Foodborne Disease and Public Health: Summary of an Iranian-American Workshop (2008)

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6 Approaches to Health Education Moderator: Ali Ardalan D uring this session, participants learned about three very different approaches to health education. First, Keith Yamamoto outlined the vision for integrated medical research training at the Univer- sity of California at San Francisco; then Mohammad Reza Zali described the medical education approach now being used in Iran; and, at the conclusion of the meeting, Ali Ardalan used the Internet to familiarize the group with an open source Internet library called Supercourse—a resource that is available around the world. INTEGRATED MEDICAL RESEARCH TRAINING AT THE UNIVERSITY OF CALIFORNIA Presenter: Keith Yamamoto Describing the integrated medical research training at the University of California as a work in progress, Yamamoto focused on the vision that the University of California at San Francisco has for integrating health science training with research. He suggested that institutions that enhance the opportunities for physicians and Ph.D. researchers to interact pro- ductively will be rewarded by achieving new levels of excellence. Once he had introduced the topic, Yamamoto described four new programs that are underway at the university and then finished with a few closing remarks. 61 

62 FOODBORNE DISEASE AND PUBLIC HEALTH Introduction Academic medical centers have four core missions and responsibili- ties: education, research, patient care, and community outreach. At the University of California at San Francisco, all four are carried out simulta- neously, and, considered as individual efforts, each has been excellent. In 2002, however, a closer look revealed a medical curriculum that was very conventional. Science courses, for example, were neither con- nected with each other nor with the practice of medicine; and the depart- mental residency programs were focused on the specialty needs of the department. On the other hand, for many years the doctoral programs and orga- nized research units had taken the form of umbrella programs (large pro- grams that crossed department lines, and, in some cases, crossed school boundaries). The Cardiovascular Research Institute, for example, was trans-departmental, dealing with clinical medicine as well as basic sci- ence. The question arose, then, “Can the four core missions be integrated better?” The university’s response, as summarized by Yamamoto, is given below. Integrative Changes Being Made The integrative changes involve four new programs: 1. A new medical curriculum 2. The Clinical and Translational Science Institute 3. The Program in Quantitative Biology 4. The Institute for Molecular Medicine and the Graduate Program in Molecular Medicine Medical Curriculum The new medical curriculum integrates basic, clinical, and social and behavioral sciences throughout the medical school’s four-year course of study. Students often work in small groups, and their instruction empha- sizes problem solving and the relationships between research and clinical outcomes. The elective Pathways to Discovery feature of the program is designed to create a culture of inquiry, innovation, and discovery that will benefit all medical trainees. Pathways to Discovery brings together medical students and residents across department boundaries. Each of the pathways includes courses, research, and mentoring; and each pathway   “Translational” refers to finding applications of scientific discoveries in patient care. 

APPROACHES TO HEALTH EDUCATION 63 leads to a certificate or, in some cases, a master’s degree. In the future, some of the pathways may lead to a doctoral degree, Yamamoto said. Clinical and Translational Science Institute The goal of the Clinical and Translational Science Institute is to accel- erate the pace of translation of scientific discovery into patient care. The National Institutes of Health Roadmap provided the funding for this institute (more than $100 million for 5 years) through its Clinical and Translational Science Awards program. More than 200 faculty members have been involved in designing 14 programs that will promote transla- tion by creating or integrating services, resources, and policies in the fol- lowing five separate areas: 1. Education 2. Basic, translational, and clinical research 3. Clinical trials 4. Corporate alliances (locally, nationally, and globally) 5. Community interactions Program in Quantitative Biology This graduate program in biomedical research was designed to attract faculty and students from the physical sciences, mathematics, computa- tion, and engineering. These disciplines are now all well represented in the resulting umbrella program. Previously, such representation was absent. Yamamoto indicated that the program has led to changes in the nature of research and in the way it is conducted—no matter whether that research is basic, translational, or clinical. Institute for Molecular Medicine The Institute for Molecular Medicine offers an umbrella program for medical trainees. A consortium of the university’s medical departments oversees joint faculty recruitment and space allocation and administers the M.D./Ph.D. program, the molecular medicine residency/fellowship program, and the Graduate Program in Molecular Medicine. The Graduate Program in Molecular Medicine serves as a point of access into the Institute for Molecular Medicine—a portal of entry that is available to graduate students in any doctoral program. The program offers seminars, symposia, and intensive mini-courses that focus on the mechanisms of disease and that range from basic principles to patient care. Because the program offerings are designed to attract graduate 

64 FOODBORNE DISEASE AND PUBLIC HEALTH students, fellows, medical students, residents, and faculty, the learning opportunities serve a key integrative function. Discussions among partici- pants from different educational and experiential backgrounds may lead to the discovery of a range of approaches and opportunities. A person may choose to attend formally, with the goal of qualifying for a certifi- cate, or informally. A student in the pharmacology program might, for example, decide to spend two weeks learning about Alzheimer’s disease from experts. Closing Remarks Academic medical centers have an opportunity to find new levels of integration that will lead to new levels of excellence. Yamamoto expects that the new opportunities generated by improved integration will lead to new discoveries and will speed the course of discoveries in basic sciences and in the translational and clinical areas. HEALTH EDUCATION IN IRAN Presenter: Mohammad Reza Zali With the establishment of a primary health care system throughout Iran during the period from 1980 to 2003, life expectancy increased dra- matically, maternal and infant mortality decreased dramatically, and the rate of population growth slowed substantially. Now Iran’s population has a large percentage of young people and also a growing number of the elderly. The population is also gradually becoming more urban. The major causes of mortality in 2003 were cardiovascular disease, cancer, and accidents. All of these factors are relevant to the future needs for health care services and medical education in Iran. In his presentation, Zali briefly described the relationship of the Ira- nian health care system to the medical science universities. Then he pro- vided an overview of medical education and a description of curricular reform in undergraduate medical education. Relationship of the Health Care System to Medical Education The Ministry of Health and Medical Education oversees both the health care system and medical education, as mentioned in Chapter 2. Figure 6-1 gives the organization of the Medical Sciences Universities. The Deputy of Health oversees the teaching hospitals as well as the state, urban, and rural health network described in Chapter 2. 

Medical Sciences Universities: 55 Deputy of Education Deputy of Research Deputy of Health Deputy of Finance and Administration Deputy for Therapeutic Affairs School of Nursing School of Paraclinical School of Medicine School of Dentistry School of Pharmacology and Midwifery Sciences FIGURE 6-1  Iran’s Medical Sciences Universities organizational chart. SOURCE: M. Zali, Shaheed Beheshti University of Medical Sciences. 65 Figure 6-1 

66 FOODBORNE DISEASE AND PUBLIC HEALTH Overview of Medical Education The curriculum for medical education is standardized across the Ira- nian medical schools. In a seven-year program, the first two years are spent in the basic sciences, and the third year covers pathophysiology and the study of the signs and symptoms of disease. Subsequent years are focused on the externship and internship. Iran has 28 medical schools in the public sector, 5 in the armed forces, and 22 in the private sector. Of the 1,600 medical students enrolled each year, more than 50 percent are female. The providers of health care in Iran must deal with the needs of a growing young population who face problems related to addiction, violence, accidents, and communicable diseases. They also must deal with the needs of a growing elderly population struggling with diabetes, cardiovascular disease, obesity, cancer, Alzheimer’s disease, and other ailments. To address these challenges, Iran recognizes the importance of developing its human resources and taking appropriate actions, particu- larly in the following three areas: 1. Improvements in medical education, including the revision of medical curricula 2. The training of a new generation of medical researchers 3. Increases in the amount of patient-oriented and disease-oriented research, including both basic and clinical research Notably, biomedical research citations from Iran have increased sharply since about the year 2000. Curricular Reform in Undergraduate Medical Education In an effort to help improve medical education in Iran, the University of Shaheed Beheshti undertook a pilot study on the reform of medical school curricula. The proposed curriculum reform would take an inte- grated approach, with case-based study; the opportunity for students to enroll in either science or public health research; and an opportunity for students to become familiar with a scientific career. The developers of the Iranian curriculum reform plan attempted to be comprehensive in their approach. The reform is to be based on the best available evidence, using a formal process of option appraisal. This pro- cess produces the “evidence-based” content that is mentioned below. The resulting curriculum must be in accord with international and national standards. The effort began in 1999 with a needs assessment. This was fol- lowed by an extensive series of curriculum-development activities under- taken by a broadly interdisciplinary team. The proposed plan required 

APPROACHES TO HEALTH EDUCATION 67 and obtained approvals from a number of officials, including the Minister of Health. The pilot study was implemented beginning in 2004 with such steps as the development of new courses, the writing of textbooks, operational planning, and capacity building. Emphasis was placed on evidence-based content. Interdisciplinary, curriculum, and steering committees were assembled to provide input and direction. The resulting new curriculum vertically integrates clinical content with the study of organ systems. Courses include lecture-based courses, self-directed reading modules, small study-group modules, project modules, and laboratory-work mod- ules. One very important aspect of the reform is getting the students involved in community health care. Figure 6-2 illustrates a typical flow of activities that could take place when interns work in the community. Mohammad Reza Zali emphasized the key role played by specially trained clinical preceptors. They work with medical students in super- vised learning facilities, skill laboratories, and ambulatory clinical train- ing; and they provide guidance about learning portfolios and logbooks, educational prescriptions, and study guides. The curricular reform program has been undergoing both internal FIGURE 6-2  A typical flow of activities when interns are placed in the community. fig 6-2 SOURCE: M. Zali, Shaheed Beheshti University of Medical Sciences. this is a scan of the hard copy sent to NAP. The wmf lost the symbols under Clerks Sructured and Community The Word file couldnt be used because much of the content was different 

68 FOODBORNE DISEASE AND PUBLIC HEALTH and external evaluation. Observations, questionnaires, and interviews are used to obtain data on context, input, process, and output. A key aspect of the evaluation is to determine whether the program meets national standards. The preliminary report, which will be released soon, indicates that students have been performing well. In particular, the reformed medical education is resulting in improvements in the knowledge, skill, and awareness of the participants. Closing Remarks Mohammad Reza Zali is hopeful that talented students will attract other talented students to research. He quoted from Plato’s The Laws, written in 490 B.C.: “Good clinical medicine is a marriage of scientific knowledge and human care.” SUPERCOURSE—THE GLOBAL HEALTH NETWORK Presenter: Ali Ardalan, with Ronald LaPorte by Telephone The last presentation covered Supercourse, the open source Internet library developed under the leadership of Janice Dorman and Ronald LaPorte at the World Health Organization Collaborating Center at the University of Pittsburgh’s Graduate School of Public Health. Other devel- opers include Ali Ardalan, Faina Linkov, Mita Lovelekar, Francois Sauer, and Julia Shubuikova. During the presentation, Ardalan connected with the Internet site and projected an assortment of pages on the screen to illustrate the contents and uses of Supercourse. Afterward, LaPorte com- mented via a telephone connection. Overview Supercourse is a global repository of lectures on public health and prevention, which is designed for use by educators across the world. It can be accessed at http://www.pitt.edu/~super1/, and the materials on the site may be used at no cost. Supercourse has a network of more than 42,500 scientists in 174 countries who share materials. Together they have created a library of more than 3,232 lectures in 26 languages. As indicated on the website, the Supercourse sometimes is called the Global Health Network University. The Supercourse offers lectures on epidemiology, surveillance, nutri- tion, cancer prevention, and a myriad of other topics, identifying each of the authors of those lectures and the dates the lectures were written. 

APPROACHES TO HEALTH EDUCATION 69 Numerous Nobel Prize winners have contributed lectures to the Super- course. Many of the lectures have been translated into Chinese, Span- ish, Arabic, and other languages. The site includes a number of ways to search for articles, including an option called “New Lectures.” Ardalan specifically recommended viewing the lecture called “The Golden Lecture of Prevention.” Improving Disaster and Public Health Education Worldwide One way to improve disaster education and public health education is to share effective lectures and slide presentations for free. The Super- course does this. Currently the site holds 250 lectures that deal with pre- paring for and responding to disasters; they were submitted by experts from 50 countries. When a health emergency occurs, the Supercourse can play a key role in providing relevant information through its “Just-in-Time Lectures.” Within days of an event, experts can develop lectures and disseminate them through the Supercourse network. This occurred, for example, after the 2004 Indian Ocean tsunami. The network recruited 40 global experts, who generated a lecture within 3 days; that lecture was distributed to 120 countries and reached approximately 200,000 students. Another Just-in- Time Lecture dealt with severe acute respiratory syndrome (SARS). Closing Comments One goal of the Supercourse is to provide an expert global network and expert content online—useful information that is available in advance of adverse events—thus helping to protect the public health through such measures as the prevention of outbreaks of foodborne illness. DISCUSSION Moderator: Ali Ardalan Three major topics were covered during the discussion period: the extent of curricular reform in Iran, aspects of the integration of medi- cal research training that are potentially applicable in both Iran and the United States, and some details about the Supercourse. Highlights appear below.   Baruch S. Blumberg, Leland H. Hartwell, Eric R. Kandel, Klaus von Klitzing, Joshua Lederberg, Merid Murad, Paul Nurse, Doughlas Osheroff, and Rolf R. Zinkernagel (http:// www.pitt.edu/~super1/Nobel/nobels.htm). 

70 FOODBORNE DISEASE AND PUBLIC HEALTH Curriculum Reform in Iran The pilot study of the curriculum reform program is being carried out only at Shaheed Beheshti Medical University. If the pilot study shows favorable results after 5 to 10 years, the government will allow other uni- versities to adopt the reformed curriculum. Organ system-based education, evidence-based education, and a new evaluation system are three of the reform program’s main emphases. In the pilot program, the students focus on evidence-based medicine, in part by performing extensive searches of reliable sources on the Internet. Nosratollah Naderi, a preceptor in the program, said that the reform pro- gram has been successful in providing students with the knowledge they need to treat their patients and to solve problems. Integration of Medical Research Training Government Approval of Programs Participants noted that if the government must approve program changes, as is the case in Iran, it can substantially delay the implementa- tion of plans. Dr. Yamamoto said that the types of changes—such as the establishment of umbrella programs—being made at his university (the University of California) did not require approval by the governing body of the university, but that new degree programs would require approval and thus would require more time to get started. Certificates Offered by the Graduate Program in Molecular Medicine Dr. Yamamoto explained that the certificates offered in the Graduate Program in Molecular Medicine do not yet have intrinsic value, but they may be useful additions to the graduate’s curriculum vitae. If the employ- ers who hire the graduates determine that the training has been valuable, the certificates will acquire value. Supercourse Dr. LaPorte of the University of Pittsburgh expressed great appre- ciation to colleagues in Iran, especially Ali Ardalan, for their invaluable assistance as collaborators on the Supercourse project. Its courses are translated by volunteers who reportedly like to do this work. One person in Mexico is translating 800 lectures into Spanish. About 140 medical students in China are translating the entire Super- course into Chinese. 

APPROACHES TO HEALTH EDUCATION 71 It is possible to identify the most recent lectures on the website, and one can trace changes in the content of lectures on similar topics over time. Dr. LaPorte closed by repeating a comment made by the head of Internet technology at the U.S. National Aeronautics and Space Administration—that it is better to have an expert global network and expert content available before a food-associated outbreak occurs than to accumulate the information afterward.