The first two decades of the 21st century have brought a surge of enthusiasm and progress for global health. From celebrity activists and academics campaigning to end poverty, to the World Health Organization's transition from “Millennium Development” to “Sustainable Development” goals, to entities like the President's Emergency Plan for AIDS Relief (PEPFAR), the Bill and Melinda Gates Foundation, and the Global Fund committing hundreds of billions of dollars toward eradicating major causes of death and disease in the world, there has never been an era like ours for alleviating global suffering. Since 2015 and the publication of the Lancet Commission on Global Surgery, there has also been a growing appreciation for the critical role that surgery and anesthesiology (or lack thereof) play in the global burden of disease. With this, the rising tide of global health enthusiasm is buoyed by anesthesiology trainees who are eager to contribute. It takes more than enthusiasm, however, to address the problem of inequitable health care delivery in an ethical, sustainable, and respectable way. As stated eloquently in a recent editorial by Wollner et al., “Global health equity issues affect everyone everywhere, and are ours collectively to solve” (Can J Anaesth 2020;67:924-35). The why, what, and how of teaching our trainees well is one place to start.
Why trainees should learn about global health equity
The mission of “global health” is as broad as the name implies, and as an academic discipline it includes research, advocacy, practice, and policy directed toward improving health and achieving equity in health care access worldwide (Lancet 2009;373:1993-5). “Global surgery” has emerged as a sub-category of global health, reflecting the crisis of inequitable availability of safe and affordable surgery, obstetric, and anesthesia care and the myriad health impacts this incurs. In light of a history checkered by colonialism and often dictated by high-income actors, global health has recently shifted toward “global health equity” (GHE) with a focus on equalizing long-term benefit to communities of patients and professionals from global health efforts, which often takes a biosocial perspective. This shift necessarily affects our global health training and service models and requires an approach centered holistically on the aims of those in communities of need. It also pertains to academic recognition and research output, which has historically been inequitably shifted to benefit high-income country (HIC) individuals more than their low- and middle-income country (LMIC) collaborators.
There is a consistently high interest in pursuing GHE experiences among anesthesiology residency applicants and residents in the United States. Program availability of GHE opportunities has been cited as an important reason for choosing a residency, and thus, residencies with formal GHE partnerships are seen by many applicants as more desirable when compared to those without (Lancet 2009;373:1993-5). To this end, many anesthesiology trainees actively seek out GHE experiences during their residency. Unfortunately, time, clinical duties, funding, and other practical constraints often make participation in long-term, sustainable projects challenging during residency, which may shift available experiences for trainees toward short-term, clinical, “mission-based” work. These programs undoubtedly help individual patients; however, if conducted inappropriately, they may lack long-term, sustainable, collaborative goals and benefit to the LMIC populations they aim to serve. In some cases, these experiences can create a burden. It has been shown that LMIC hosts may find HIC trainee visitors imposing, and visitors may even cause workflow disruption and increases in patient complications (JAMA Surg 2021). Despite these challenges, exposure to formal GHE curricula can have a broad, positive impact on trainees' career paths and the populations they serve. It has been demonstrated that formal exposure to GHE education significantly increases the likelihood of trainees dedicating at least part of their careers to addressing health disparities in both HICs and LMICs (JAMA Surg 2021).
What trainees should learn about global health equity
Many anesthesiology residency programs sending trainees abroad for GHE experiences lack formal training in basic GHE principles, variations in clinical care, country-specific cultural competence, and the historic inequity in health system development and academic output. Furthermore, it is crucial for trainees and residency programs to realize that GHE is not simply defined by participation in clinical or educational activities for underserved populations outside the borders of HICs. GHE principles cross borders; even within HICs, disparities exist regarding equitable access to care, as has been seen at the forefront of the populations most severely affected by the COVID-19 pandemic. Thus, education in GHE should not be limited to those pursuing such work outside the U.S., as it can have meaningful benefit to all trainees.
The Consortium of Universities for Global Health (CUGH) has outlined three competency levels for global health equity training, ranging from basic knowledge applicable to all trainees to advanced coursework necessary for active career participation in GHE (www.CUGH.org). This structure may be adapted to anesthesiology training to cover the breadth of skills necessary for various levels of involvement (Table). Although competencies for GHE specific to anesthesiology have yet to be developed, there are practical ways to integrate these concepts into training and evaluation. The ACGME Core Competencies all have applicability to domestic and international equity issues. Examples include mastering a biosocial understanding of health (Medical Knowledge); managing anesthesia with an expanded formulary such as with halothane and pancuronium (Patient Care); communicating effectively across cultural barriers (Interpersonal and Communication Skills); allocating resources ethically (Professionalism); framing improvement in terms of equity (Practice-based Learning and Improvement); and describing health systems differences and their impacts on population health (Systems-based Practice). As more formal GHE programs in anesthesiology are developed, additional tools will become available.
How trainees should learn about global health equity
One of the distinguishing features of medical training is the apprenticeship model that daily pairs trainees and clinician educators together. A foundation of clinical knowledge is laid through didactic instruction, self-study, and guided experience leading to graduated responsibility throughout the training process. With progression through key milestones, trainees are declared competent and permitted to continue independently on a career of continuous education and improvement. Given the complexity of patient care and cultural acclimation required for service, research, and education in resource-variable settings, training for GHE should be no different. Academic departments engaged in GHE training need to recruit and equip faculty to serve as mentors for global health apprentices. Because of the array of biosocial issues involved in global health, these mentors may not necessarily be anesthesiologists and could include surgeons, disaster relief specialists, public health experts, policymakers, entrepreneurs, and any number of other disciplines. In addition to learning from mentors in high-resource settings with GHE experience, a posture of equity demands that training programs give voice to the interests and concerns of patients and providers from resource-limited settings, as well. This may be in the form of reading assignments, recorded lectures, live talks, and in-person visits and often requires establishing relationships with educators from a diverse background.
As mentioned above, for many trainees interested in global health, participation in an international clinical trip is a defining educational experience (Figure). To maximize this experience for the benefit of trainees and their hosting institutions, significant pre-departure preparation, monitoring, evaluation, and feedback are critical. Protocols to ensure the safety and security of traveling residents are paramount. A clear set of clinical and social expectations informed by local preferences is required to prevent misjudgment and misunderstanding. An education plan building on prior training and fostering reflection on the biosocial contributors to health systems deficiency guided by mentors and local hosts will deepen the impact of such an experience. Finally, given the investment required and risk assumed by host institutions bringing in foreign visitors, an equitable plan for reciprocal benefit must be in place. This may be in the form of service or education provided on site or expand into educational exchanges and research collaboration as part of a broader partnership. The ASA Committee on Global Humanitarian Outreach recently convened a task force to make recommendations on the design of global health experiences for anesthesia trainees and aims to produce a practical document outlining these ideas.
Ultimately, the structure of GHE training must reflect its values. Richard Horton, editor of The Lancet, said that “Global health is an attitude. It is a way of looking at the world. It is about the universal nature of our human predicament. It is a statement about our commitment to health as a fundamental quality of liberty and equity” (Reimagining global health: an introduction. 2013). While many anesthesia residents now enter training with this attitude, it must also be carefully cultivated to achieve the lofty goals to which it ascribes. A thoughtful approach to global health equity education will accomplish this.