Practicing and teaching medicine in international settings can be fascinating. Here I explore what lies beyond fascinating—beyond the signs and symptoms of conditions common to people who live in remote parts of the world and the unique situations that we, as physicians trained in the US, experience when we find ourselves embedded in cross-cultural encounters. I want to examine some of the deep satisfaction that the word “global” can bring to our work as clinicians and teachers working in both international and domestic settings.
The one aspect of global medicine I believe most deeply touches us, whether we are across the ocean or in our own backyards, is relationship. I note “relationship,” rather than “relationships,” because I mean something more than the interactions we have with our patients, our students, our colleagues, and our friends. These relationships are not unimportant; in fact, they are critical to our engagement with life at work and at home. Rather, what I want to communicate is a broader sense of what relationship in global medicine means: that is, where we see ourselves in relation to the people with whom we work; where we see ourselves in relation to both the natural and built environments in which we live; and where we see ourselves in relation to the systems of health care in which we practice. Relationship is the core lesson learned from my over 25 years working in safety net and corrections health clinics in the US, as well as teaching and practicing medicine, public health, and medical anthropology in various international settings.
Defining the Dimensions of Relationship
Five themes shape this core lesson of relationship:
Global Geography—Commonly, global health is used as a synonym for international health, which itself is used as a synonym for geographic or international medicine. Much has been written about the fine distinctions between these constructs, but I see them succinctly, thus:
- Global means everywhere, including the US;
- International means elsewhere, outside the US, principally signifying the majority world
- Health means relative well-being, with added emphasis on how cultural, political, and structural factors can contribute to or hinder it; and
- Medicine is the contribution that doctors and other professionals offer to patients who suffer from diseases, including efforts at disease prevention.
How we see our relationship with these concepts very likely alters what we choose to do and how we do it. Even when treating specific diseases with targeted therapies, we expand the breadth of our work in global medicine, potentially contributing to global health, by incorporating a holistic view of biology, social context, and collective and individual capacity.
Social Environment—The basis for being successful in medicine in any setting is doing our best wherever we are, with whatever we have, in the moment at hand. Context is key. Rural suggests an environment different from urban. Resource-poor suggests one different from resource-rich. Community health suggests one different from tertiary care. As global physicians, we are likely to be called to participate in educational activities and patient care in each of these settings. How we work in relationship with the particular realities of the surrounding milieus is an integral part of how patients, students, professional colleagues, and community members view our efforts, and whether or not they will see them as genuinely helpful.
Systemic Practice—There are numerous frustrations in the domestic practice of medicine today. Concomitantly providing competent medical care and inviting a shared presence with those who seek our guidance and skill often seems beyond our reach. Going abroad appears an increasingly common response; we are often able to do internationally what we are not able to do at home. Nonetheless, although medical needs are blatantly obvious in settings of grave material want, the structural causes of those needs exist everywhere.8 Whatever we do as global physicians should not only contribute to the common good elsewhere, but also help us take note of ourrelationship with the system at home and commit to making it fairer through advocacy and political engagement.
Personal and Professional Development—There are a variety of reasons physicians enter into the work of global medicine and global health. For many it is a calling. For some it is prompted by interest in growing new skills. For others it is in response to a larger, globalized, social awareness. For all, work in global medicine helps us grow our sense of self in relationship,6 building on the power of the metaphorical space in between us and others, by offering the kind of experiences that emphasize collaborative learning, personal and professional growth, and community engagement over more conventional measures of academic and professional success.
Healing Values—Work in global medicine often strengthens our relationship with the healing values of resiliency, solidarity, and generosity that are commonly suppressed under the weight of the bureaucratic demands that currently exist in the US. Such values help us move beyond our understanding of social determinants to a recognition of social interdependency, the awareness that we are all, ultimately, in the same boat as human beings. Social interdependency suggests none of us is so disconnected that we cannot desire for others what we desire for ourselves. As global physicians we may not be able to fix every extant problem, but we can work toward making both medical education and medical practice slightly more just, more fair, and more socially accountable, especially by offering up measures of affinity and reciprocity in our professional encounters with students and patients.
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-William B. Ventres, MD, MA
This article originally appeared in the August 2016 issue of The American Journal of Medicine.
