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Global Health: Easy to Promise; Difficult to Achieve

Defining a University's Role

Fagin auditorium
Photos: Hoag Levins
The University of Pennsylvania's annual Alumni-Faculty Exchange focused on the university's global health initiatives.

PHILADELPHIA -- Eleven years ago, the largest gathering of world leaders ever convened at United Nations' headquarters ratified the Millennium Declaration, a manifesto for life-improving changes throughout the developing world to be achieved by 2015.

With great pomp and worldwide publicity, they declared that "As leaders we have a duty to all
Amy gutmann

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Penn President Amy Gutmann: "The single most pressing problem of our interconnected world." (1:09 sec.)
the world's people, especially the most vulnerable and, in particular, the children of the world, to whom the future belongs."

The office of then-UN Assistant Secretary for Strategic Planning Michael W. Doyle subsequently worked with world development organizations to define what would become eight measurable Millennium Development Goals (MDGs). Three of those were health care-specific and sought to dramatically reduce child mortality, maternal mortality, and reverse the spread of HIV/AIDS, tuberculosis and malaria by 2015.

Last week, Doyle's wife, University of Pennsylvania President Amy Gutmann, noted how those efforts have thus far fallen short in a world where malaria still kills 91 people
Sandy Schwartz

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J. Sanford Schwartz recounts a 1972 global health experience that changed his life and career. (1:50 sec.)
every hour of every day, despite the fact that it's a treatable, preventable disease.

"We know how to do this (treat malaria)," she told an audience in the auditorium of the university's School of Nursing, "but where there's a way, there's not necessarily a will."

Gutmann's keynote remarks opened the "Global Health in a Connected World" alumni-faculty panel discussion sponsored by Penn Alumni, Penn Medicine, Penn Nursing, and the Leonard Davis Institute of Health Economics.

"Making life-saving health care available to hundreds of millions of people who desperately need it may be the single most pressing problem of our interconnected world,"
Neal Nathanson

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Neal Nathanson said that by 2004 there was a 'tsunami' of student interest in global health studies. 00:45 sec.)
"Thousands of would-be mothers die from complications related to pregnancy and childbirth. Millions of babies are stillborn. Add to these numbers the countless men, women and children living with chronic health conditions around the world and the importance of global health systems is thrown into high relief."

Since Gutmann became President of Penn in 2004, the university has expanded its health-related international activities. Every year, Penn Medical School's Global Health Programs, the Botswana-UPenn Partnership and the Afya Bora Consortium engage more than 250 students and residents from across all Penn schools in rotations in more than 25 countries throughout Africa, Asia and South America.

Those participants provide on-site health care services in the host country at the same time they help train local
Arthur Rubenstein

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Arthur Rubenstein: The faculty lagged behind the students when it came to global health initiatives. (00:58 sec.)
health care professionals to improve their technical skills and credentials.

Panel moderator J. Sanford Schwartz noted some critics ask how the university can justify devoting funds and resources to such international work "when we have vulnerable, underserved populations with unmet health needs and huge disparities in the U.S. and, indeed, even close to the University of Pennsylvania."

Schwartz, a Penn Professor of Medicine and Health Care Management and Economics, said one reason the Medical School moved into international programs was because growing numbers of its students demanded it. "It was an area where the students were initially out in front of us," he remembered.
Afaf Meleis

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Afaf Meleis: "Securing women's health around the world is not only a moral obligation, it's fundamental to human progress." (1:13 sec.)
He served as the initial advisor to the student affinity group that formally asked the school administration to develop "total immersion" clinical exchange programs with underdeveloped nations.

In 2004, panelist Neal Nathanson led the development of the medical school's new international efforts, which he currently oversees as Penn's Associate Dean for Global Health Programs. He said the experience of an immersive clinical rotation abroad has profound, life-long effects on students and residents.

'A searing experience'
"It shapes their whole outlook," Nathanson said. "We recently had students coming back from Botswana; each one of them said 'This has changed the way we think about life. This was a searing experience that I'll never forget. This will change the way I deliver care.'"

It is, Nathanson said, an experience that is not reproducible in any other way, and one designed to take students "along a pathway which starts with the heart and goes to the head. In other words, a commitment to global health."

But panelists didn't agree on the exact long-term strategies or short-term tactics to best achieve the most effective synergy between a U.S. university and the heath care system of an underdeveloped country.

Panelist Arthur H. Rubenstein, outgoing Dean of Penn's School of Medicine, questioned whether programs that assist and help train health care professionals in other countries have addressed what he sees as a huge problem: those same countries' brain drain. After earning their degrees in their own countries, many foreign nationals emigrate to the United States, Canada, Australia and other nations where pay is higher and living conditions better. The end result is that the money and resources invested in their training fail to ultimately benefit the underdeveloped countries.

'A very, very serious problem'
"This is a very, very serious problem," said Rubenstein, who himself trained in South Africa before moving to the U.S. "I do believe, just to be provocative, that (programs like Penn's) are less an answer in terms of what has to be done to improve health in these countries than we believe. Despite all our efforts and skills and knowledge and partnerships, it really is just the beginning of what to do."

"Is there a way," Rubenstein asked, "for (the U.S.) to partner, particularly with African countries and their health systems, to try to provide opportunities for health care workers to stay in those countries and be successful and take over, slowly but importantly, the leadership so that our role will be diminished -- which, of course, would be our greatest success?"

Panelist Afaf Meleis had a completely different take on a grand strategy for global health improvement. She argued that focusing narrowly on specific diseases like HIV/AIDS, tuberculosis or malaria isn't the answer. The real answer, said Meleis, the Dean of Penn Nursing, can be found in the plight of women.

Not meeting the goals
"The students volunteering for these global programs tell us they want the profession to focus more on 'service, social accountability and a social mission.' They feel professional schools haven't articulated that social mission well; and that's what we need to do. We are almost at 2015 and there are lots of recent reports about how we are not meeting the Millennium Development Goals," Meleis said.

"Women are the first to take care of the vulnerable sick but the last to receive preventive care or life-saving treatment themselves," she said. "Women are twice as likely as men to be infected with HIV. The World Bank estimates twice as many women as men live in poverty throughout the world. They remain disadvantaged in many areas of life that put them at risk."

"I worry very much that when we focus only on diseases, we lose sight of who is more marginalized and who is more compromised in this process," she said. "Focusing on women's health around the world provides us with an engaging social mission, increases that sense of social accountability the students talk about, and may prepare our graduates to actually handle the Millennium Development Goals, understand why they are so important, and help us all to achieve them."

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