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Grand Rounds

Global concerns
By James Strickler, M.D.

This magazine has often featured stories about Dartmouth Medical School students and faculty who study, do research, or provide clinical care in countries all over the world. These international pursuits reflect DMS's growing interest in global health, especially in the developing world, where the pattern of diseases is different than in the United States and where assessing the health needs of populations, not just individuals, is critical. Schools of public health have traditionally emphasized the need to understand diseases in a global context and to focus on the health of populations. It's time now for more American medical schools to expand their horizons and likewise become more globally oriented.

Transmission: The globalization of world commerce, communications, and transportation has globalized disease transmission. Poor health in any country can spread beyond its borders to adversely impact the health, the economy, and the security of any other nation, including affluent, industrial nations like the United States.

The globalization of world commerce, communications, and transportation has globalized disease transmission.
Illustration: Suzanne DeJohn

During the past three decades, at least 14 new infectious diseases have been identified. Witness, for example, the economic, social, and political havoc caused by the dissemination of HIV/AIDS. In addition, a number of long-recognized infections that were previously geographically contained have now spread far and wide. Witness the emergence of West Nile virus in the U.S. and the reemergence of dengue fever in the Caribbean and Central America. Drug-resistant diseases—like tuberculosis and malaria—are spreading rapidly, too. And the more Americans travel overseas, the more important it is for them to understand health risks they will encounter abroad, including exposure to diseases not well known to most American physicians. Then add to these challenges the fear that contagions such as smallpox or anthrax may be used by terrorists.

Dilemma: Gro Brundtland, the director-general of the World Health Organization, summarizes the dilemma by saying, "All humankind today paddles in a single microbial sea. There are no health sanctuaries." The message is clear: the U.S. needs more physicians who recognize the global patterns and intricacies of infectious diseases.

A 1997 report of the Institute of Medicine's Board of International Health—titled "America's Vital Interest in Global Health"—states that "the direct interests of the American people are best served when the United States acts decisively to promote health around the world."

The report's authors predicted that by 2020, ischemic heart disease, unipolar depression, and traffic accidents will replace infectious diseases and perinatal conditions as the leading causes of morbidity and mortality. The U.S., with its strength in medical science and technology, is expected to be an international leader in addressing global health concerns. The report also points out that the burden of worldwide illnesses can best be addressed by cooperative partnerships among nations and nongovernmental organizations.

In the past, health problems in foreign countries have been an ethical but not a strategic concern for those who set our foreign policy. A significant amount of U.S. foreign aid has been directed toward improving health in poor countries, but most experts feel the primary incentive for this aid has had little to do with national security. But today, owing in large measure to the destabilizing political and economic impact of HIV/AIDS, most notably in Africa, widespread ill health in poor countries is emerging as a major foreign-policy concern. The threat of bioterrorism since September 11 has significantly increased this worry.

Strategic sense: A report by the Council on Foreign Relations—"Why Health is Important to U.S. Foreign Policy"—explains that "improving the health of people in other countries makes both strategic and moral sense as an integral part of future U.S. foreign policy." Secretary of State Colin Powell agrees.

In sum, a strong case can be made for strengthening our expertise and leadership in global health. The reasons are intensely political and economic, not just humanitarian. U.S. medical schools should recognize the importance of nurturing a strong cadre of physician leaders in global health, adjusting their educational objectives and opportunities, if necessary. A modest step would be to increase the number of well-designed overseas educational and research opportunities for medical students and faculty. The principal purpose of these offerings should be to inform more students about health in other lands and to motivate some to seek careers in global health. This curricular adjustment should enhance, not compromise, schools' core missions, which are to teach students how to become thoughtful physicians and to advance knowledge in the biomedical sciences.

DMS is already playing an important role in the global health arena by encouraging medical students and physicians to participate in clinical and research opportunities throughout the world. Expanding and improving these opportunities will inspire more students and faculty to assist the medically underserved everywhere, while concurrently strengthening both health education and research.

"Grand Rounds" (formerly titled "Faculty Matters") covers a topic of interest to the Dartmouth medical faculty. Strickler is a former dean, a professor emeritus of medicine and of community and family medicine, and a 1951 alumnus of DMS; he also cochairs the International Rescue Committee and is a director of the Global Health Council.

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