In 1966, when the medical school first began offering international fellowships to medical and public health students, the typical fellow was a young man getting his first passport. Today’s fellows are much more diverse—they are as likely to be female as male, six of the 20 fellows who went abroad in 2008 weren’t native-born Americans, and because they came of age in the era of affordable air travel, all have previously visited a foreign country.

“The profile of the student now interested in getting the fellowship has changed,” said Kaveh Khoshnood, M.P.H. ’89, Ph.D. ’95, assistant professor of epidemiology (microbial diseases) and chair of the Committee on International Health (CIH), which administers the Downs International Health Student Travel Fellowship. “Forty years ago, it was a lot of white kids from Kansas who’d never been outside the United States.”

As the student body changes, the fellowship program faces an emerging challenge: balancing the relative importance of taking a culture versus taking in a culture. As more people come to the United States as refugees or immigrants, do students have to travel abroad to gain foreign experience?

The late Wilbur G. Downs, M.D., M.P.H., a renowned Yale virologist, started the fellowship program with the idea that students should have a chance to do research in the Third World, where their work could do the most good. His experiences in Africa had left him with the deep understanding that poverty, malnutrition and infectious diseases, combined with the corruption often seen in single-party nation-states, lead to grave health consequences. Students would find a Yale mentor and a mentor in the host country, travel somewhere they’d never been—typically to Asia, Africa or Latin America—and conduct rigorous and ethical scientific research. Downs felt that they should immerse themselves in the culture during their stay, but the program’s new director, Khoshnood, wants to take a fresh look at what it means to explore a different culture.

A longstanding foreign imprint

Yale alumni, faculty and students have embarked on inter-national health missions since 1834, when Peter Parker, M.D., a medical school graduate and missionary, established the Ophthalmic Hospital in Canton (now known as Guangzhou), the first Western hospital in China. In 1915 the Yale-China Association opened another hospital in Changsha. After World War II, medical school faculty were active in the Atomic Bomb Casualty Commission’s epidemiological studies in Japan. When Yale President Kingman Brewster established a program to send students abroad in 1965, Downs secured a $5,000 grant from the Rockefeller Foundation to launch the fellowship. Since then the program has sent 444 Yale students to scores of resource-poor nations and has expanded to include nursing and physician associate students as well as those from the schools of medicine and public health.

Downs fellows have studied diseases spread by sand flies in Peru, HIV transmission among drug users in Vietnam, the eating disorder pica among Haitian women of childbearing age, and post-traumatic stress disorder (PTSD) among survivors of war in East Timor. Though he retired as a professor of epidemiology and public health in 1972, Downs remained committed to the program until his death in 1991. Curtis L. Patton, Ph.D., professor emeritus of epidemiology, longtime friend, colleague and traveling companion of Downs, took over as CIH chair until his retirement in 2006.

“We like to think of it as one of our flagship programs,” said Paul D. Cleary, Ph.D., dean of public health. “We’re proud of it, and we try to bolster and promote it.”

According to Khoshnood, however, the program needs to adjust to the changing demographics of the students. As an Iranian-American, he personifies the change not just in the program, but also in Yale and in academia, where minorities make up an increasing portion of the student body.

“Global health could mean practicing outside the United States, but it could also mean working with the immigrant population in the United States,” he said.

He also thinks that the fellowship needn’t be limited to developing countries. “We’re not going to send you to the capitals of Europe,” he said, but he sees nothing wrong with, say, a Downs fellow working with North African refugees in Spain. “What if a student wants to go live among them to see if they have health issues? These scenarios were raised. We decided to table that this year because we couldn’t reach an agreement.”

And Khoshnood hopes to rethink the program’s reluctance to send students to ancestral homelands or countries they already know. “The fact that they are familiar with the culture and language is a good thing,” Khoshnood said. “Their research would benefit from this existing knowledge.”

One of Khoshnood’s students, Farnoosh Hashemian, M.P.H. ’05, a 2004 Downs fellow, convinced the CIH to let her travel to her native Iran to study the mental health of Kurds exposed to chemical weapons during the Iran-Iraq war of 1980-1988, noting that she would benefit culturally because she grew up in Tehran and her work was in the rural Kurdish region, a far cry from the life she knew. “Iran is not a homogeneous country,” she said. Her work, which found high levels of PTSD among those exposed to chemical weapons even 16 years after the war ended, was published in 2006 in JAMA: The Journal of the American Medical Association—a rare feat, Khoshnood said, for a project done in only two months and on a shoestring budget.

Tim Mercer, an M.P.H. candidate and 2008 Downs fellow, argued that his two previous trips to Kenya would help him to do research there on the lives of street children. “The more you visit a foreign place, the more you learn about the culture, the more entrenched in it you become,” he said.

Patton acknowledged that familiarity can help, but added, “This is not a fellowship to visit aunts or uncles.”

The debate continues. Some longtime committee members regard the cultural experience as sacrosanct. According to Herbert S. Sacks, M.D. ’52, HS ’56, clinical professor in the Child Study Center, and a founding member of the CIH, one goal of the program is to get students out of what he called “academic lockstep.”

“We give them an opportunity to start looking at themselves and to reflect about their goals,” Sacks said. “What better opportunity to do this but in a contrasting culture? One of the questions is, ‘Why do you have to go to Zambia? Why not just go to the ghetto areas in New Haven, Bridgeport or Hartford?’ I think it’s too easy to go to these areas and work eight hours a day and return to your buddies and the routine of everyday academic life.”

Nicole Britten, an M.P.H. candidate whose 2008 Downs fellowship took her to Colombia to study tuberculosis transmission among family members, said a balance is crucial. “It would be wrong to sacrifice scientific rigor for cultural experience, but it would be disappointing to have a rigorous project with no cultural experience,” she said. Britten said she was struck by the hospitality of even her most destitute subjects in Colombia. While she required an interpreter for her research, “I have also learned how far body language and facial expressions can go in putting a person at ease when talking about sensitive issues.”

Sending students to do research in resource-poor countries also helps them learn to think on their feet in the face of power failures or inadequate water and medical supplies. Erik Hett, M.P.H. ’00, who studied disease transmission by tsetse flies in Kenya in 1999, learned to trap the flies by putting jars near water buffalos, whose scent attracted the insects. He and a colleague were extracting DNA from the flies with a centrifuge when the electricity in their village failed, threatening to wipe out their entire day’s work. They drove 20 minutes before finding the only working generator in town, at a beauty salon. “There were four hairdressers and a few patrons, and we had a centrifuge on their only table,” he recalled.

“We can’t imagine the things they have to deal with,” Patton said. “Research has been done on the hood of a car. They have to be resourceful.”

Safety and culture shock

Each trip by a Downs fellow starts with a research proposal submitted in January and reviewed by a Yale mentor. The Human Investigation Committee then reviews the proposal to ensure that it meets criteria for protecting research subjects. Proposals must also pass muster with institutional review boards in the host country, which provides yet another lesson, this time on how to navigate a foreign bureaucracy. Then the Downs committee interviews the student. “They’re not going to get exposed to stressful interviews, but the questions are designed to help them further refine their proposals and clarify their motivations,” Sacks said.

Khoshnood notes that the final proposals are often far removed from the original submissions. “I tell the students that this is a great project if you have five years and $500,000,” he said, “but you have three months and $5,000.”

“As young people, we have grand ideas of what we’re capable of doing,” said Patton.

The awardees are announced in early March; last year 27 students applied for the 20 available fellowships.

The student must also find a mentor at an academic institution or organization in the host country. Often the on-site mentor is found through personal relationships with Yale faculty, and sometimes at the last minute. Khoshnood would like to develop “more sustained and long-term partnerships with a few institutions rather than one-time student projects.”

Funding for the fellows’ two- to three-month stays comes not just from the Downs fellowship—an endowment that covers travel expenses, visas, insurance, immunizations and medications and provides a modest stipend—but also from the School of Medicine’s Office of Student Research, which provides an additional $5,000 for research expenses. [See “Downs Fellows Cover the World”]

In 2008 the CIH had all applicants take the extra step of filling out a one-page statement about how they would protect themselves. They needed to learn not only about the political climate and the history of the country but also whether there were any disease outbreaks that could affect them. They also needed an alternate plan in case their first proposal doesn’t work out. “We’re not hovering parents, to say the least, but we want to make sure we’re not putting anyone in the lion’s mouth,” Sacks said.

“We put them through the hoops of attending to their own affairs,” Patton said. “There are things they may not have thought of when they first applied, like how to protect yourself with words.”

Food riots in Haiti last summer diverted nursing student Eden Garber from her plan to conduct nutritional assessments of children there. “It was a bit frustrating,” said Garber, who had been studying Creole for two years. After some last-minute revisions to her application, she was off to Uganda.

“Uganda wasn’t on my list of places I want to go before I die,” Garber said. Still, she fell in love with the country and with the people she worked with.

Safety is not the only issue confronting Downs fellows. Among the elements of culture shock is the realization that they often stand apart from the local population. “I was constantly hissed at in the street and received a lot of attention from men,” said nursing student Jessica Pettigrew, who worked with Haitian refugees in the Dominican Republic after the food riots stymied her plans to go to Haiti. “Everyone turned and stared at me, so I was constantly riddled with a certain self-consciousness. When I was doing my fieldwork in the sugar cane fields, there was this assumption that we could heal and help everyone.”

Hett didn’t enjoy being gawked at while he studied tsetse flies in Kenya, but he recognized its sometimes discomfiting perks. “You get treated like royalty for no reason. Just the color of your skin opens up doors,” he said. “It puts you in sort of an awkward position. You want to try to get to know people, but I guess you could never cross that barrier to get to really know them.”

Although Rosha Forman, a nursing student who studied the practices of midwives in Zambia in 2008, found friends quickly in the expatriate community, that wasn’t why she’d gone there. “My challenge was to not fall into easy friendships with foreigners, but instead to work at my friendships with Zambians, as those were the people I was coming to get to know,” she said.

The complexities of foreign research are nothing new. One of the earliest Downs fellows, Leonard M. Milstone, M.D. ’70, HS ’77, research scientist and professor emeritus of dermatology, went to Trinidad in 1967 to trap mosquitoes and isolate arboviruses. Because English was the common language and the Caribbean island was not as poor as other developing nations, Milstone said he didn’t experience the disorientation other Downs fellows have described. The next summer, however, Milstone traveled to a Native American reservation in New Mexico for a non-Downs research project. Although in both locations he lived in Western-style housing and ate Western food, he found the Trinidad experience less culturally challenging in a way that presages Khoshnood’s approach to cultural immersion. “I found the culture on the Indian reservation in New Mexico far more foreign than the culture I experienced in Trinidad,” Milstone said. YM