PLANETARY HEALTH WEEKLY

Blog# 7
Jay D. Kravitz, MD, MPH

April 8, 2021

When planning an overseas experience, important criteria and questions should be considered prior to departure. Proper preparation will make one’s educational and personal engagement more valuable and enjoyable and, perhaps, pave the way for others to follow. The data points listed below were integral to the preparatory process I helped organize at my former university. The motive was to guide both academic supervisors and students to determine if a chosen destination was sufficiently substantive, safe and worthy of consideration. Provided information in this commentary can guide all health profession scholars, including medical, nursing, physiotherapy, policy and management, public health, pharmacy, laboratory and dental students – and residents, clinicians and researchers.

From an institutional perspective, one’s home university must assure student safety and make this priority one. Faculty and administrators must also be confident that students neither interfere with local practices or policies nor place a financial or physical burden on the host institution. Training programs should aspire to provide the prospect for mutual benefit, when possible, with local hosts and stakeholders – and identify those activities that might be considered harmful. Discrete, respectful visitors’ behaviour is certainly part of that equation.

One notion to consider is whether home-university faculty might accompany students. Visiting faculty could provide local mentorship for visiting and local students and hosts. And importantly, it should be acknowledged that not everyone who wishes to work in a foreign country is a suitable candidate for such an endeavor.

One objective of international electives is to form a foundation for interested students to consider careers oriented towards global health. The serious burden of illness and mortality, constrained infrastructure, unique vulnerabilities and inequalities, unsuitable clinical practice guidelines and insufficient numbers of local, skilled personnel provide powerful lessons and opportunities to make impactful contributions in lower resource settings.^1,2

These realities also raise ethical questions, however, for all participants. Patients may benefit from the attention paid to them, but levels of training and diagnostic skills must be clearly expressed, so that others do not infer – and students do not overstate – their value, experience or competence. Over-assumptions (or over-delegation of responsibilities) could compromise patient safety, lead to distrust or disrupt local health care delivery.

Educational guidance can be found at the Consortium of Universities for Global Health website: https://www.cugh.org/resources/educational-products/

Future blog commentaries will provide more detailed recommendations for travel health, safety and professionalism.

General Information when planning an overseas experience:

1. Identify the name, location and brief description of organization or program
2. Is the student in good standing at their institution and approved to take an elective course overseas?
3. What type of clinical, research and community development opportunities are available within a chosen program or destination?
4. What is the application process?
5. What orientation does the program offer to students?
6. What language and cultural barriers might exist?
7. If this program is approved by the home university, has the student read, signed and submitted a university Release of Liability/Waiver form, an “off campus authorization”?
   Does this program have fees, “tuition” or housing costs? Have travel costs been considered.
8. Are medical supply donations encouraged or expected?
9. What types of students are appropriate for this program? (e.g. dental, engineering, medical, nursing, pharmacy, physician assistant, public health, resident, research and/or pre-professional students)
10. What prior training is necessary or expected by your university and potential hosts?  (e.g. level of clinical, research skills or educational background)
11. What skills and perspectives might students gain from the program?
12. What responsibilities and duties are expected of student guests?
13. Should students gain some level of proficiency of host country language prior to entry?
14. Are local language programs available?
15. If necessary, are interpreters available on site?
16. Is a medical school or university associated with the chosen destination?
17. What on-site mentorship and supervision available? If so, who provides clinical supervision?
18. How many students can be accommodated at one time?
19. When is the chosen program available or practical for students?  (e.g., anticipated arrival dates or specific months of the year that do/do not work for immersion rotations?)
20. What time commitment is expected from participants (weeks to months)?
21. Are there any particular expectations by the home university supervising the student’s planning process and after they arrive at the overseas destination?
22. Are any specific preventive health precautions recommended by the host for the student prior to arrival?
23. Has the student consulted a health care provider and/or an International Travel Clinic to assure that preventive health services (immunizations and medications) have been taken prior to departure
24. Has a thank you letter or card been sent to a funder supporting a student project?
25. If a research project is intended, has a proposal been submitted to the Internal Review Board (IRB) for ethical approval at the home university and host site, as required?
26. Is a Principal Investigator guiding intended research at the home university and/or at the host site?
27. What academic reporting procedures are in place? Will the student agree to send a mid- experience 500 word report to their academic office?
28. Will the student agree to send a summary report upon completion of the project to the academic office and funder?
29. Will the student provide a presentation of their experiences at a home university forum? It is also an appropriate expectation to share the findings of one’s work with their hosts.
30. Will a paper be written for journal submission and publication?
31. Appropriate behaviour is expected of all participants in an overseas experience. Liabilities remain the responsibility of the student. Students must remember that they are ambassadors for their university, their country and themselves.
32. When traveling abroad, one inevitably encounters unexpected social customs and behaviours that may be contrary to one’s life experience. For example, in S.E. Asia the head is considered “sacred,” and may not be touched without permission. Also, when sitting on the floor, it is considered impolite to point one’s feet outward. Taking photographs requires a courtesy to first ask the subject of interest.
33. Professionalism: While students must be instilled with the responsibility not to practice beyond their skill level, they should not be discouraged from a spirit of inquiry, while promoting the social and physical well-being of the patients and populations with whom they interact.

Logistics:

1. Closest and/or most affordable airport
2. Suggested transportation to/from program site and airport
3. What types of accommodations are available (e.g. home-stay, dormitory, project-supported housing, local hotel), local transportation to/from airport and program site, meals and amenities (e.g. toilets, water source, internet access, emergency phone access)?
4. Does the student have sufficient monetary assets?
5. Obtaining some amount of the local currency prior to travel is a good idea.
6. Has the student reviewed travel safety guidelines prior to departure?
7. If someone becomes ill or injured whom should they contact?
8. Has mandatory travel and evacuation insurance been obtained?
9. Is the training environment considered secure from conflict and political tensions? Is it considered safe to visit by the appropriate government agency?
10. What level of burden would accommodating a student present to the host community and medical and community facilities?
11. Unintended consequences potentially loom. While experiences may be illuminating and exciting, stress and guilt (or depression) are possible. Should a student develop psychological stresses, with whom can/should they discuss their situation?
12. Local and international contacts for assistance and communication (Names, email addresses, telephone and mobile phone numbers, mailing address and fax).
13. Must the student obtain a visa?  When and how can this best be accomplished?
14. Has the student registered with their home country embassy in the destination country?
15. Has the student provided to a family member or friend the planned itinerary, a scanned copy of their passport picture page (Passport should have at least six months before its expiration date)?
16. Does the destination host have a religious affiliation? (If so, are volunteers required to participate?)

Perhaps, several of these ideas were not previously considered on your travel planning radar. Other thoughts, not expressed here, may inferentially stimulate further reflection. I hope this list of preparatory criteria, questions and concerns will enable facile planning and entry, while supporting constructive, positive educational experiences when working, studying and traveling abroad.

Recommended References:

• Sanders D. The Struggle for Health. Macmillan Publishing Company. London. 1985. During his honoured career Dr. David Sanders was a well-respected faculty member at the University of Zimbabwe School of Medicine in the Community Medicine Department (where he served as my extraordinary public health mentor); Professor at the University of Kwazulu-Natal in Congella-Durban, South Africa; and founding Director of the School of Public Health at the University of the Western Cape in Cape Town, South Africa. Professor Sanders was a gifted, global health practitioner and a founding member of the Peoples’ Health Movement. His compelling book was well-regarded by my students! Sadly, he passed away a few years ago.

• Maaløe N, Ørtved A, Sørensen J, Dmello B, van den Akker T, Kujabi M, Kidanto H, Meguid T, et al. The injustice of unfit clinical practice guidelines in low-resource realities. The Lancet Global Health; Published Online March 22, 2021.

https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00059-0/fulltext/

• Kravitz J. Commentary: Redefining Global Health; Integrating an Alma Ata Declaration Retrospective. Community Medicine & Public Health Care 2019;6(2):1-4. https://www.heraldopenaccess.us/openaccess/redefining-global-health-integrating-an-alma-ata-declaration-retrospective/