More than 15 years ago, as Albert I. Ko, M.D., was working in the urban slums of Brazil as a physician and field epidemiologist during his infectious disease fellowship at Cornell. One of his advisors asked him to return to the U.S., mentioning that the only way to succeed in academic international medicine was to pursue laboratory-based pathogenesis. Instead, Ko, associate professor of epidemiology (microbial diseases) and of medicine (infectious diseases) stayed in Salvador, Brazil, for 15 years. During that time he worked with Brazilian health professionals and researchers, studying the effects of slum life—poverty, illiteracy, malnutrition, lack of clean water, open sewage, no access to health care or vaccinations—on the health of marginalized and neglected urban populations, and identifying and implementing interventions at the community level.
Ko described his experiences there in his keynote address at the Department of Internal Medicine’s symposium on May 5, “From Resident Education to Global Medical Care, Education, and Capacity Building.” The symposium celebrated 30 years of the department’s international relationships including what is now called Yale/Stanford Johnson & Johnson Global Health Scholars Program.
Those relationships began in 1981, when Michele Barry, M.D., HS ’77, and Frank J. Bia, M.D., M.P.H., FW ’79, began sending residents abroad for clinical rotations as part of their training. “Nobody else was doing it,” Barry recalled in May. “Now it has become incredibly popular. Is this a paradigm shift in thinking or is it a fad?”
Barry, formerly on the Yale faculty and now senior associate dean for global health at the Stanford University Medical Center, spoke at grand rounds on May 5 in celebration of the international program. Since 1981 the program has sent more than six hundred residents and attendings to countries in the developing world. What was then called tropical medicine has expanded to global health. At the end of the program’s first decade only one in five medical schools offered global health opportunities. Now, said Barry, all medical schools do.
For people in the developing world, Barry said, disparities in income, literacy, access to clean water, pharmaceutical research and development, and the health care workforce contribute to poor health outcomes.
“Where my heart is now is in innovation,” Barry said. At Stanford she works with faculty from the business school, the engineering school, and the design school to design drugs, diagnostics, and devices in innovative ways. Among their innovations are a low-cost incubator for infants and a $25 nylon prosthetic limb.
Asghar Rastegar, M.D., professor of medicine and director of the Office of Global Health at the Department of Medicine, noted that the interest in global health coincides with demographic and other changes. By the mid 1990s, he said, 13 percent of the population in the United States was born abroad, and 60 million Americans had traveled abroad. Global health also met a desire among doctors to volunteer, both locally and abroad. And there were the threats of emerging pathogens in the developing world. “HIV changed the world,” Rastegar said.
Over the years the international program has adopted different forms, philosophies, and goals. It started with one training site in Haiti, grew to 16 sites around the world, and now sends residents to five.
“By 2003 we were all over the place, said Bia, former co-director of the program and now medical director at AmeriCares. “It felt like a travel agency. This couldn’t go on forever. If you want to do something and do it well, you have to go deep. You have to narrow it down. That’s what’s happening now.”
A prototype for the new model of collaboration was developed over the past 16 years in Kazan, Russia, under the leadership of Majid Sadigh, M.D., associate professor of medicine. The five current sites—in Uganda, South Africa, Liberia, Indonesia, and Rwanda—share a focus on bilateral training and capacity building. The Uganda project, for example, focuses on training subspecialists at the medical school at Makerere University and the Mulago Foundation, while the South Africa site, under leadership of Gerald Friedland, M.D., professor of medicine, focuses on treatment of HIV/TB co-infection and training young investigators committed to improving care in under-resourced regions of the world.
“The focus,” said Rastegar, “has shifted from being a program for residents and students to the impact on the care of the patient at the host institutions. It is not about us, it is about them.”