. Home visits to disadvantaged families under guidance by community nurses provide unique understanding of the tremendous global inequity in health determining life conditions. Several collaborative projects and reciprocal exchanges of students and teachers result from the contacts created. Students evaluations are very positive and typical comment is 'I lost prejudice and gained a new view of the world', indicate that the impact goes far beyond learning new facts.

The course provides knowledge and perspectives that will be useful in the next century whether today's student will work in pharmaceutical research, clinical practice or be an role player in the discourse on global development. The Karolinska Institute invites other medical faculties to collaborate in the development of teaching in global medicine and will share experience with all interested institutions.

References

Bandaranayake DR, International health teaching: a survey of 100 medical schools in developed countries, MedEduc 1992; 27; 360-2

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