U NDERGRADUATE M EDICINE P RE - CLERKSHIP

G LOBAL H EALTH L ONGITUDINAL E LECTIVE

P ROGRAM D ESCRIPTION

Prepared by: Amitha Kalaichandran (1T2) and Calvin Ke (1T2)

January 14 2010
I. I NTRODUCTION

The Social Determinants of Health, as stated by the Public Health Agency of Canada and the
World Health Organization, have a salient role in determining the health of an individual,
community, and nation. However, the role of politics and war, income distribution (the struggle
between the haves and the have-nots), measures of national wealth, gender roles, local and global
legal frameworks (and human rights), as well as basic needs such as access to water and
sanitation, safe birthing practices, and immunization, all which are inequitably distributed around
the world, lead to differences in life expectancy and morbidity between and within nations. Why
does the life expectancy between rural Botswana and rural Ontario differ by decades? Why,
perhaps closer to home, are morbidity rates for certain ailments such as diabetes, amplified in
Canada’s First Nations communities. How can we prepare ourselves, as future physicians, for
addressing these issues with our patients, particularly if they arrive from a low-resource setting
and/or country of war? How might we prepare health professionals to engage in these discussions
when conducting clinical work in low-resource settings? What is the role (if any?) of the medical
student and physician in advocating for “health for all” within and outside our national
boundaries? In the present ‘globalized society’ there is an urgent need to prepare future physicians
for dealing with these pressing global health issues.

Houpt and colleagues (2007) have noted the rising trend of US medical students participating in
international medical electives; this trend has been echoed in the United Kingdom (Tissing 2009).
Further, an increasing number of Canadian medical students opt to participate in international
medical electives (Izadnegahdar 2008), particularly at the University of Toronto (Goldstein,
personal communication). However there is a need to discuss the competencies and roles of the
students choosing to partake in such electives (Shah 2008), as well as the ethical implications of
conducting work in a low-resource setting (Pinto and Upshur 2009). A sound academic elective in
global health should thus emphasize both the ethics and issues involved in conducting medical
work in marginalized settings, as well as provide adequate preparation for students partaking in
these endeavors.

Recent events have inculcated the importance of global health, and the fact that disease knows no
political boundaries. Indeed, inter alia, the SARS epidemic, and more recently, the H1N1
pandemic, speak to the interconnectedness of health around the globe. Moreover, the epidemics
of obesity and other chronic diseases are interwoven within issues of trade and globalization.
Further, today’s political climate calls for an increased emphasis on global health. In fact, the
Obama administration has recently agreed to invest heavily in health issues affecting low and
lower-middle income countries (Institute of Medicine 2009). The Canadian government, through
direct monetary foreign aid and the work of bilateral organizations such as CIDA, has also
acknowledged the salience of health as both a medical and political issue. Future physicians,
therefore, will soon be expected to be well versed in these issues, both in order to provide excellent
care to patients in communities at home and to understand and/or serve marginalized
communities elsewhere.

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A pre-clerkship academic elective1 in Global Health (the “Global Health Longitudinal Elective,”
or hereafter simply “GHE”) would serve to prepare University of Toronto medical students to
better address the determinants of health affecting marginalized populations within Canada as
well as within underserved communities abroad. This elective serves an immediate need within
the University of Toronto undergraduate medical community - where over 1/3 of students have
indicated a strong interest in global health.2 A recent Canadian study evaluated the current status
of global health education within the medical curriculum, and concluded that Canadian medical
students are ill-equipped to handle global health issues (Izadnegahdar et al 2008). Thus, this
elective serves as an appropriate response to the paucity of global health curricula in Canadian
medical schools.

The creation of global health curricula in medical schools is not a novel idea – the incorporation of
global health education within medical schools has been listed as a priority by the Association of
Faculties of Medicine of Canada (AFMC 2006). Further, Canadian medical students have made
the case for incorporating global health education into the curriculum, despite acknowledging the
vast amount of clinical and biomedical knowledge students are expected to learn during their
undergraduate medical training (McAlister 2006).

While some researchers have called for a curricula based on three basic competencies (Houpt et al
2007), the AFMC Global Health Resource Group (2006) has suggested a coordinated national
approach towards implementing global health education comprised of curriculum centered
around five key competencies. However, as the format of medical training varies widely between
medical schools, and the upheaval of medical curricula in order to incorporate global health is a
long and tedious process, it may be appropriate to offer an elective course in Global Health to
address the immediate demand for global health education at the undergraduate medical level. In
doing so, the elective developed by the University of Toronto may serve as a model for other
medical schools, and contribute towards the development of a nationwide standard in global
medical education, to be incorporated directly into existing curricula.

II. V ISION
To provide a curriculum, complementary to the existing biomedicine courses, that will equip
future physicians with the tools necessary to provide healthcare in today’s globalized world.

III. M ISSION
To address the current gap in global health education in the undergraduate medical curriculum.
To encourage students to critically think about pressing global health issues facing their
generation. To elucidate the role of the medical student and physician in the field of global
medicine – particularly in low-resource settings in Canada/Toronto and abroad.

1
Emphasis is added to the word “academic,” to distinguish this course from overseas “Clinical Electives” conducted
by 3rd and 4th year students
2
An online survey of 224 Year 2 UofT medical students was conducted in early 2009 to determine interest in this
course

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IV. R ELEVANCE

A. University of Toronto Undergraduate Medical Education

Research has shown that global health education can improve cultural sensitivity among ethnic
minority populations, allow students to recognize rare disease presentations, and improve clinical
care administered by physicians in low-resource settings (Drain 2008). Further, many students
who pursue global health education may opt to pursue primary care specialties in order to obtain a
wide variety of skills applicable in resource-limited settings, where high-tech equipment may be
scarce (Drain 2008).

It is clear that the GHE fits neatly within the mandate of University of Toronto Undergraduate
Medical Education. This body states:

“In keeping with the Faculty of Medicine’s vision of International Leadership in Health Research and
Education, the Undergraduate Medical Curriculum will encourage, support and promote the
development of future academic health leaders, who will contribute to our communities, and improve
the health of individuals and populations through the discovery, application and communication of
knowledge.” (Faculty of Medicine 2008).

B. CanMEDS Roles
In 1996, the Royal College of Physicians and Surgeons adopted a novel framework of core
competencies (“CanMEDS”) to guide both undergraduate and postgraduate medical curricula
across Canada. These competencies are: Scholar, Collaborator, Communicator, Manager,
Professional, and Health Advocate. These roles are centered around the core role of “Medical
Expert” (RCPS 2005) and are illustrated in the figure below.

Figure: CanMEDS Roles

Source: Royal College of Physicians and Surgeons of Canada 2005

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Currently, CanMEDS Development is in Phase IV, described as the “systematic implementation
with enhanced materials and faculty development.”

The Global Health Longitudinal Elective reflects the CanMEDS roles in the following manner:

1.Medical Expert: (in global medicine and global public health): students will become familiar
with public health interventions in developing country settings. Students will be introduced to
Rapid Assessment Procedures and basic epidemiology relevant to global health. Students will
also learn about the global burden of disease. The overall theme of the elective incorporates the
practice of medicine in low-resource settings; thus students will learn ways in which medicine may
be adapted in such settings.

2.Scholar: students will be given suggested readings for each lecture and case study portion of
the course. They will learn to critically appraise and discuss classic literature/academic papers on
a variety of global health issues, and evaluate topical readings on global health from mass media
sources. In addition, global health research techniques, ethical implications of global health work,
and academic careers in international medicine will be discussed.

3.Communicator: students will be expected to contribute to debates and discussion both

during lectures and case study sessions. By the end of the course, they will have mastered methods
of expressing ideas and articulating arguments based on their point of view, using supportive
evidence. Further, students will understand that communication methods vary across cultures;
cultural sensitivity will be inculcated as a crucial aspect of working in divergent health settings.

4.Manager: students will learn a variety of effective managerial skills. Clearly, by agreeing to
partake in this elective, they will be required utilize time management skills in order to balance
other required responsibilities from academic, extracurricular, and personal realms. The crucial
role of a manager in global health organizations, as well as in the field and physician-patient
clinical setting will be cemented through case studies, where students will be expected to delegate
and make informed decisions about issues such as humanitarian emergencies, access to treatment,
and political advocacy.

5.Collaborator: similar to the communicator role, students will build upon their collaboration
skills during the case study sessions. They will be required to work in groups to discuss ways of
approaching both theoretical and practical global health issues. Further, facilitators of the case
studies will possess a variety of academic backgrounds; thus encouraging interprofessional
collaboration and discussion.

6.Professional: throughout the course, students will be exposed to lecturers who exemplify
professional behaviour in their community. Moreover, a lecture focused solely on the “global
medical practitioner” will emphasize the requirement for professional, respectful, and courteous
behaviour in all settings. The challenge and ethics of working as a physician in low-resource
environments, the overarching theme of this elective, further lends itself to continuous discussion
about professional behaviour in the medical profession.

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7.Health Advocate: the role of the “health advocate” is a key component of this elective.
Students will learn that the role of the global medical practitioner extends beyond one defined by
biomedicine, to reach and encompass aspects of human rights, ethics, and policy. Through
separate sessions on these topics, students will become familiar with the role of a health advocate,
and form a personal conclusion regarding how they, as future physicians, can effectively advocate
for better global health.

V. A DMINISTRATION AND L OGISTICS (Format Adapted from Pakes 2008).

Program Leadership: While this Elective is unique in that it is a student-run venture, the
elective requires collaboration from a variety of academic bodies. The Undergraduate Electives
Committee and the Faculty Curriculum Committee are two key players in seeing this elective to
its full potential. Student leadership is contingent on a planning committee (a list of participants
in the inaugural committee is listed at the end of this document) to oversee the overall theme and
vision of the elective. While subject to change in the future, the elective is currently within the
portfolio of the Global Health Liaison (a member of the Medical Society) with support from the
University of Toronto International Health Program (UTIHP) Global Health Education
Coordinator. The latter roles are crucial for the sustainability of the elective, in order to guarantee
leadership from year to year.

Program Partners: Through the involvement of lecturers from a variety of fields of expertise,
the Elective partners with a variety of downtown UHN hospitals and research organizations, as
well as civil society organizations/NGOs. Further, a number of University of Toronto
Departments (e.g. Faculty of Law and Faculty of Arts and Sciences; Dalla Lana School of Public
Health) will be represented through the selection of lecturers and case study facilitators.

Participant Selection: While we hope to allow every second year student with an interest in
Global Health to participate in the course, students will be required to indicate their interest
through a short 250-word statement of interest, goals, and expectations. We hope to have an ideal
mix participants will include students with extensive experience in social health causes, along with
those who have had limited experience but possess an interest and curiosity about global health
and social medicine. It is estimated that around 50-60 SECOND-YEAR (Year 2 of
undergraduate medicine) students will register for the course.

VI.C OURSE F ORMAT AND E XPECTATIONS

Course Description: This GHE will occur once a week for 2 hours from mid-January to mid-
April 2010. The course will be structured in a “paired” method of lecture and discussion/small
group problem-solving. For instance, two to three weeks will be spent on a lecture on a specific
topic (e.g. War and Health). The following week will involve a case study that will be discussed in
small groups, as well as larger classroom discussion and/or debate. A description of the Course
Format can be found below.

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Expectations - Elective
The aim of the GHE is to put forth practical solutions founded on academic skills students
have garnered throughout their first 1.5 yrs of undergraduate medicine, while encouraging
creative thinking and engagement in interdisciplinary (e.g public health, economics,
sociology, law and medicine) fields. At the end of the course, the students should have attained a
“toolbox” of skills to use both in the ‘field’ setting as well as with patient-physician interactions in
marginalized communities and diverse cities. Upon completion of the course, and adherence to
the expectations outlined below, students shall receive a Certificate acknowledging completion of
an “Introductory Course in Global Health” by the Medical Society and University of Toronto
Faculty of Medicine.3

Expectations – Students
In order to ensure that the Vision and Mission (described earlier) are attained, students will be
expected to do the following:
• Prepare for lecture/case studies through recommended and, if possible, optional readings
(journal articles of original research or perspective pieces; news media; blogs). Usually,
the recommended readings total 10-15 pages per week (this would be the equivalent of 2
peer-reviewed journal articles or 1 journal article and 1-2 media articles).
• Participate in discussions during lecture and case study sessions. Where the student may
disagree with a point made by a lecturer and/or classmate, they shall be encouraged to
articulate the point (with supportive evidence if possible) in order to enhance the overall
learning goals of the elective and the student participants.
• Conduct themselves professionally during lecture and case study discussions. This
includes being punctual for each session. Students will be permitted to miss TWO (2)
sessions for an appropriate reason. Should students miss a session, they will be required to
submit a short reflective piece based on the readings and presentation (either slides or
online audio presentation) from that week.

3
This Certificate has been discussed with the Electives Committee, and has been approved

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VI. W EEKLY S CHEDULE – G LOBAL H EALTH E LECTIVE [Monday Evenings(6:30 to
8pm) from January 11th to April 12th2010 in MSB 2172; no class Feb 15 and March 15]

W k # D ate Topic

I. JAN 11 t h - DEFINING GLOBAL HEALTH AND RE-VISITING THE SOCIAL DETERMINANTS OF HEALTH;
Health Inequalities and the Health-Wealth Paradigm – Dr. Jeff Turnbull (incoming CMA
President)

II. JAN 18th - QUALITY OF CARE & ACCESS TO TREATMENT AND PREVENTION – Professor Lisa
Forman (Dalla Lana School of Public Health) and Dr. Paul Caulford (Volunteer Clinic for
Medically Uninsured Immigrants and Refugees; Dept of Community Medicine UofT)

III. JAN 25th – CASE STUDY #1: Access to Treatment/Care in Toronto and in the Field

IV. FEB 8th - GLOBAL DISEASE EPIDEMIOLOGY AND BURDEN OF DISEASE – Dr. Prabhat Jha (Centre
for Global Health Research)

V. FEB 22nd CASE STUDY #2: Basic Epidemiology and Rapid Assessment

VII. MAR 1st - GLOBAL HEALTH ETHICS I - Dr. Ross Upshur (Joint Centre for Bioethics, UofT); GLOBAL
HEALTH AND HUMAN RIGHTS AND LEGAL DISCOURSE IN GLOBAL HEALTH - Professor Rebecca
Cook (Faculty of Law, University of Toronto)

VI. MAR 8th – GLOBAL HEALTH ETHICS II (incl humanitarian law)- Dr. Barry Pakes (Dalla Lana School
of Public Health); PHARMACEUTICAL INDUSTRY AND GLOBAL HEALTH - Dr. Nancy Olivieri
(Toronto General Hospital)

VIII. MAR 22nd - PANEL: GLOBAL HEALTH AS A MEDICAL PRACTITIONER, RESPONSIBILITY OF

PHYSICIAN, PHYSICIANS AS GLOBAL HEALTH ADVOCATES – Dr. Jane Philpott (Give a Day) and Dr.
Andrew Pinto (Department of Community Medicine, UofT)

IX. MAR 29th (4:30pm – 5:30pm) – PANEL: POLITICS OF MEDICINE AND MEDICAL CARE in low-resource
settings and ROLE OF NGOS – Dr. James Orbinski ( Dignitas) and M r. Leo Johnson (CURE Canada)

MAR 29th – CASE STUDY #3: Human Rights and Ethics

X. APR 5th (4pm-6pm)- MATERNAL AND CHILD HEALTH: Maternal health - Dr. Rachel Spitzer (Mt Sinai
Hospital Dept of Ob/Gyn); Child health - Dr. Kevin Chan (Hospital for Sick Children)

XI. APR 12th - WAR AND HEALTH/MEDICINE IN HUMANITARIAN EMERGENCIES: Dr. James M askalyk
(MSF); Dr. Samantha Nutt* (Warchild Canada; informal roundtable discussion off-campus)

*=Date to be confirmed

Suggested Textbook(s)
Birn AE, Pillay Y, Holtz TH. Textbook of International Health: Global Health in a Dynamic World. 2009.
Merson MH, Black RE, Mills AJ. International Public Health: Diseases, Programs, Systems, and Policies. 2005.
Werner D. Where there is no Doctor. 2nd Ed. 2007.
Please note that reference copies of these textbooks will be available in the MedSoc office. These textbooks are by no
means necessary for the course

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R EFERENCES

Association of Faculties of Medicine of Canada Resource Group on Global Health. Towards a Medical
Education Relevant to All: The Case for Global Health in Medical Education. Ottawa: Association of
Faculties of Medicine of Canada; 2006:25.

Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global health in medical
education: a call for more training and opportunities. Acad Med. Mar 2007;82(3):226-230.

Faculty of Medicine (2008). Undergraduate Medical Curriculum: Goals and Objectives. Available at:
http://www.facmed.utoronto.ca/Assets/ume/goalsobj.pdf. Accessed February 2009.

Goldstein M. Personal Communication. March 2009.

Houpt ER, Pearson RD, Hall TL. Three domains of competency in global health education:
recommendations for all medical students. Acad Med 2007;82(3):222-225.

Institute of Medicine. US Commitment to Global Health. Recommendations for the New

Administration. National Academies Press 2009. Available at:
http://www.nap.edu/catalog.php?record_id=12506. Accessed June 18 2009.

Izadnegahdar R, Correia S, Oohata B, Kittler A, ter Kuile S, Vallancourt S et al. Global Health in
Canadian Medical Education: Current Practices and Opportunities. Acad Med 2008; 83: 192-198.

McAlister CC and K Orr. A Student’s Plea for Global Health Studies in the Medical School Curriculum.
Clin Invest Med 2006; 29(4): 185-6.

Pakes B. Global Health Education Institute: Global Health Certificate Program Proposal. 2008.

Pinto AD and RE Upshur.Global health ethics for students. Devel World Bioethics 2009; 9(1): 1-10.

Royal College of Physicians and Surgeons. CanMeds Summary. Available at:

http://rcpsc.medical.org/canmeds/CanMeds-summary_e.pdf. Accessed May 18 2009.

Shah S and T Wu. The medical student global health experience: professionalism and ethical implications.
J Med Ethics 2008; (34(5): 375-8.

Tissing EK. Medical education, global health and travel medicine: a modern student’s experience. Travel
Med Infect Dis 2009; 7(1): 15-18.

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A CKNOWLEDGEMENTS

Leadership Committee
Sarah Basma (1T2)
Rob Ciccarelli(1T1)
Kelly Emms (1T1)
Roopan Gill (1T1)
Christe Henshaw (1T2)
Nikki Hoffman (1T2)
Denise Jaworsky (1T1)
Amitha Kalaichandran (1T2)
David Katz (1T2)
Calvin Ke (1T2)
Kenneth Lee (1T2)
Hanna Lee (1T2)
Tri Nguyen (1T2)
Ali Okhowat (1T0)
Carla Pajak (1T2)
Maria Petre (1T2)
Rachel Rae (1T2)
Vanessa Rambihar (1T2)
Aleida ter Kuile (1T1)
Soumitra Tole (1T2)
Kenneth Vanderwark (1T2)
Julie Wright (1T2)
Jason Zhu (1T2)

Advisory/Support Committee
Andrew Pinto, MD
Barry N. Pakes, MD
Alice Han, MD MSc
Mara Goldstein, MD
Abi Sriharan, PhD(c)
Martin Schreiber, MD
Jay Rosenfield, MD

Contacts :
Amitha Kalaichandran (amitha.kalaichandran@gmail.com)
Calvin Ke (calvin.ke@utoronto.ca)