INTRODUCTION

There is an upsurge of interest to participate in global health. Health professionals and students are demanding education programs that will prepare them to work in global health, and academic institutions, particularly in North America, are creating new global health initiatives. Yet, there is no common understanding of the term global health, agreement about the content of global health courses, or of what it means to work or conduct research in global health. Nor is there an obvious trend to develop academic global health initiatives in low- or middle-income countries. This may be because global health is primarily being defined by developed country institutions and in terms of their working with developing countries. For developing country institutions, global health, defined in this way, is business as usual. There is a danger that all this new energy for global health will result in it becoming an activity developed through the lens of rich countries, ostensibly for the benefit of poor countries, but without the key ingredients of a mutually agreed, collaborative endeavor.

We suggest that academic institutions have an opportunity – as well as a responsibility – to assure that leadership for global health be as inclusive and worldwide as the tasks ahead are broad and daunting. That is, now is the time for academic leaders to come together across geographic, cultural, economic, gender, and linguistic boundaries to reach for mutual understanding of the scope and nature of global health – if indeed the new initiatives are to amount to something new. With leadership from such a broad and inclusive group, academic programs around the world can combine expertise and assets to lead research and education to significantly improve the health of vulnerable people wherever they may live. One indication of success would be emergence of a new generation of global health leaders working worldwide on a shared and better defined agenda – and doing so on equal footing.

In the pursuit of a clearer understanding of the phenomenon of global health as it is promoted by academic institutions, we compare it to earlier international health efforts, tropical medicine and international health, as a means for detecting what seems new. Next we focus on academic institutional trends, noting far greater use of the term global health in North America than elsewhere. We observe that the phenomenon of global health is part of a broader trend to internationalize higher education and offer some suggestions about supporting academic institutions in developing countries to steer the future of global health, and point out the need to monitor intention against experience as today's nascent programs mature.

SO WHAT IS NEW ABOUT ACADEMIC GLOBAL HEALTH PROGRAMS?

Institutions offering global health programs explain the term differently, and scholarship to date provides examples or characteristics of global health rather than delineating its boundaries. A commonly referenced definition of global health is that developed by the Institute of Medicine (IOM) in the United States National Academy of Sciences: Health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions (1).

This definition demonstrates a common ambiguity; that the term "global health" is used descriptively to mean the state of health of populations worldwide and the issues pertaining to it, and it is used actively to mean working in a new field called global health, as a practitioner to address issues such as those set out in the IOM definition. We believe that both uses of the term are important to academic institutions. The former can further the frontiers of scientific research, helping us to understand challenges in addressing disparities in health outcomes and to set priorities for doing so. The latter offers an approach to improve the effectiveness of strategies for practice and research that impact health everywhere.

The IOM also conveys the importance of the sharing of lessons learned through international cooperation. An explanation of the term offered by Kickbusch communicates a similar sense of interdependence particularly among the key players working in the global health arena: The term Global Health stands for a new context, a new awareness and a new strategic approach in matters of international health. Its focus is the impact of global interdependence on the determinants of health, the transfer of health risks and the policy response of countries, international organizations and the many other actors in the global health arena. Its goal is the equitable access to health in all regions of the globe (2).

The new academic global health programs, and their funding sources, are predominantly organized around working internationally, and particularly in developing countries – on the grounds that these are the countries in greatest need. The Fogarty International Center of the United States National Institutes of Health, for example, in supporting academic institutions to build multidisciplinary Framework Programs for Global Health, defines "Global Health activities" as research, teaching, clinical care, prevention, and outreach activities directed towards addressing health concerns that contribute a significant burden of disease and disability in low- and middle-income countries and are of general concern to the international health community (3).

Yach and Bettcher argue that international partnerships and transnational actions are required for "countries and communities to go beyond narrow self-interests in order to address problems and take advantage of globalization," and that this "will need to be supported by a strengthened educational and research capacity" (4).

We suggest that the continued emphasis on support for developing countries challenges us to differentiate new global health endeavors from the longstanding ones of tropical medicine and international health. When the IOM asked 29 international health leaders what they understood to be the difference between global health and international health, some thought global health implied global interdependence, and better capitalized on and responded to globalization, and others thought the difference was semantic (5).

Tropical Medicine

Europeans coined the term tropical medicine when their explorers, on return from "the tropics," talked about diseases not seen in Europe and challenged the scientific community to explain them. Sir Alfred Lewis Jones, a Liverpool ship owner, provided the funds to establish the Liverpool School of Tropical Medicine in 1898, and others around the world quickly followed (6). Together they defined tropical medicine with regard to identifying, preventing, diagnosing, and treating diseases most prominent in tropical climates. Its major early disciplines were entomology, parasitology, clinical medicine, epidemiology, and community health (7). Tropical medicine grew as a discipline throughout the middle of the 20th century, a time when many doctors and scientists from Africa, Asia, and Latin America visited Europe for training and returned home to establish and teach in schools of medicine and public health, integrating aspects of tropical medicine into their curricula and setting up research institutions dedicated to tropical medicine.

In the mid-1990s, around the time that the term global health started to appear in the published literature, several European academics engaged in a heated debate about the appropriateness of the term tropical medicine, bringing into focus its colonial past and the very different situation today (8, 9, 10, 11). Emphasizing the worldwide incidence of HIV/AIDS and the re-emergence, in developed countries, of infectious diseases such as tuberculosis (TB), de Cock et al., argued that tropical diseases could be studied in departments of infectious diseases, and pointed out the neglect of clinical care for many other causes of morbidity and mortality in "resource-poor" settings (9). McClarty et al., emphasized that, whatever the name, the focus should be on developing countries and diseases of poverty, not just on those found in warm climates, and pointed out the need to include non-communicable diseases (12). Cutts and Mills warned that "effective delivery of the 'essential clinical package' involves people outside medicine" (13).

As an indication of the geographic spread of existing academic institutions of tropical medicine, a PubMed search, conducted in May 2008, of 1,019 papers published in 2007 with author affiliations that included "tropical medicine" and ("university" or "institute" or "college" or "school") identified institutions in Austria, Belgium, France, Germany, Italy, Poland, Portugal, Netherlands, and UK; Canada and US; Australia, Brazil, China, Cuba, Egypt, Indonesia, Iran, Japan, Jamaica, Kenya, Korea, Philippines, Sudan, Taiwan, and Thailand.

International Health

Around the middle of the 20th century, international health grew as an activity to set health interventions within a broader health systems and policy context both nationally and internationally. Its arrival corresponded to greater international regulatory cooperation to prevent the transmission of infectious diseases between nation-states, and, in 1948, to the formation of the World Health Organization (14). International health also became an area of professional activities that involved development of international programs to promote health, prevent and control disease, and support developing countries in strengthening delivery of their health programs, including combining these into better functioning health systems. In the late 1970s, as international organizations promoted programs to deliver immunization, family planning, and growth monitoring among others – as elements of improving primary care – schools of tropical medicine, and of public health led the development of research and education programs in international health. Training in international health became and remains popular among health professionals living and working in developing countries, who want to complement their clinical expertise with skills in health promotion, epidemiology, health system management, and program development, delivery, and evaluation. Its appeal is apparent also among health professionals from developed countries wanting to work with non-governmental organizations, ministries of health, or international agencies to plan, implement, and evaluate health programs in developing countries.

The geographic spread of existing academic institutions of international health is not as wide as that of tropical medicine. A PubMed search, conducted in May 2008, of 365 papers published in 2007, of author affiliations that included "international health" and ("university" or "institute" or "college" or "school"), revealed institutions in Denmark, France, Germany, Italy, Netherlands, Norway, Spain, Switzerland, and UK; Canada, and US; Australia, India, Japan, Korea, and New Zealand.

Global Health

It appears to us that, unlike tropical medicine and international health, global health has not emerged as an activity or as a discipline that corresponds directly to a set of skills. This new phenomenon seems to reflect: (1) a greater international connectedness that leads to increased opportunities to work overseas, to conduct research and market its products, and to promote education programs; (2) more public awareness of common vulnerabilities to the spread of communicable diseases and to the spread of risk factors for non-communicable diseases that necessitates national and international strategies to protect against them; (3) discomfort that there are huge inequalities in disease burden between rich and poor countries and between rich and poor people anywhere, which translates into a desire for greater understanding of the distribution of disease burden worldwide, and the availability of new funds for the development and delivery of interventions to alleviate the disease burden of the most disadvantaged.

Interest in working in global health extends beyond a small group of health professionals who specialize and dedicate their careers to working internationally. Professionals with expertise in business, law, agriculture, economics, veterinary medicine, environmental science, the basic sciences, for example, and from a wide range of health specialties want to participate, even on a part-time basis, and new public and private funding for global health offers them career opportunities. The narrow geographic reach of global health programs and their funding constrains their development to a North American perspective and limits opportunities for global health training in other parts of the world.

THE GEOGRAPHIC REACH OF GLOBAL HEALTH PROGRAMS

Compared to academic tropical medicine and academic international health, global health appears to be more of a North American academic phenomenon. Of 434 papers ever published in the PubMed database (searched in May 2008) by authors with "global health" and ("university" or "institute" or "college" or "school") in their affiliation, 87% were from North American institutions.

It appears from the affiliation of authors in the PubMed database, that the first academic institution to incorporate the term global health in its name was the University of California, San Francisco with its Institute for Global Health, which it established in 1999. Since then, departments of public health and schools of medicine, and nursing, have formed global health initiatives and training programs, while some universities have opted for greater institutional involvement in the process by creating campus-wide global health frameworks. It is hard to count academic global health initiatives because new ones appear so rapidly and because there is no accredited list of global health education programs. As an indication of the number of new programs, in 2006 and 2007, the Fogarty International Center funded Framework Programs for Global Health at 18 US academic institutions (15), and a recent volume of Academic Medicine described some of these programs as well as six additional programs in the US and one in Canada (16). Profusion of these new programs seems to have eclipsed a suggestion by Hotez in 2004 for consideration of a North American School of Global Health (17).

In Europe, the schools of tropical medicine and institutes of international health continue to conduct research and teach courses that the new global health programs in North America resemble, but Europeans have rarely changed the names of their institutions to include global health. This may be because global health is not yet sufficiently differentiated from international health or tropical medicine. However, University College London has set up an Institute of Global Health that parallels some of the North American initiatives by bringing together a number of departments and institutes across the same university campus. Six other colleges of the University of London have together established the London International Development Centre, which takes a different approach. It brings together expertise from multiple disciplines to address international development goals that include but are not exclusive to health. We also found departments of global health at the University of Oxford, the Universities of Lund, Malmö, and Umeå in Sweden, and the University of Dublin in Ireland.

We searched to find academic initiatives elsewhere in the world with global health in their names but because this search was limited to the English language, we have likely excluded institutions, particularly in Latin America. We found a group of universities, outside North America and Europe, that received Fogarty International Center Global Health Framework Program funding in 2005 and 2006, for example at the Universidad Peruana Cayetano Heredia (Peru), Federal University of Rio de Janeiro (Brazil), National Institute of Public Health, (Mexico), Fudan University School of Public Health (China), Pavlov State Medical University, Russia, Muhimbili University of Health and Allied Sciences (Tanzania), University of Zimbabwe, and the University of Ibadan (Nigeria) (15).

Of 30 papers published (by May 2008) in PubMed by authors with affiliations that included "global health" and ("university" or "institute" or "college" or "school") for institutions outside North America and Europe we found few: four universities in Japan with departmental initiatives (Universities of Hokkaido, Okayama, Ryukyus, and Kyoto); a Clinical Research Unit and Institute of Biomedicine/Center for Global Health at the Federal University of Ceará, Brazil; the Ben-Gurion University MD Program in Global Health, Israel; the Center for Research on Global Health and Youth at Risk, at the University of Puerto Rico; the Centre for Global Health Research, in the Kenya Medical Research Institute; Global Health at Deakin University in Australia, and the Nossal Institute for Global Health, at the University of Melbourne in Australia. The earliest paper with this kind of affiliation was published in 2001.

REALIZING THE MISSION OF GLOBAL HEALTH

We have gathered, for comparison, the mission statements of some of the new North American academic global health initiatives, some of the academic international health programs around the world, and some of the existing European institutes of tropical medicine (Table 1). The common thread among them is a desire, through teaching and research, to address disparities in health outcomes and access to health care, and to alleviate the disease burdens of populations that extend well beyond their own national borders. The target group is defined varyingly as developing countries, less developed countries in the tropics and sub-tropics, resource-limited settings of the developing world, low-income countries, underserved populations (abroad and domestic), the world's most vulnerable populations, or simply worldwide.

Table 1 - Mission statements of some academic initiatives in "tropical medicine," "international health," and "global health".

Full table

Despite the altruism of their mission statements, the new academic programs in global health must be set within the growing trend towards the "internationalization of higher education." Contemporary emphasis on free trade means that education has become a commodity, and "...academic programs, institutions, innovations and practices [are] created to cope with globalization and to its reap benefits." (18). Under increasing pressures to demonstrate their relevance to society, to meet student demands for a multi-cultural experience, and to find new funding opportunities, academic institutions (of any discipline) in North America and Europe are designing new courses to prepare their students to live in a global society and arranging overseas experiences for them, recruiting overseas students, providing internet-based distance learning programs, selling courses overseas, and setting up off-shore branches of their institutions. They also compete for funding that is earmarked for international activities (19).

Altbach observes that: ...deep inequalities undergird many of the current trends in globalization and internationalization in higher education .... A few countries dominate global scientific systems, the new technologies are owned primarily by multinational corporations or academic institutions in the major Western industrialized nations, and the domination of English creates advantages for the countries that use English as the medium of instruction and research. All this means that the developing countries find themselves dependent on the major academic superpowers (20).

We suggest that the term global health has become a means to brand the global prestige of an academic institution, and to strengthen its capacity to work globally by facilitating disciplines to organize across campuses, providing education that fulfills the expectations of students, offering research opportunities that meet the international interests of faculty, and by accessing new and large sources of funding for global health.

There is a very narrow window of opportunity for global health to become the exception to the rule, where institutions from the North usually control the process. We explore some of the activities currently conducted in the name of global health and suggest ways in which they could be re-aligned to become more egalitarian and to strengthen developing country institutions as well as developed country institutions, and to prepare all our future leaders to protect the world's populations against future health threats.

Providing Students with Overseas Electives

Overseas electives attract students because they expose them to different cultures, diverse health problems and systems, and enable them to start career networking. A rough estimate of the number of US medical students either receiving or requesting an overseas experience is 4,000 per year (16,000 medical graduates and assuming about 25% participating in a "global health experience" (21)). This translates into the need for 4,000 overseas mentors dedicating 31 person-years per year for supervision (assuming each mentor spends 2 h a week supervising an 8-week elective). This explosion of North American interest for electives in developing countries has increased the burden of hosting the electives and can actually undermine the host institutions. We recommend that the host institutions are involved in the planning of these electives and that they be fully reimbursed by the sending institutions for the costs of mentoring.

Students from developing countries have similar aspirations for cultural exchange and could similarly gain from international electives but lack opportunities open to their peers in developed countries. In the ongoing global health programs, this has not been well addressed. We suggest that an international group of academic institutions collaborate to set up and seek funds to implement an International Global Health Elective Program through which students from any country can compete for placements in any participating country, with supervisors from both host and sending institutions.

Training Students for Careers in Global Health

There is no clear vision about what it means to work in global health and thus what global health training is preparing students to do. One common assumption is that working in global health means going from a developed country to work in a developing country. This assumption narrows the scope of global health by excluding health problems of developed countries. For example, a special report in Nature recently announced that: "The international effort to address the health crisis in the developing world is providing a wealth of career opportunities" and gave five "top tips for pursuing a career in global health" (22). If global health careers are defined in this way, why is it that the health professionals working in their own low-income countries, who will likely supervise these visitors embarking on a career in global health, are not also described as working in global health? The recruitment of professionals from developing countries to medical facilities in the North has opened opportunities to travel to Northern countries and for those coming from developing countries to share their expertise. Surely, they too need preparatory training in global health? The solution to such ambiguities requires a consensus among health leaders from developed and developing countries about the purpose of global health training and the content of a curriculum.

We suggest that the primary place for global health education is at the undergraduate level where every student can be exposed to all aspects of globalization and to domestic and international health disparities, the organization of international health responses, and prepared to work collaboratively with international partners whether at home or abroad. Such courses can be provided at any university, even if it has not formed a global health initiative, and can be integrated into general education as well as being featured in more professionally oriented health programs.

Investing in Global Health Activities

New international health initiatives, for example to control HIV/AIDS, TB, and malaria, are well funded and attract international academics and their graduates to conduct research, supply training, and provide technical expertise in developing countries. Universities in North America and Europe are organized to bid for contracts and to obtain research grants for these activities. The resulting income underpins the development of their global health programs. By contrast, in developing countries, when local health professionals are attracted to do the same kind of work, employed by international agencies or non-governmental organizations, an increasingly common reaction worldwide is to interpret such "brain-drain" as undermining of local institutions. We recommend that the North American and European academic institutions share their financial management expertise with counterpart institutions in developing countries to enable them to bid directly for development contracts and research grants so that they can employ the national and international expertise required to undertake these programs. The proceeds from such activities could be used by the developing country institutions to build academic environments that attract and retain their best academics to perform local and international global health activities.

We suggest that academic institutions can contribute in closing the developing country/developed country dichotomy by generating global health leaders who can address developing and developed country priorities simultaneously wherever they are based. This requires active networking and the leadership of an enlightened group of donors. Since all academic institutions are in receipt of extra-mural funding, their donors are in a strong position to bring them all to the table. The Ford, John D. and Catherine T. MacArthur, Rockefeller, William and Flora Hewlett, Andrew W. Mellon and Kresge Foundations, for example, have demonstrated the power of such a group through the Partnership for Higher Education in Africa, which has been successful in catalyzing resources to strengthen universities in Africa (23). A model of networking and collaboration in international health is the tropEd Network of 31 institutions of higher education in Europe, China, Indonesia, Mexico, Tanzania, and Vietnam, whose focus is on the "exchange of experiences" and the "establishment of a common standard in education and research" in international health (24). A global network of academic institutions such as this could provide the platform to develop some of the activities we have proposed here.

Rather than repeating the colonial approach of the early days of tropical medicine, or the development aid approach of international health, the increased connectedness of the 21st century provides academic institutions around the world the opportunity to work collaboratively to develop research programs to redress health disparities and education programs to nurture global health leaders capable of tackling looming global threats wherever they occur. Arranging practical ways to monitor the extent to which these academic initiatives fulfill their intentions is a crucial next step.

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ABOUT THE AUTHORS

Sarah B. Macfarlane is Director of Program Development and Planning at UCSF Global Health Sciences. She worked previously as a Reader at the Liverpool School of Tropical Medicine in the UK and as a program officer in health equity at the Rockefeller Foundation.

Marian Jacobs is Dean of the Faculty of Health Sciences at the University of Cape Town in South Africa. She is a public health paediatrician who has held various positions in global health initiatives. She is currently Chair of the Board of the Council on Health Research for Development (COHRED).

Ephata E. Kaaya is the Director of Continuing Education and Professional Development at the Muhimbili University of Health and Allied Sciences (MUHAS), Dar Es Salaam, Tanzania. He is a professor of Pathology and Consultant Pathologist for the Muhimbili National Hospital and the principal investigator of a grant from the Fogarty International Center for a Framework Program in Global Health, which enabled him to plan a curriculum for Global Health.