It is low and middle income countries (LMICs) who bear the brunt of the burden of many ‘global health’ challenges, from migration to infectious diseases epidemics to malnutrition. Study of UK postgraduate medical training curricula, highlights that a majority (not least the only curriculum common to all postgraduate doctors, the Foundation Programme) include few or no learning objectives related to global health.1 Yet, for at least three important reasons, clinicians in high income counties (HICs) such as the UK still have a key role to play in addressing these global health issues, and there is a strong argument for postgraduate trainees and educators achieving and demonstrating competence in global health.
Image: Five domains of Global Health competency approved by the Academy of Medical Royal Colleges
Firstly, the highest morbidity and mortality burden of global health issues may fall in LMICs, but HICs are still feeling the pressure of health challenges that cross international borders. For example, the IPCC report published this month predicts that 1.5 degrees C of warming will be reached between 2030 and 2052 if progress continues at current rates.2 Climate change is a global health threat, and heatwaves are among its direct health consequences. A heatwave took the lives of over forty thousand people in Europe in 2003, and hot summers, particularly when there are not cooler temperatures in the evening, continue to increase morbidity and mortality related to MI, stroke, respiratory disease and heat stroke.3
Migration is another example of a global health issue with very tangible UK health effects. In 2017, the UK government granted asylum to 14,767 people, of whom 5,866 were children (26,350 applications for asylum were made to UK).4 While debate rages about how many migrants, of what origin, background or skills, should be allowed to enter the UK, the reality is that conflict, natural disasters, and other factors contributing to migration are not going away and cross border flows of human beings continue. Given the psychological and physical challenges associated with forced migration and migration journeys and the variety of backgrounds that they come from, refugees often have specific health needs and cultural or communication preferences. Providing the most effective treatment in these circumstances requires global health competence.
Secondly, whether or not these global health challenges are impacting the populations that we see and treat in the UK, our impact on environmental, social and economic determinants of health extends beyond UK borders. An informed patient who makes healthy diet and lifestyle choices is more likely today than ever before to be part of and influence global networks and societies. Thus, we may have the opportunity to influence health positively and widely through providing culturally appropriate health information and counselling. Yet without careful attention, we also can inadvertently and negatively impact global health. The 21 million tonnes of CO2-equivalent emissions that the NHS is producing per year5 will contribute to climate change related death and disease around the world. Newcastle Hospitals’ Sustainability Team have taken great strides to enable those at the coalface to reduce, reuse and recycle, but this can only have an effect when health professionals choose to walk the walk also, for example, avoiding single-use instruments where possible and using the correct bins to limit incineration and landfill.
Awareness and understanding of these issues can motivate and enable us to ‘do no harm’ (or even just to do less harm and more good) through our healthcare practice. Just as communication with and treatment decisions for any one NHS patient have ramifications in terms of societal expectations about healthcare, human behaviours and resource availability within and for the local population; as international boundaries become more porous to people, cultures, trade and information, global health competence includes recognising and addressing our impacts on environments and populations who are geographically remote from us.
Thirdly, we have a voice that can have international impact. News and health professional voices can travel fast. Investigation in Northern Pakistan where one fifth of all surgical instruments are produced, found that labour conditions and wages for workers ($2/day in many cases) were poor.6,7 This is impacted by local procurement policy as well as national and international trade standards and workers’ rights legislation. Without leaving the North East, health professionals have an opportunity to protect health by advocating to the hospital trust, to UK government and at international level.
We can also advocate for Royal Colleges to include Global Health in postgraduate curricula. The Academy of Medical Royal Colleges (AoMRC) have endorsed a framework of competencies in five domains:
- Diversity, ethics and human rights
- Global epidemiology of disease
- Environmental, social and economic determinants of health
- Global health governance
- Health systems and health professionals
For more information and example competencies in each domain, see supplementary material in the paper in International Health and the two-sided pdf downloadable from this website.8
- Hall JA, Brown CS, Anj LP, Ramsay ATLMR. Fit for the future ? The place of global health in the UK ’ s postgraduate medical training : a review. 2013:1-8.
- IPCC. Global Warming 1.5 Degrees C. Incheon; 2018. http://report.ipcc.ch/sr15/pdf/sr15_spm_final.pdf.
- McMichael AJ, Lindgren E. Climate change: present and future risks to health, and necessary responses. J Intern Med. 2011;270(5):401-413. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=21682780.
- UK Government. Migration statistics. How many people do we grant asylum or protection to? https://www.gov.uk/government/publications/immigration-statistics-october-to-december-2017/how-many-people-do-we-grant-asylum-or-protection-to. Published 2018. Accessed October 13, 2018.
- NHS Sustainable Development Unit. Carbon Footprint Update for NHS in England 2012. Cambridge; 2013. http://www.sduhealth.org.uk/documents/Carbon_Footprint_summary_NHS_update_2013.pdf.
- Bhutta MF. Fair trade for surgical instruments. BMJ. 2006;333(7562):297-299. doi:10.1136/bmj.38901.619074.55
- BMA. Ethical procurement – why it matters. https://www.bma.org.uk/collective-voice/influence/international/global-justice/fair-medical-trade/ethical-procurement-issues. Accessed October 13, 2018.
- Walpole SC, Shortall C, van Schalkwyk MC, et al. Time to go global: a consultation on global health competencies for postgraduate doctors. Int Health. 2016;8(5):317-323. doi:10.1093/inthealth/ihw019
Author Details: Dr. Sarah Walpole in her own words: I graduated from Leeds, and I’ve since since worked in Yorkshire, Newcastle, Greece (for Syrian American Medical Society) and DRC (for Medecins sans Frontieres). In the UK, I’m a Med Reg and a member of Alma Mata http://almamata.org.uk/about/ and the Sustainable Healthcare education network https://networks.sustainablehealthcare.org.uk/network/sustainable-healthcare-education.