Carmi Z Margolis on global health education

When he first entered the spacious great room, a colleague exclaimed: “What an amazing place! I’ve always wanted to come to Bellagio! How did you do it?” I imagine most of our conference participants had similar thoughts. The Rockefeller Foundation Bellagio Conference Centre, situated on the grounds of an ancient villa that belonged to the aristocratic Sfondrati and Serbelloni families, stretches from the shore of Lago di Como, deepest of Italy’s Lombardy lakes, to the summit of a steep hill. Bellagio’s reputation rests not so much on its idyllic surroundings as on the brilliance with which these surroundings have been re- designed. Airy, comfortable conference rooms and widely spaced, personalized accommodations facilitate the lengthy, intense discussions, occasional relaxing walks with endless surprising views and excellent Italian cuisine that provide just the right setting for a scientific conference on a single controversial topic.

Over the last 50 years, the centre has “served as backdrop for a number of meaningful advances. It was the staging ground for efforts to mobilise an agricultural revolution that saved a billion lives in Latin America and Asia…It was the setting for negotiations and agreements that make it easier for people suffering from HIV/AIDS … to access better vaccines and drugs… Bellagio conferences and participants are selected from around the world…” 

Getting accepted for a Bellagio conference is not easy. It involves submitting a proposal that is judged according to whether it addresses a global issue, can be expected to lead to a concrete, innovative outcome and expand opportunities for poor or vulnerable people. Our proposal aimed to stimulate international discussion about teaching and evaluating Global Health Education (GHE), with a particular emphasis on medical students. Conferences are limited to a maximum of 23 participants and everyone we approached agreed at first to come without knowing the date. Finally, after only four withdrew, 22 experts participated in September, 2008, from 8 countries and 15 institutions.

Each of the conference themes was discussed in a brief paper circulated prior to the conference. Unusual examples of GHE were presented in posters (e.g. the required International Health and Medicine Track of the Medical School for International Health).  Each theme was then presented from several viewpoints, followed by general discussion.  Nominal Group Process (NGP)  in small groups was used to process a central question related to the theme. The following summary presents a key recommendation related to each of the five themes. For a complete discussion of these issues, please see our article. 
Definition/ Scope of Global Health (GH)

There is no all-inclusive definition of GH. Any definition should  emphasize four concepts:

1. Health equity= health for all;

2. Global preventive medicine and public health;

3. Interaction of the practical disciplines of medicine, allied health professions, public health and medical care administration;

4. Application of a cross cultural approach that is linked to a knowledge base in various existing disciplines, (e.g. medical anthropology) and involves capability to work with practitioners of relevant disciplines, (e.g. agriculture).

GH Competencies

There are general GH core competencies that may be applicable to an individual or to a community and locally defined ones that are tailored to a specific site. General GH competencies apply across sites around the world, for students from low and middle income countries as well as high income countries. Most important for the medical student or medical graduate is an approach of cultural humility,  respect and curiosity towards cultures other than one’s own. This must precede effective learning of both general and local core GH competencies.

Guidelines for international placements

An international placement is the best place to learn cultural humility. Such placements must be based on inter-institutional understanding and cooperation that is strengthened by discovering ways in which each of the partner institutions can help the other.

Establishing relationships between international institutions: Effective inter-institutional collaboration requires transparency, trust and professionalism in reaching mutual understanding regarding commitment to a long term institutional partnership that includes educational, research and service activities. The collaboration should be defined in writing. 

Evaluation:  Three  types of evaluation, including program, individual and long term or impact evaluation, should be planned for GHE. Emphasis should be placed on qualitative techniques, such as supervised reflection  and narrative medicine , to evaluate validly the student’s approach to cultural humility.

On the last night, we rearranged the furniture in the great room in an irregular circle. Everyone came to what had been advertised as an optional Talent Night.  After repeated protestations of talentlessness, fascinating presentations ranged from  the declaiming  by heart of Service’s epic ballad of the late 19th century California gold rush, “The shooting of Dan McGrew,” to jokes from Ethiopia and Huguenot France, a game from India, a poem about the earthy Einstein statue in Washington, dance and Yoga classes, stories from Nepal, Zambia, Uganda, Fiji and Canada, to, finally, singing mystical Jewish poetry passed on for three generations.

Perhaps closest to our conference’s topic was one of our African Dean’s recounting how he walked to school barefoot, 2 to 14km, until he first wore shoes in high school. He then explained that he once taught himself to play the ‘mouth organ,’ pulled out a harmonica and proceeded to play a fine, sweet tune —talentlessly, of course.

Carmi Z Margolis is Dean Emeritus, Medical School for International Health, BZ Hersch Professor and Chair, Moshe Prywes Center for Medical Education, Ben Gurion University, Beer-Sheva, Israel.