Pre- and postgraduate education in international health

Abstract

The aim of this article is to provide information about possibilities for medical students and doctors to obtain knowledge about international health. Increasing globalisation requires knowledge about international health in such a way that Danish doctors are able to diagnose and treat patients, regardless of the patient's nationality and ethnic background. Denmark has a global responsibility towards low and middle income countries to increase the standard of health. Increased knowledge and research in these countries are important both at an undergraduate and postgraduate level.

Why is it important to educate Danish health personnel in international health, and why ought this to give credit at medical school and during specialisation? The world is becoming progressively smaller and the composition of the Danish population more multiethnic. In order to keep up with globalisation it is necessary to achieve international insight into health issues. Not just to be able to help ethnic patients living in Denmark but also to help patients living outside of Denmark.

In a global context, Denmark especially carries the responsibility of low and middle income countries. In these countries we can increase the standard of health by providing knowledge, research and by exchanging Danish doctors. The Hippocratic Oath is universal and not limited by the borders of Denmark! The aim of this article is to provide information about the possibilities for medical students and doctors to obtain theoretical and practical knowledge in international health at pre- and postgraduate level.

At the three Danish health faculties there are different possibilities of obtaining knowledge and education in international health. None of the medical faculties have international health as an obligatory subject and as such one can obtain the medical degree without systematic knowledge on this subject. The Health Faculties carry a responsibility for the professional and attitudinal profile of newly educated doctors. A survey at the three faculties (Copenhagen University (KU), University of Aarhus (AU) and University of Southern Denmark (SDU)) has shown that pregraduate possibilities of focusing on international health are obtained during the one-year research education (AU) or the mandatory OSVAL-paper (CU), while medical students at SDU have the possibility to join a five-week course in international, transnational and global health. Moreover, medical students and doctors can sign up for the Summer School on Global Health at CU. This is a four-week course provided each year in August for different professions (i.e. midwives, anthropologists, economists etc.) who plan to work in developing countries. The course includes the study of diseases, anthropological issues and cultural differences. At postgraduate level it is possible to obtain a Master in International Health (MIH) at CU. This is a one-year programme focussing on poverty-related health problems and health systems in low- and middle income countries. The students come from many different countries and have a background within health or social studies.

However, further good initiatives are launched. In 2005 Centre of International Health and Development (CISU) - a cooperation between research institutes in Copenhagen - was established. The Danish financed Bandim health project in Guinea Bissau is part of CISU. The Centre houses different research activities of which the Graduate School of Public Health is one counting 45 PhD students since 1995. Furthermore, CU started Copenhagen University School of International Health, under which all the activities of international health will be brought together, and it is the vision to develop a Bachelor and Master degree and to participate in developing an expert education in international health [1]. Education in international health can also be obtained from shorter or longer stays at foreign universities including obtaining a Master or PhD degree. If one has obtained this kind of education from a foreign university, the National Board of Health needs to approve this before it can grant transfer credit in Denmark. An approval at advance from the National Board of Health should be obtained before the studies at foreign universities are started.

Likewise, research stays at universities and other research institutions present an opportunity to learn about different aspects of international health. This is both possible abroad and in Denmark. Research projects may include health problems in low income countries as well as migrants' health and access to healthcare in middle and high income countries. The Danish Statens Serum Institut's health project in Bandim has shown how profitable cooperation between Danish research institutions and institutions in developing countries can be. The exchange of knowledge and research with developing countries enhances the understanding of causal connections and may optimise Danish treatment strategies to the benefit of both parties.

The practical experience, which can be obtained through the Bandim project may, however, also be acquired elsewhere by participating in clinical work at hospitals and clinics in developing countries. Medical students may acquire this kind of practical skills working on the International Medical Cooperation Committee's (IMCC's) medical projects in developing countries. They can obtain some transfer of credits for this in their education. Moreover, fully trained medical doctors may work abroad through humanitarian organisations such as Red Cross and Doctors without Borders. Unfortunately, it can be difficult to obtain leave of absence for this kind of work. Already ten years ago a questionnaire study showed that it could be difficult to obtain leave of absence in that only 44% out of 110 doctors, who had worked abroad, had been able to obtain leave from their workplace [2]. However, there are recent examples of doctors, who in their work contract have been able to negotiate the opportunity to take leave to do humanitarian work. A recent survey among the 14 counties in Denmark showed that none of the counties have formulated policies on leave of absence concerning humanitarian work. Several counties, however, declare that they anticipate better possibilities of granting doctors leave to do humanitarian work when the counties are replaced by regions in 2007. It is, of course, necessary that such an overall regional policy is followed up by and implemented by the administration of hospital departments and other relevant institutions.

The above-mentioned survey [2] additionally found that, concerning specialisation, doctors who had done humanitarian work experienced difficulties when trying to obtain credit for their humanitarian work. Just as the faculties are responsible for the students, the National Health Board in cooperation with specialist organisation and the Danish Medical Association are responsible for the professional education and attitudinal profile of medical doctors. Fortunately it appears that in recent years increasingly more specialities have begun to transfer credits for humanitarian work as part of specialist training. Great variation exists in the way in which specialists' organisations credit humanitarian work. Some organisations credit the total stay abroad as part of their specialisation and others only a minor part of the stay. However, there is a general accept that Danish doctors may obtain important knowledge during a stay abroad.

There is, however, a need for standardised guidelines concerning specialist organisations' ways of crediting humanitarian work for specialist training. In this context, it could be useful if the National Board of Health in cooperation with specialist organisations formulated clear-cut guidelines for transfer of credits for humanitarian work. Table 1 

  shows an overview of the special organisations that recognise and give credit to medical humanitarian work in developing countries. Fundamentally, the efforts to use competence assessment when evaluating the students in the new education system make possible to take the evaluation of untraditional education even more in consideration.

The medical profession should support the principle that Danish doctors also have a global responsibility and recognise the importance of knowledge on international health among medical professionals. Through the Hippocratic Oath Danish doctors have an obligation to assist humans in need whether they live within or outside the borders of Denmark.

This article is based on an article first published in Ugeskr Læger 2006;168:3013-5.