Helen Macdonald: Do I practise global health?

helen_macI was strolling around the poster hall at the WONCA conference in Prague yesterday, when the question occurred to me. I fell into conversation with the presenters of two linked posters. Joane Baumer and her colleagues, who were visiting from Texas, USA. They work for the JPS health network and have a developed a global health track in family medicine residency—that means their trainees are trained in global health and see patients from diverse cultures with diverse pathologies.

Their two posters were interesting and explained how creative thinking had resulted in an opportunity for junior doctors, and plugged a health need for their the local population. They work in a public centre seeing predominantly asylum seekers and immigrants from diverse cultures with diverse pathologies and health needs. Residents also have the chance to go abroad. Before the global health track started, working in this area of rural Texas was unpopular.

Step one was to lure more, and stronger, residency candidates to the scheme by creating a programme in global health—a draw for a subset of family medicine residents. It’s global health focus made the scheme more competitive. They have the stats (admittedly small numbers) to show that the programme is associated with recruiting more candidates with higher grades.  In return, the local community gets a group of young doctors particularly interested in their diversity and perhaps better trained to meet their needs.

I thought about my own clinical training in the UK, first in east London as a medical student and foundation doctor, and currently in a mixed area of east Oxford where my day to day work sounded remarkably similar to my Texan colleagues.

Have I subconsciously been practising global medicine for some time? Perhaps I have, and it alarms me slightly. I don’t recall having learned all that much about global health beyond a couple of lectures at medical school about rare tropical diseases that I have long since forgotten, and the experiences of doctors delivering healthcare in resource poor settings.

Now I stop and think about it, I have had experience of global medicine, it’s just that I’ve never labelled it as such. My experience of global medicine is as a junior doctor working in diverse areas of a high income country with universal health coverage. For example, I quickly ticked off my observed births among the Bengali community in Whitechapel, while my male student colleagues sat bored and excluded in the corridors of The Royal London Hospital. As a foundation doctor I have reached for the sickle cell crisis folders from the top shelf in the Homerton hospital admissions ward. I have sat sweaty and a little intimidated in a cramped cupboard (the only place in the emergency department with a phone) to get language line and to assess the mental state of a cuffed and agitated suicidal asylum seeker facing deportation, with the huge policeman who sectioned him watching over me. I’ve taken a few grossly inadequate histories when the translators have gone home, for example questioning a lady from the Democratic Republic of the Congo in Spanish with her answering me in Portuguese. I’ve learned about how to separate culturally congruent beliefs from delusions in psychiatry, and taken a smear confused by the jumbled anatomy of female genital mutilation. In GP, I’ve tried to get a Nepali patient on board with reversing a dubious diagnosis of hypertension, explained to a Polish patient that in the UK it is a GP, not a specialist who will care for her on the whole, and that annual smear tests are not needed.

So it’s been there all along. Am I alone in never having recognised this? As a profession do we recognise the impact of global health on UK clinical medicine in primary and secondary care? Should we know more? And, for my generation of doctors, can we build and design healthcare better in our own countries to serve patients irrespective of their country or culture of origin?

Helen Macdonald is an assistant editor, BMJ.