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David Geffen School of Medicine

The New Medical Missionaries

To read the complete version of this article, go to The New England Journal of Medicine page at http://content.nejm.org/cgi/content/full/354/17/1771
Noelle Benzekri is a UCLA medical student with a mission. Even before the New York native spent a year as a clinic assistant and polio vaccinateur in Senegal, she knew global health was her calling. “It’s the reason I decided to go to medical school,” she says. Spurred by memories of her African patients, Benzekri intends to return to Africa to train local health workers to deliver care to the poorest of the poor.

Benzekri’s classmate, Sue Tuddenham, is another UCLA medical student with prior global-health experience and big dreams. After graduating from Yale, she completed a degree in international relations at the London School of Economics, worked in the Hanoi office of the Population Council, and then took a job with the International Trachoma Initiative evaluating trachoma- control programs in Niger, Tanzania and Vietnam. During her first week of medical school, she was already seeking mentors for a career in globalhealth policy.

Many students and trainees atUCLA share Benzekri’s and Tuddenham’s hopes for greater global equity in health in their lifetimes. They are hungry to discuss diseases of poverty as well as international policy and aid programs. In the curricula at most medical schools and postgraduate institutions in the United States, however, these topics receive little time and attention. A new generation of activists could change that. In 2003, at least 20 percent of students graduating from U.S. medical schools had participated in overseas activities related to international health, compared with 6 percent of 1984 graduates, according to Association of American Medical Colleges (AAMC) surveys. Those who go overseas often are inspired by peers who have already rotated abroad. Benzekri and Tuddenham, for instance, may look to Sagar Vaidya, an M.D.-Ph.D. candidate at UCLA who has volunteered at a rural clinic inMexico and has also completed clerkships in India and Vietnam. Or Shilpa Sayana and her husband, Rishi Manchanda, residents in internal medicine who recently participated in a rollout of antiretroviral drugs in Durban, South Africa.

Trainees who search hard enough and can pay their own expenses will always find exciting international medical opportunities. But their schools and residency programs rarely give anything more than moral support and elective credit. As a result, the few travel fellowships available each year to medical trainees are flooded with applicants. Last year, a program sponsored by the American Society of Tropical Medicine and Hygiene received 130 applications and awarded 10 student fellowships for projects in a variety of venues, including an entomologic field site in Senegal, a war-torn setting in Uganda, and a mobile, railroad-based hospital in India. Rarely, a department head will use discretionary funds to pay for trainees’ overseas electives—as Dr. Gautam Chaudhuri, executive chair of the UCLA Department of Obstetrics and Gynecology, has done. Nearly all of UCLA’s OB-GYN residents, traveling in pairs and accompanied by at least one faculty member, now spend three weeks in Eritrea, a country in which the rates of complications during childbirth are among the highest in the world.

What is fueling the hunger for overseas learning among the next generation of medical professionals? Many of these young people have already traveled a lot, says Michele Barry, cofounder of the Yale-Johnson & Johnson Physician Scholars in International Health program, and media coverage has raised their awareness of global-health issues. In addition, she notes, first-generation Americans whose families come from developing countries often want to give back to less-privileged people and regions of the world. Surveys have shown that graduates of the Yale- Johnson & Johnson program express a greater commitment to underserved populations at home and abroad than do non-participants.

No matter what motivates them at the outset, long-termbenefits can accrue fromtrainees’ spending even a few weeks overseas—and not just broadened clinical and cultural competence. The weeks that residents spend in low-resource settings teach cost-conscious practice and back-to-basics diagnosis. And according to Dr. Malini Anand, an OB-GYN resident at UCLA, returning residents also continue to bear witness—to colleagues, family, and friends—regarding the health conditions they have seen. Their reports, in turn, increase public awareness, which may be partly responsible for the recent increase in U.S. foreign aid for global health.

Historically, so-called missionary medicine was focused on spreading religion as well as compassionate care. Today, the forces behind global-health efforts aremore secular.Nonetheless, the movement continues to be motivated by a sense of mission—a word with a Latin root, mittere (to send), that suggests an important question: If there is new fervor for global health on the part of medical professionals and international policymakers, shouldn’t the “sending” process be more organized—and the vision bigger and bolder?

In a 2005 report, the Institute of Medicine recommended establishing a federally funded U.S. Global Health Service that would send mid-career professionals overseas to help augment local responses to human immunodeficiency virus infection and AIDS, tuberculosis and malaria; provide fellowships and partial repayment of student loans; foster international healthcare partnerships; and create a global-health employment clearinghouse for paid or volunteer positions. The establishment of such a federal program would offer some hope of support for young professionals who are ready to dedicate themselves to global health.
Written By Claire Panosian, M.D. and Thomas J. Coates, Ph.D.

Thomas J. Coates and Claire Panosian are co-founders of UCLA's Program in Global Health at the Division of Infectious Diseases. Adapted with permission from The New England Journal of Medicine (April 27, 2006, Copyright © 2006 Massachusetts Medical Society, all rights reserved)


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