Learning Medicine By Reaching Around the World

By Andrea Crawford

Although he rejects the label, Craig Spencer, MD, MPH, is often called a hero. “He’s a hero to our students,” says Stephen Nicholas, MD, associate dean for admissions at P&S and a leader in global health. “He’s a hero to me.” Dr. Spencer, of course, is the Columbia emergency physician who volunteered for Doctors Without Borders to treat people with Ebola in Guinea last year and after returning home became the first person diagnosed with the disease in New York City. Following news of his diagnosis, the assistant professor of medicine was both vilified and lionized, called a fraud and a hero. “The truth is,” Dr. Spencer wrote in the New England Journal of Medicine in March, “I am none of those things. I’m just someone who answered a call for help and was lucky enough to survive.”

https://www.youtube.com/watch?v=tgnGKwXt0FM

But answering that call for help despite the risks he would face—like so many others before and since—in fact resonates powerfully among Dr. Spencer’s peers in health care. “These experiences touch very deeply the core values that bring you into caring for others,” says Dr. Nicholas, a pediatrician. “These are not old-fashioned values; they’re timeless and the reminder of where your interest comes from in the first place.” That may be especially so for physicians in training, students like many today at Columbia who demonstrate a growing interest in global health education and training opportunities.

This year P&S has been building upon Columbia University’s deep history in international work across the medical school and other divisions to enhance the training in global health available to its students and to respond to their heightened interest. “We’ve expanded the locations, opportunities, and funding available for students,” says Lisa Mellman, MD, senior associate dean for student affairs at P&S. Last fall, P&S launched the Dr. Edgar Housepian Global Health Lecture Series, in partnership with the Wu Center for Global Health Initiatives and the Grodman Dual Degree Program. The Wu Center, established with an endowment from Columbia University trustee emeritus Clyde Y.C. Wu’56, and his wife, Helen Tseng Wu, will oversee joint pilot research projects and exchanges of faculty and fellows between CUMC and the Zhejiang University School of Medicine in Hangzhou, China, building on a link between Columbia and China that dates to the 1920s.

These programs join a long roster of opportunities for students to gain global experiences at multiple points in the curriculum. While many of the offerings are new, they augment others in existence for decades. Recently, P&S has placed particular focus on Africa, specifically on work in Lesotho, where Columbia is helping to develop a medical school. P&S faculty and students have worked for 15 years in the Dominican Republic, where P&S has recently partnered with the Universidad Nacional Pedro Henriquez Urena (UNPHU), creating stronger ties with a country to which 70 percent of the residents of the medical center’s Washington Heights neighborhood trace their cultural heritage.

In November, P&S administrators renewed the school’s affiliation with the Medical School for International Health at Ben Gurion University for another five years, perpetuating the availability of training opportunities at sites in Israel, India, Sri Lanka, Ethiopia, Kenya, Nepal, and Peru. English-speaking placements in Australia, England, and Ireland also are popular with students, says Dr. Mellman.

Students also can participate in the Next Generation Program at ICAP. Situated at the Mailman School of Public Health, ICAP at Columbia University has become a global health leader since it was established in 2004 to improve the health of families and communities currently in more than 25 countries around the world. Through ICAP, students selected for the Next Generation Program engage in real-world experience working hand-in-hand with ICAP staff in-country and with staff from organizations with which it partners. “Students spend two to six months engaged in the design, implementation, and evaluation of ICAP-supported programs while working side-by-side with global health experts in sub-Saharan Africa and Asia,” says Wafaa ElSadr, MD, University Professor and founder and director of ICAP. “Not only do they gain so much from these experiences, but they certainly contribute through their enthusiasm, curiosity, and commitment.”

The possibility for students to take advantage of global learning opportunities increased sharply a few years ago when P&S instituted a curricular overhaul. As part of the new curriculum, students pursue scholarly projects during a four- to 10-month period of dedicated research in one of six tracks, of which global health, under the direction of Dr. Nicholas, is one. In 2014, global health was the second most popular scholarly project track. The new curriculum is augmented by the option for first-year students to spend up to eight weeks doing summer international research or study. And following the major clinical year, students may pursue international senior electives, for which P&S has 29 exchange agreements in place encompassing every continent except Antarctica. Students also may pursue electives offered in conjunction with ICAP at sites in sub-Saharan Africa and Central Asia; the Earth Institute’s Millennium Villages Project, with sites in sub-Saharan Africa; and the IFAP global health program in the Dominican Republic, founded by Dr. Nicholas in 1999.

Students see the world, and the world’s opportunities and challenges, in global terms and they come to medical school with the interest and expectation of participating in global experiences. “It’s a particularly well-traveled generation, even for those without means,” says Dr. Mellman. “Historically, international opportunities were limited to students whose families could afford to send them to other countries,” says Dr. Nicholas. “At P&S we have tried our best to provide financial support for travel and living expenses so the opportunity is available to any student who wants the experience.”

Working abroad is what brought Rachel Criswell’17 to medical school in the first place. Former co-president of the longstanding student-run interest group, which recently changed its name to the Global Health Organization, Ms. Criswell earned an undergraduate degree in Slavic languages and was awarded a Fulbright Scholarship to research women’s reproductive health in Ukraine. Afterwards, she went to work for an NGO supporting rural primary health care clinics in Liberia—where she realized she wanted to do clinical work. People of her generation have often traveled on short-term medical mission or medical research trips, Ms. Criswell notes, and “when they’re there, they like it and see the need for deeper involvement and a deeper understanding.”

One of her classmates, David Bridgman-Packer’17, also worked abroad as an undergraduate, volunteering as an EMT in Haiti after the 2010 earthquake. There he was exposed, he says, “to the really difficult problems that exist in the NGO community in trying to respond to disasters in an appropriate and productive way when there’s limited information, resources, and means.” He was subsequently drawn to medicine as a way to extend his interest in science and apply it in a political and social context.

It was Mr. Bridgman-Packer, along with Nathan Brand’17, who approached Dr. Nicholas last year to express interest in starting a medical student journal club devoted to global medicine. “What’s great about Columbia is that there are many faculty members who are doing work in global health,” says Mr. Bridgman-Packer. “The difficulty for us was creating a centralized place where students could identify potential opportunities and mentors to work with.” Out of those conversations with Dr. Nicholas emerged a committee that included faculty as well as Mr. Brand, Mr. Bridgman-Packer, Ms. Criswell, and other students who worked to create a new course.

The Dr. Edgar Housepian Global Health Lecture Series launched last September with a keynote lecture by Elaine Abrams’82, professor of epidemiology at Mailman and professor of pediatrics at P&S and senior director for research at ICAP. It concluded in December with a finale by Dr. Nicholas, the course director, on how to bring the lessons of global medicine back to local communities. In the weeks between, the course covered issues of global emergency medicine and trauma; maternal health, family planning, and abortion care; diseases of poverty and challenges to health and survival; global surgery and anesthesia; global nutrition and obesity; global mental health; global tobacco epidemic; non-communicable diseases; and HIV, TB, and malaria. One evening in late September, Stephen Morse, MD, professor of epidemiology at Mailman and director of the infectious disease epidemiology certificate program, was scheduled to give the lecture “Ebola—A Surprise?” That day the Centers for Disease Control and Prevention confirmed the first case of Ebola diagnosed in the United States, in Dallas, Texas, and Dr. Morse had spent hours fielding calls from reporters. To speak to students uninterrupted that night, he had to turn off his phone.

The optional course, with its lectures, break-out sessions, and required readings, gave students a grounding in the literature and topics. “It provided a foundational body of information to the students that has been complementary to the core curriculum,” Dr. Mellman says, and it has provided “a list of really wonderful faculty who will come and talk about the work they’re doing and, in that formal way, further expose students to their work.” Another goal for the students, says Mr. Brand, was to identify faculty who might serve as mentors, and the lecture series was a successful initiative in facilitating the process of linking interested students with potential mentors working in global health.

While the lecture course was in development, Dr. Nicholas said, organizers did not know if the course would attract even 20 students. But 180 students applied and 60 were accepted. Those enrolled came predominantly from P&S but also included students from Mailman, the College of Dental Medicine, the School of Nursing, and the School of International and Public Affairs.

In addition to mastering a foundational body of knowledge in global health, students must be culturally, psychologically, and practically prepared for work abroad. The process is extensive—with an emphasis on cultural competence, as well as such nitty-gritty concerns as pre-departure orientation and security briefings. The process does not end when students depart the United States. Like any health care professional who has worked in difficult locations around the world, students face a sometimes difficult transition when they return home. Dr. Nicholas likens it to when he, a self-described pale-faced cowboy from Wyoming, began working in New York City in the 1980s: “What did I know about Harlem? Well, all I knew was I didn’t know anything. That was a useful thing to know.”

Medical students going abroad must start with the premise of, first, do no harm, he says. And they need to know that they can do harm simply by their presence, by requiring time of their hosts, or by being judgmental or dismissive, even if those responses are unintended. It is easy for visitors to say, for example, “I can’t believe you don’t have this medicine or that diagnostic test,” Dr. Nicholas notes. “We can’t help it because we come from such different places.”

Frustrations can accrue when one works in a resource-limited setting, and students need to be trained on how to manage that frustration before it calcifies as anger or depression. But frustration, Dr. Nicholas says, “can also be part of the richness of learning how to problem-solve amidst challenges and limitations”—lessons that are invaluable to students of medicine, regardless of whether they plan careers in global health.

Dr. Nicholas learned of the unintended benefits of global experience firsthand. At the peak of the epidemic in 1990, when AIDS was the leading killer of children in Harlem, he was head of pediatrics at Harlem Hospital. By the late 1990s, as transmission rates in the United States plummeted, Dr. Nicholas—who had never thought about working in international health—“felt a moral obligation in a world filled with HIV to think beyond our own shores,” he says. At the time the Caribbean had the second-highest rate of HIV infection in the world, second to sub-Saharan Africa, and 85 percent of all infected individuals resided on one island, Hispaniola, shared by Haiti and the Dominican Republic. He launched IFAP in 1999, introducing the first AIDS treatment for pregnant women. In the province where the program is based, the rate of mother-to-child HIV transmission is now as low as New York’s. The clinic, which opened in 2004, is now one of the largest providers of care and treatment for children and adults in the country. IFAP started hosting P&S students there in 2002 and added students from other disciplines in 2008. Since then, about 500 students have done rotations in the Dominican Republic. “We’ve been able to bring the transmission rates way down nationally,” Dr. Nicholas says. “In the province where we’re working, we’ve had no infected babies for the last two years.”

Those are results he set out to achieve. But after he began working in the country—immersing himself in its language, place, and culture—Dr. Nicholas was surprised to see that he was becoming a better doctor for his patients at home, too. “I thought I was a pretty good doctor for them, but I just didn’t realize how limited I was,” he says. When your patients are immigrants—newly arrived or even second-generation—understanding their culture of origin often makes a physician more empathetic, he says. “It gives you a more sophisticated way to interact with patients, and they then trust you more.”

Strengthening connections with local communities is an important goal in global medicine. Rafael Lantigua, MD, who has been instrumental in building CUMC’s partnership with UNPHU, puts it this way: “There’s an air bridge daily between New York and Santo Domingo that’s moving around 4,000 people every day one way and the other.” In addition, students have recently worked with patients in Chinatown, as well as with immigrant groups that settled in the outskirts of Beijing. Programs also seek to link students who care for people of the West African diaspora in Harlem to efforts in their countries of origin. As Mr. Bridgman-Packer says, “In New York City, we need to be sensitive to our patients’ vast range of different cultures, identities, and ideologies.”

Students understand how important this level of cultural awareness is for their future careers, no matter where they may be working. Students see the principles of global health as benefiting them as physicians working in the United States, Ms. Criswell says, because the issues at play around the world are relevant at home too. Moreover, as people, ideas, and products move across borders, so do diseases. What happens globally directly affects how medical professionals engineer their local health care systems.

Thus the benefit of broader experience is more than cultural, but clinical and technical as well. Resource-limited settings do not have the many tools and laboratories that physicians now typically rely on, so work in such an environment sharpens one’s skills. “Your differential diagnosis capacity goes way up because you’ve got to deduce what’s going on,” says Dr. Nicholas. And students are introduced to diseases they do not often see in the United States. When students do a rotation at the children’s hospital at UNPHU in the Dominican Republic, says Dr. Lantigua, they see dengue fever, polio, and rheumatic heart disease. And when chikungunya, a new, mosquito-borne virus, first appeared in the Caribbean at the end of 2013, P&S students who had seen the virus when they worked in the Dominican Republic were able to recognize it when it appeared in the emergency room at Columbia. It is a perfect example, Dr. Nicholas notes, of how context and exposure make one a better doctor.

These wide-ranging benefits of global medicine, however important, are not ultimately what calls someone to work in locations around the world. Students say their desire lies in the impulse that made them want to care for others in the first place. For many students today, that urge is manifest in a broader call for social justice in medicine, a call in which the global and the local are intimately intertwined. Says Mr. Bridgman-Packer: “The themes of inequality and their impact on health that we generally study in resource-poor settings are also highly relevant in New York because in many ways the inequalities here operate on the same principles as inequalities existing anywhere else in the world.”