The Art of Mastering International Health

In a constantly shifting global world, the effects of climate change, demography and population place huge demands on health care workers, not least in low and middle income countries. Progress in international health, such as better survival rates for babies and mothers, the ability to deal with infectious and noninfectious diseases, water and sanitation is not merely a matter of money. It’s also a question of education, cooperation and additional field training, which is offered by the University of Copenhagen, Denmark, which each year sends students from all over the world to India, where they get a chance to test their new skills and get acquainted with a different kind of health care system.

I’d travelled from Copenhagen, Denmark to India to meet a group of health care workers from Asia, Africa, Europe and America, who would be spending five weeks in Vellore, Tamil Nadu, as part of their one-year training to gain a master’s in international health from the University of Copenhagen. A trip that was possible due to a long-standing partnership between this Danish university and the Christian Medical College of Vellore and in particular the cooperation between Danish Professor Ib Bygbjerg and Indian Dr Abraham Joseph.

The purpose of my visit was to document and photograph their work, but it also gave me a unique opportunity to talk to doctors, students, undergraduates, public health nurses, medical officers, dentists and many others to hear about their career choice and views on the challenges facing global health today. I also wanted to observe their new skills on field work in the impoverished villages surrounding Vellore. This was possible only since Tamil Nadu is known to have one of India’s best functioning health care systems, which take issues such as overpopulation very seriously, and advocating a two-child policy.

“The proper allocation of funds to the health sector is one of the challenges for many developing countries,” said 40-year old Ali Hassan Suleiman, a public health officer from Zanzibar. “I’ve seen with my own eyes how the state of Tamil Nadu takes health care seriously and distributes funds for this sector. The provision of free drugs and other necessary services really impressed me.”

A few days earlier the students had been actively learning about the Tamil Nadu health care system under the tutelage of energetic Doctors Kuryan George and Jasmine Helan Prasad at the Christian Medical College in Vellore. In groups they’d been discussing reproductive health and mother-child healthcare, and developed questionnaires to bring out into the field so as to conduct their own surveys on infant mortality. The numbers for infant mortality are high in low and middle-income countries regardless of whether you are in Zanzibar, Ghana, Nigeria, Nepal or India.

I travelled with Jasmina, Rita, Florence, Azza, Ralitza and Hanumantha Rao from the Christian Medical College. As soon as we left the confines of the college, we were caught in the savage and deafening traffic of Vellore. The terrain outside Vellore was very different and here we saw small villages, or even just clusters of houses, overseen by district nurses in white and dark pink saris and traditional women’s garb. After we bumped, rattled and clanked over progressively worse roads – some not even built yet – we had to get out of our tiny bus, and dodge huge, thundering machines in the process of laying roads and bringing progress to these remote areas. As we then climbed the hills, the group tried to go over the questionnaire they had prepared for 15 new mothers from the local villages, who’d volunteered to help them. All living in 15 different villages!

“I am quite surprised at the willingness of the local communities to participate in our survey-activities,” Florence told me when we stopped for a moment and was served local coffee and given flowers to put in our hair.

Though the young women seemed eager and happy to answer queries from the interpreter, the group had to contend with mother-in-laws hovering over the young mothers barely out of their teens. I wondered what other types of challenges healthcare workers have to face when they decide to go out in the world and fight for health on a global scale.

“The proper allocation of funds to the health sector is one the challenges for many developing countries.”

On and off the bus we hopped. From village to village, while the students began to wonder, if their questions were clear enough, and if the interpreter was capable of translating to the young mothers what was meant.

The heat was one thing to cope with; the other was the humidity left by the monsoon which saw the entire group soaked to the skin by midday. Only Hanu, from the neighboring province of Andhra Pradesh, seemed indifferent to the climate, while he told the group about the building styles in the villages and some of the customs of the local population.

But the first signs of fatigue were beginning to show as the days of hard, relentless study and work, different surroundings, and new foods, and cultural differences took their toll. Hanu absently tossed a used juice carton out of the bus window. Suddenly tempers flared, what seemed like a relatively incongruous act became the subject of intense scolding by some of the Westerners, who noticed the huge amounts of trash littering the road sides in this country which clearly has other priorities than their own.

Tempers eventually cooled and I realised, that working within the field of international health far from home, is not only a question of skill. If healthcare workers are to perform well in other areas of the world, they also need to have a very distinct personality, not just an academic mindset, but one that can also handle waiting around for long periods of time, cultural differences even between members of the same group, and adjust to new climates and environments.

Finally we returned back to the CMC – and air conditioning – and I had some time to talk to some in the group and other MIHstudents about their reasons for taking a masters in international health.

“At home we experience a lack of community involvement, due to health projects and interventions being imposed by authorities,” said Dr Godfather Kinaro from Tanzania. “This course has really broadened my way of thinking.”

“We used to plan and implement what we think is right for the community without involving them,” says Azzah Nofly, a medical officer from the Ministry of Health and Social Welfare in Zanzibar. “This has caused our interventions to fail. I’ve learnt that it’s important that the local communities actively participate in health issues. I work in the field of reproductive health and the knowledge gained during my MIH-training will help improve my performance and also improve public health.”

Florence wanted to learn more about global health issues, and also about how to manage healthcare systems. And on top of her intense studies, homework and re-adjustment to a new environment she also had a chance to improve her computer skills. Only halfway through her MIH-study year, she already felt that she could perform better as a manager – since her thinking and way of doing things had changed. “I can now analyse data that had been generated from services, in order that I can plan for resources that will help to improve the health of the community and people in my country.”

Cyril Chukwudi, a doctor from Nigeria, had long wanted to augment his clinical training in obstetrics and gynecology with a post-graduate academic course in an area relevant to the advancement of female reproductive health and research. “That dream was realised when the European Commission offered me the Erasmus Mundus scholarship for the program in International health,” he told me.

“It’s important that the local communities actively participate in health issues.”

Kathleen Evans, a 23-year old bachelor student in Global Resource Systems wanted a broad base of knowledge in international health before she decides to specialise in an area relevant to public health in low and middle income countries, while 35-year old Katrine Lundsby from Denmark, an MSc in agriculture wanted a career change after two years in Zambia. She felt she had to update her theoretical knowledge to be able to work with health related issues in developing countries. A change of direction was also what prompted dentist Hanu to sign on for the course.

Ali Hassan wanted to learn more about research. “I’ll be using evidence-based decisions in the area I work in upon my return,” he said, but also remarked that they would need full support from staff within the health sector.

Charity wanted to equip herself with current skills and strategies in health promotion and research to enable her to be effective and productive in her work. “I will share the new knowledge with my supervisor and immediate colleagues, who have an interest in district health systems and research,” she told me. “I think I’ll be able to meaningfully contribute to the process of strengthening district health systems in my country.”

“I’m able to see what’s working and what’s not – and how a system can be adapted for other areas.”

“Generally,” says Cyril Chukwudi,” the course in Copenhagen offered integrated training designed to expand our exposure to the health problems of developing countries with respect to problem identification, research and computerbased report writing. Here in India, we are exposed to the practical aspects of health issues and the Tamil Nadu health care system is a good case study.”

“I’ve gained practical research skills,” says Kathleen,” such as a comprehensive understanding of the local healthcare system, I’m able to see what’s working and what’s not – and how a system can be adapted for other areas.”

After having spent days with the MIHstudents, spoken to them and followed them around during lectures and field-trips, I was impressed by their determination and pure stamina. But it also strengthened my realisation that skills and supplementary training is important, as equally as tolerance, patience and openmindedness towards different cultures, customs, and practices.

The Biggest Challenges to Global Health…

—from an MIH-student’s point of view

Charity: “Lack of vaccines against malaria and HIV and the emergence of diseases such as H1N1. Global warming and sanitation issues remain a threat to the attainment of health.”

Azza: “In my opinion the biggest international health challenges facing the world today are infectious diseases and life-styles which increase non-communicable diseases.”

Florence: “The emergence of new diseases like HIV/AIDS. The transition from infectious diseases to non-infectious diseases (diabetes and hyper-tension) creates new problems, and climate change may create an entirely new set of health problems.”

Ali Hassan: “Poverty in the majority of the population in developing countries. A lack of education and low income makes health issues more complex.”