Key Messages Identified by Individual Speakers and Participants
- Arguments for the curricular redesign toward a One Health concept include the growing risk of disease caused by overcrowding and urbanization, changes in food production and supply systems, and extreme weather conditions, environmental degradation, and the inappropriate use of antibiotics. Solely focusing on human or animal or environmental health would not set a foundation for learning about or addressing these 21st-century challenges. (Colwell, Fox, Kahn, Olsen)
- Learners are being prepared for a health system that no longer exists. (Scrimshaw)
- There needs to be a functional model for educators to follow that would quickly capture the attention of leaders who possess the power and the money to create real change. Community-based education could be the broad, overarching construct from which everything else follows. (Cox)
James Fox, representing the Association of American Veterinary Medical Colleges (AAVMC), provided the background for the session he moderated on building a global health workforce through the One Health framework. He started by describing the origins of the One Health concept that began with Rudolph Virchow who argued in the mid-1800s that no
dividing line exists between animal and human medicine (Schultz, 2008). Adding the environmental context, this forms the basis for the present day One Health concept: “Unite the entire spectrum of medical expertise with the goal of improving and protecting the health of humans, all other animals, and our environment, worldwide.”
Fox went on to describe the world as complicated, shrinking, and changing. With a changing environment, populations are increasingly exposed to a multitude of organisms through a plethora of different animal species. He called it the convergence model (see Figure 4-1) and described it as the perfect storm in terms of physical, environmental, genetic, and biological factors that influence the outcome of disease. It includes wildlife vectors and insults to wildlife caused by the demands of encroaching human population. These demands are driven by social, political, and economic concerns that impact the ecology and are inextricably linked to human and animal health.
Fox and his veterinary colleagues realize how important diseases transmitted from animals to humans are: they constitute 60 percent of all known infectious organisms in man and 75 percent of emerging pathogens
FIGURE 4-1 Convergence model.
NOTE: EID = emerging infectious disease.
SOURCE: Fox, 2015, with kind permission of Lonnie J. King, Ohio State University.
FIGURE 4-2 Global map of emerging infections.
NOTE: DHF = dengue hemorrhagic fever; JE = Japanese encephalitis; SARS = severe acute respiratory syndrome; TBE = tick-borne encephalitis; VEE = Venezuelan equine encephalitis.
SOURCE: Gibbs, 2005, as presented by Fox on April 24, 2015.
(AVMA, 2008). The literature is replete with examples of the interface of climate change and infectious disease and how these two are affecting our various ecosystems and they way diseases present. This is not only evident in humans but also in various species of animals whose survival is also being negatively affected (Altizer et al., 2013). Figure 4-2 is a global map of emerging infections. It is because of the complexity of ecological environments and the encroachment upon native habitats that exposure to different species of bats carrying pathogens has become an increasingly important global problem.
Another often overlooked point is that by 2050 there will be 9 billion people inhabiting Earth. This has profound implications for the food supply and food security, both of which are impacted by animals. For example in Asia, 6 percent of the annual rice harvest, or roughly enough to feed Indonesia’s 240 million people for 1 year, is ingested by rats. This is an example of how the intricate balance of our food production supply chain is so important and will be increasingly important in the future (Normile, 2010).
The One Health Commission is addressing One Health issues through public, government, and academic education programs. The International One Health Platform Foundation has created a new, open access One Health Journal with Elsevier. It is a global initiative, but there are other
efforts underway through the AAVMC. It recently launched a project that seeks to integrate One Health concepts into degree programs of health professional students through interprofessional case studies. This project demonstrates how One Health advocates promote multidisciplinary approaches and encourage collaborations that break down walls through enhanced educational programs for local, national, and global improvement.
ENVIRONMENT, CLIMATE, AND HUMAN HEALTH:
Rita R. Colwell, Ph.D., D.Sc.
University of Maryland, College Park
Rita Colwell from the University of Maryland extended the One Health foundation set by Fox in his opening remarks by providing an example of how human health is closely intertwined with aquatic systems and how it is affected by climate and nonhuman life forms in and around bodies of water.
She began by explaining that there are at least two dozen diseases that are transmitted by water (see Table 4-1). Cholera and diarrheal diseases alone account for 1.5 billion cases every year, and close to 2 million deaths. And while the disease is transmitted person to person under conditions of poor sanitation, she and her colleagues were able to show that the bacte-
TABLE 4-1 Water-Related Diseases
|Cases per Year||Deaths per Year|
|Arsenic||28–35m exposed to drinking water with elevated levels|
|Diarrheal disease, including cholera||1.5 billion||1,800,000|
|Dracunuliasis (guinea worm)||>5,000||—|
|Fluorosis||26 million (China)||—|
SOURCE: Colwell, 2015, courtesy of Rita Colwell, University of Maryland, College Park, and Antar Jutla, West Virginia University.
FIGURE 4-3 Theoretical framework for predicting cholera outbreaks in epidemic regions.
SOURCE: Colwell, 2015, courtesy of Rita Colwell, University of Maryland, College Park, and Antar Jutla, West Virginia University.
rium Vibrio cholerae is part of the natural flora of the environment. They then developed a model using changes in air temperature and rainfall, to predict cholera outbreaks in such places as Bangladesh, Haiti, and India where there is either a poor or a damaged infrastructure for delivering water and handling sanitation (see Figure 4-3). In each of these countries, there was an interaction of the environment, the weather patterns, and exposure to Vibrio cholerae at a time when the populations were most vulnerable leading to a cholera epidemic.
Colwell then applied the One Health example she presented to education and cultural interactions that demonstrate how holistic one must be in understanding and dealing with public health. Having spent 25 to 30 years working in Bangladesh, she and her colleagues had uncovered what she described as a waterborne vector (the copepods) responsible for transmitting the cholera as a carrier. With their satellite imagery, they could predict when an outbreak would occur—but Colwell wanted to help the villagers in remote areas prevent cholera. She developed a variety of simple filtering materials that could remove 90 percent of the copepods and particulate
FIGURE 4-4 Vibrio cholerae.
SOURCE: Colwell, 2015.
matter from the water (see Figure 4-4). With financial assistance from the National Institutes of Health (NIH), Colwell undertook a 3-year study in 50 villages involving 150,000 Indian villagers. To reach the populations, Colwell set up health care extension agents, much like the agricultural extension agents; these were women who taught others how to take a square of used old sari cloth, fold it four to eight times, and then place it over the carafe where they collect water for their family for the day, and pour the water through the filter.
It did not take a lot of convincing for their extension agents and for the women in the villages to see that the water was clear after filtration compared to the turbid water that they were otherwise serving to their families for their drinking water. Through this system of education and outreach using local villagers, Colwell and her colleagues were able to reduce cholera by 50 percent in this population.
To test whether their intervention was sustainable, Colwell returned to India 5 years later. She was interested in testing the effectiveness of their educational program by comparing cholera rates between groups of villagers who did and did not receive the intervention. This proved to be
a difficult task because the control villagers had discovered the filtration. Roughly 75 percent of the population was now filtering their water. But what Colwell did learn was there appears to be a herd effect that is similar to vaccines. By being surrounded by families that filter their water, those who do not filter are actually protected.
This is an example of condensing all of the sophistication to understand the transmission of this disease, its relationship to the environment, and then provide a simple workable technique for the population that is shared through local resources.
PUBLIC HEALTH AND GLOBAL HEALTH AS VENUES FOR
CROSS-DISCIPLINARY HEALTH PROFESSIONAL EDUCATION
Christopher W. Olsen, D.V.M., Ph.D.
University of Wisconsin–Madison
Christopher Olsen is a professor of public health in the School of Veterinary Medicine at the University of Wisconsin–Madison (UW–Madison). He is also Associate Director for the One Health, Global Health Institute, which is why he was asked to speak about public health and global health as opportunities for cross-disciplinary health professional education. Olsen feels strongly that public health and global health education provide venues for bringing students across multiple disciplines together to learn together and to learn how to cooperate and work effectively together. Because almost all of the health professional programs are in close proximity to each other on a single campus, his university is uniquely positioned to facilitate learning across the professions. In particular, education programs at UW–Madison that began as cross-disciplinary among the health professional programs have grown to include nonhealth professions such as agriculture, engineering, law, the arts and humanities, and education. He provided two examples to illustrate his point.
Master of Public Health Program
The first example Olsen provided is the UW–Madison cross-disciplinary master in public health degree program. Launched in 2005, it had an intentional cross-disciplinary perspective right from its start. Another important aspect of their mission is the emphasis Olsen and his colleagues placed on engaging the community particularly in the area of prevention. To accomplish their goals, Olsen reported gathering a diverse faculty with expertise in climate change, environmental health, epidemiology, pharmacy, biostatistics, global health, nursing, and veterinary medicine, among others, that reflect the One Health concept.
More than 400 students have participated in the nondual and the dual degree programs that include combining the master’s in public health with degrees in medicine, veterinary medicine, nursing, pharmacy, law, and public affairs.
Certificate in Global Health
The second is the Certificate in Global Health program that focuses on global health topics and health issues that transcend national and disciplinary boundaries. Its curriculum emphasizes health and disease in developing countries as viewed through a cultural lens and incorporates complex, upstream determinants of health. Implementation of the certificate program is a collaborative effort of the Schools of Medicine and Public Health, Nursing, Pharmacy, Veterinary Medicine, and the Division of International Studies.
As part of the certificate program, there are faculty-led summer field courses in three different countries: Ecuador, Thailand, and Uganda. These experiences provide opportunities for students across health and nonhealth professions to travel, live, learn, and reflect together on what they are experiencing in the local community. The program in Ecuador is led by an anthropologist. The intention is to help students better understand health and well-being at the intersection of humans and animals through an anthropological lens. The program is conducted in collaboration with a nongovernmental organization (NGO) called Andean Health and Development. Conversely, the program in Thailand is conducted in collaboration with a university partner, Mahidol University in Bangkok. This program has a strong focus in tropical medicine and in community health. Students traveling to both Ecuador and Thailand live in local homes. They are imbedded in the communities where they are learning and working. The third program in Uganda also has a strong focus in community health. It emphasizes what it means to manage HIV/AIDS patients in a developing country setting.
Both the programs Olsen presented rely upon a cross-disciplinary group of faculty for support (see Table 4-2). This is a challenge. And while it is difficult to get the different faculty members together, they have managed to overcome this obstacle mainly because the faculty themselves are committed to the programs. UW–Madison is not the only place successfully bringing the diverse professions together, which means it is not impossible to do. Olsen believes that competencies for interprofessional education, global health, and One Health could be drivers of collaborative educational models.
Olsen closed with an apt quote from Ren Wang, who is the Assistant Director General for the Agriculture and Consumer Protection Department of the Food and Agriculture Organization of the United Nations (FAO).
TABLE 4-2 Faculty Demographics (2004–2014)
|Public health||Multiple years||Multiple years|
|Veterinary medicine||Annually||Multiple years|
|Pharmacy||Multiple years||Multiple years|
SOURCE: Olsen, 2015.
Wang said: “In today’s world, we humans have become increasingly linked not only to each other, but also to all other life on the planet. Human health has become ever more intertwined with the health of our environment and the animals that populate it—the animals we rely on for food, draught, power, savings, security, and companionship as well as the wildlife inhabiting sky, land, and sea” (FAO, 2013).
A GLOBAL HEALTH WORKFORCE THROUGH A ONE
HEALTH FRAMEWORK: A PUBLIC HEALTH PERSPECTIVE
Laura H. Kahn, M.D., M.P.H., M.P.P.
Laura Kahn is a physician and research scholar with the Program on Science and Global Security at the Woodrow Wilson School of Public and International Affairs at Princeton University. She is a cofounder of the One Health Initiative that serves as a global repository for all news and information pertaining to One Health.1 In her presentation at the workshop, Kahn provided a public health perspective on building a global health workforce through a One Health framework that recognizes human health, animal health, and ecosystem health as inextricably linked.
Kahn started by listing traditional subjects taught in schools of public health that do not address the challenges faced by 21st-century societies (see Box 4-1). To reconcile this, Kahn advocated for a restructuring of the curriculum away from the human health focus and more toward a One Health concept. Her arguments for the curricular redesign echoed those of Colwell, Olsen, and Fox, and include the growing risk of disease
1 For more information about the One Health Initiative, visit http://www.onehealthinitiative. com (accessed July 7, 2015).
Traditional Subjects Taught Versus 21st Century Challenges
Traditional Subjects in Schools of Public Health
- Health policy and management (hospitals and health insurance)
- Population and family health
- Sociomedical sciences (applied social sciences)
- Environmental health (human health risks—carcinogens, toxic waste, etc.)
Challenges We Face in the 21st Century That Impact Global Health
- Increasing populations and megacities
- Massive waste production
- Human and animal
- Water and food contamination
- Potential food shortages
- Antibiotic resistance
- Environmental degradation
- Mental illness
- Public mistrust of vaccines
- Emerging infections
- Climate change
- Extreme weather events, droughts, floods
SOURCE: Kahn, 2011, as presented by Kahn on April 24, 2015.
caused by overcrowding, changes in food production and supply, extreme weather conditions, environmental degradation, and the indiscriminant use of antibiotics. Solely focusing on human or animal or environmental health would not set a foundation for learning about or addressing these 21st-century challenges. As such, the curriculum needs to change and Kahn proposed how she would redesign it.
Her curricula would set up professional education and training using a One Health framework. There would be a greater emphasis on zoonotic diseases, including entomology and parasitology. While there are some courses taught on zoonotic diseases, she argues that it is not enough. She would place greater emphasis on virology and bacteriology. Schools of public health would teach more about food safety and security, global health, and agriculture. Other topics would include water purity, sanitation, and hygiene in both a human and animal context including domestic and wild animal health.
Next she would involve ecosystem health. Currently this is taught as environmental health with a focus on toxins and contaminants. Kahn would instead teach ecosystem health and create an understanding of what exactly a healthy environment entails. This would incorporate ideas presented by Colwell on the importance of monitoring not only weather, but also ocean conditions. There are many things that can be monitored in the environment that directly affect health, and these areas should be taught and institutionalized in the way public health and global health are practiced. That would mean educating students about policy, and specifically, One Health policy. Currently, when schools of public health teach policy, they focus solely on hospital administration and health insurance. Kahn thinks this should be expanded to include such topics as disaster preparedness, biodefense, and food security.
An additional aspect of her One Health curricula would be to focus on teams. The work would be arranged similar to that of business schools where basically all of the student assignments are in teams and involve case-based and problem-solving activities. The curricula would reflect the interdisciplinarity described by Olsen in his talk. It would be cross-cultural learning and would include understanding qualitative and quantitative forms of research.
Kahn listed the public health core competencies developed by the Council on Linkages Between Academia and Public Health Practice (2014) (see Box 4-2). In her view, these could be expanded to include a One Health focus. The educational lens would be on local, regional, national, and international teams because that is what will be needed in a global workforce to be able to assess and address health situations in any and all contexts.
Core Competencies for Public Health Professionals
- Analytic and assessment
- Policy development and program planning
- Communication • Cultural competency
- Community dimensions of practice
- Public health sciences
- Financial planning and management
- Leadership and systems thinking
SOURCE: Council on Linkages Between Academia and Public Health Practice, 2014, as presented by Kahn on April 24, 2015.
Students would be taught how to critically evaluate public health programs, how crises are responded to, and how to develop strategies for improvement. In this way, education produces creative thinkers and problem solvers who think beyond the hospital walls.
A challenge to implementing Kahn’s vision of a global One Health workforce is the shortage of human and animal health workers who could be trained to understand a broader perspective of health. And while there are documented shortages of health workers particularly in certain regions of the world (WHO, 2006; WHO and GHWA, 2013), the global veterinary workforce is even further challenged. First, there are no universally accepted educational requirements for people working in veterinary services resulting in great variation in how veterinary medicine is taught in different countries; the World Organization for Animal Health (OIE) is advocating for defined competencies and skills and for minimum competencies (Sabin and DeHaven, 2012). Second, there is no reliable data for estimating the number of veterinary and paraveterinary workers. Some countries like India, Liberia, Malaysia, and Russia have no data at all (OIE, 2013). Kahn could also not locate any data on a global health environmental health or ecosystem health workforce.
In closing, Kahn argued there is much room for improving the education of health professionals that could be addressed using a One Health framework. It would fill many gaps, both nationally and internationally. To address 21st-century problems, Kahn said there needs to be a workforce with the education and training to assess the entire milieu where people live and work that is not just focused within hospital or clinic walls.
ENVISIONING THE FUTURE
As reminded by Mary Elizabeth (Beth) Mancini of the Society for Simulation in Healthcare, the purpose of the workshop was to explore the implications that shifts in health, policy, and the health care industry could have on health professional education and workforce learning; to identify learning platforms that could facilitate effective knowledge transfer with improved quality and efficiency; and to discuss opportunities for building a global health workforce that understands the role of culture and health literacy in perceptions and approaches to health and disease. These three areas were converted into questions that were examined in greater depth through breakout groups. Each of the participants was equally divided into three clusters and assigned one question to discuss. Joanna Cain, who grew up in the medically underserved Yakima Indian Reservation and saw firsthand how difficult it is to meet the needs of rural and underserved women, represented the American Board of Obstetrics and Gynecology and the American College of Obstetricians and Gynecologists. She was the
first to report on the question her group was assigned (noted below). Cain’s report drew from ideas presented within her small group that was led by Thomas Clawson from the National Board for Certified Counselors, Inc. and Affiliates.
What Are the Implications That Shifts in Health, Policy,
and the Health Care Industry Will Have on Health
Professional Education and Workforce Learning?
Cain divided her report into three parts that took a global perspective in addressing shifts in health, shifts in policy, and shifts in the health care industries.
Shifts in Health
Cain noted that people are living longer but with more chronic disease. There are unpredictable outbreaks of infectious disease leading to an even greater need to focus on One Health to jointly address human, animal, and environmental health in a globalized world. Also, patients are getting more involved in their own personal care. This led individuals at the table to suggest a greater educational focus on the social determinants of health, on prevention, on biomedical research, and on big data that could lead to major breakthroughs in prevention, wellness, and care. With greater patient or person involvement, Cain acknowledged a need for focusing on health literacy, lifestyle choices, and cultural diversity as key educational elements.
Shifts in Policy
Cain reported a need to continue pushing toward universal health coverage in a manner described by Francisco Campos, keynote speaker and former National Secretary of Labor and Education Management in Health of the Ministry of Health, Brazil. She reported that members at her table were particularly interested in addressing barriers inhibiting access to care for undocumented persons and low-income workers, as well as underserved, unserved, or never-served communities. She noted that it was important to continue to move toward a concept of health care as a right versus a privilege and establish policies that support this through competency sharing, both locally and globally. Her concern was that incentives to work with poor and underserved populations have been damaged by the cost of education, thus policies that facilitate loan repayment could be important incentives to overcome financial realities of health professional education. Other policies that some individuals of the group endorsed would invest in prevention. However, the effectiveness of this investment would depend on
a health literate society, so Cain suggested that science education could start in preschool for children and continue through community colleges. There might also be science education for the public and other leaders in need of an expanded view of science. She felt health literate communication was important. In this regard, the role of media in translating health material and increasing health literacy is critical to improving science education for all.
Cain proposed on behalf of members in the small group other policies that would broaden the definition of teams to recognize complementary skills and expertise and include interdisciplinary education, innovative leadership education, and community-based training. She emphasized that such policies would be established not just in Washington, DC, but at every level—in the community, at the hospital, and within professional and educational associations. In summary, the policy foci Cain identified would be on
- Investing in prevention;
- Leveraging technology to deliver care where it is most needed;
- Developing strategies and plans to effectively translate and disseminate to multiple levels; and
- Reimbursing for costs of care and education that prioritize prevention and community-oriented health delivery rather than highly subspecialized health care interventions.
Shifts in the Health Care Industry
Like the policy suggestions, Cain expressed a desire for the health care industry to adopt more team-based approaches and focus greater energy on collaborations. This would mean training the health workforce to understand how the health care system works. The training would include knowledge as well as a demonstrated ability to advocate for patients and communities. It would build a workforce that could change how the industry works. This would likely mean collaborating with insurance companies. It might also involve public–private partnerships and leveraging the health care industry to facilitate education of health professionals.
Cain also brought up fiscal constraints that could impede some of her proposed ideas. It might in part be dealt with through redistribution of resources in order to balance hospital and community-based care. Another option would be to reduce waste as a way of funding innovative initiatives, or keying in on particular technologies for saving time and money. An added benefit of virtual communication could be an expanded boundary of the hospital beyond the physical walls of the institute. In closing, Cain expressed a number of points that emphasized the importance of
- Health literacy in understanding how to navigate a health care system and complex insurance policies;
- A system that rewards prevention and healthy lifestyle choices rather than just treatment of disease; and
- Investing in community-based health promotion as a primary focus of the health care industry.
The second report to the participants was provided by Michelle Troseth from Elsevier and who was also representing the National Academies of Practice, although the session was led by Timi Agar Barwick from the Physician Assistant Education Association. Troseth provided remarks in response to the following question:
Which Learning Platforms Will Most Effectively Facilitate
Knowledge Transfer with Improved Quality and Efficiency?
To set the stage for her report, Troseth offered the words of Max De Pree, an American businessman and writer, who said, “The first responsibility of a leader is to know reality” (De Pree, 1987). She then explained how the group facilitators brought new realities to her breakout group through a video titled The Future of Education: Epic 2020.2 This was a 10-minute film that focused on current and future trends in education as a result of technology. It explored the rapidly growing market of for- and not-for-profit companies like the Kahn Academy, TedEd, and Udacity that offer online educational opportunities. These entrepreneurial companies are moving into the future by providing badges, certificates, and common learning platforms that take into consideration cost and realities of student debt. The video helped Troseth and the other small-group participants consider their roles within health professions education given the exponential growth in technology. This discussion led the group to a more focused dialogue where individuals shared lessons learned from their own personal context and experiences. Based on some of the presented ideas, group members described what each sees as the pros and cons of new learning platforms that, according to the video, are replacing traditional, classroom education. Below are individual group member’s pros and cons of technology-based learning platforms for effective knowledge transfer as presented by Troseth.
Beginning first with the positive aspects of online learning and learning platforms, Troseth stated that technology-based education would allow educators to more easily customize learning. For example, tools and techniques could enable real-time, course correction. Adaptive learning would be guided and provided at the exact moment it is required by the learner. There would also be the potential for increased virtual connections both globally and locally, that could include learning communities. Online communities would stretch connections to new and different learners, educators, and stakeholders. But while there is tremendous value in the online experience, Troseth and other individuals in the group touted the greatest benefits from blended learning. Combining virtual with face-to-face education has been shown to be more effective than either technique alone, showing increased student engagement and satisfaction.
Troseth also reported that online education is more closely aligned with today’s students’ needs and skill set. Many millennials are digital natives, meaning that they were raised in a digital, media-saturated world and are very comfortable with technology. The online platforms offer education in a format they are often more comfortable with using. Other advantages include reduced duplication of the same course in multiple schools; increased efficiency so students can learn at their own pace and in their own time; and mitigation of some of the faculty shortages.
Virtual learning has the added benefit of analytics. With real-time statistics, educators can more accurately study where learners are struggling from an individual or population level.
Troseth then went on to describe some of the disadvantages to online learning that began with a lack of business models to help support this type of learning. These models would be creative and innovative and would be used to demonstrate the effectiveness of the online education. Implementing such a model would entail training current faculty and teachers on the technology and retooling how they think, work, and guide students. This would require new infrastructures and resources to support it.
Assuming an appropriate model was available, implementers of the new learning platform would have to think through multiple aspects of the technology while it is introduced and while it is being used. Troseth compared this to implementation science that integrates research with policies and practice. For her purposes, it means thinking through all of the implications related to its use. These implications would involve cultural transformations and change that if ignored would be a strike against its
use, but if carefully crafted to embrace cultural sensitivities, could be an exceedingly effective educational tool.
What Opportunities Are Available for Building a Global Health
Workforce That Understands the Role of Culture and Health
Literacy in Perceptions and Approaches to Health and Disease?
Andrew Pleasant from Canyon Ranch Institute provided his report on the discussions that took place in the breakout group he led. To answer the question presented to his group, Pleasant divided the response into three areas: (1) opportunities for building a global health workforce that understands culture and health literacy; (2) challenges to building a global health workforce that understands culture and health literacy; and (3) outcomes of a culturally aware global health workforce. Each of these areas is described in more detail below.
The first opportunity Pleasant identified for building a global health workforce was metrics. This means using the available data for measuring success, process stability, and sustainability. Another opportunity is smartphones and information technology (IT) and the rapid proliferation of new educational platforms. Interprofessional core competencies was seen as another opportunity along with the creation of resource incentives to drive this change. Pleasant pointed out that many of the opportunities he mentioned are external to the formal health professional education opportunities and include society and the economy as a whole. They all start from a common core and then progress. One of these examples is the Patient Protection and Affordable Care Act (ACA) that created a demand for a change in the health workforce. Other opportunities Pleasant mentioned include
- Scaling-up successful community-based, health professional education activities and programs
- Starting early, before schooling begins, and reinforcing throughout a child’s education in order to create a health literate society that can make informed lifestyle and other health-related choices
- Reaching families with health messages through children and women
- Including foundation workers (community health workers, teachers, etc.) for culture and health literacy learning
Pleasant explained the last three bullets by saying these are opportunities for connecting with families through children at school and by
educating women in particular. His thought was to start early with the children and repeat the messaging often throughout their education. He also described the important role of foundational workers for reaching families. Incorporating these individuals and groups into health professions learning are opportunities for multidirectional education on culture, health, and health literacy.
Pleasant then went on to describe some challenges to building a global health workforce that understands culture and health literacy. The first is a lack of and maldistribution of resources. Another is corruption. Corruption is a worldwide problem that was evident even during the recent Ebola crisis when funds did not go where they were supposed to go (O’Carroll, 2015). It presents a challenge to many of the efforts of health professionals and educators because it limits the available resources.
The third challenge Pleasant identified was poor pedagogy. What we need, he said, is more dynamic and engaged learning. This would include better role models and stronger mentoring that support innovative learning environments and would likely include effective use of technology. Any of this could present a hurdle if used inappropriately.
More challenges Pleasant reported involved:
- Prioritizing curricular issues to avoid curricular obesity
- Changing paradigms of health professional education
- Entrenched special interests
- Outliers in education, research, and health professions
Trying to cram too many educational topics into a single semester was coined curricular obesity and described as something to avoid, but avoiding this brings up the inevitable challenge of prioritization. What topics should go first, which courses should be dropped from the curriculum, and which ones should be redesigned? Possibly even more crucial is understanding who sets the priorities and who will be responsible for redesigning the existing paradigms in ways that address the issues discussed at the workshop—issues that might include designing curricula around community-based experiential learning, health literacy, or collaborative education and care through a One Health framework. Whoever sets the priorities, said Pleasant, will also be fraught with personal or entrenched interests that will challenge the redesign process. Biases and conflicts of interest will become evident within academia but also in society as a whole. There may be an ample supply of well-educated providers and educators, but if the systems do not support the work they are trying to accomplish, the paradigm
change will never be realized. Finally, the notion of outliers in education, research, and the health professions can also create barriers to change.
Taking into consideration all the previously mentioned challenges and the opportunities, Pleasant described what a culturally aware global health workforce would look like. In essence, it would create a culture of service learning and caring. Experiential learning to achieve cultural humility was a critical component to achieving successful outcomes. That is very different than how many currently consider culture. Often, culture is thought of as something outside of ones realm instead of considering themselves as part of the rich blend of cultures that exist around the globe. If a culturally aware global health workforce could be created, that would move providers toward greater empathy. There would be mindfulness and an understanding of helping health workers—professional and otherwise—to manage stress better and how to take better care of oneself. These skills and attributes could be shared and hopefully transferred to the overall society. Pleasant emphasized the importance of promoting health, wellness, and quality of life by including a wide array of actors and environments.
The approach would be holistic. It would address the needs of the entire person, his or her world view, and impediments each person faces in their daily life that prevent them from living a happy and healthy existence. A health literate global workforce would understand how to communicate successfully in whatever mode was most effective for a given community. It might be written or spoken, through numbers, symbols, or body language. In this regard, said Pleasant, a shared understanding of disease, health, and well-being with individuals and communities is created. There would also be a greater awareness of science in the general population and hence a greater ability to differentiate between valid and faulty evidence, something that is particularly relevant when searching the Internet for health information.
Pleasant acknowledged that if there are to be outcomes, there would have to be a system to measure them as well as a set of competencies needed by health professionals in order to attain the desired outcomes. These would not be a static set of skills and abilities though. As the world changes, those skills and abilities would have to adapt to newly desired outcomes.
In closing, Pleasant emphasized the importance of basic literacy to economic development. That fundamental skill underpins all potential success and may be the most important tie to the social determinants of health.
Spectrum of Ideas Moving Forward
Malcolm Cox was asked to provide summary comments. He started by mentioning the Gaming Arcade and Showcase that was a joint effort of the IOM and the Society for Simulation in Healthcare (SSH). Taking place at the workshop, this evening event provided participants an opportunity to test 26 different games and virtual environments-based educational technology (see Appendix B for the description of the arcade and of the games that were presented). The event culminated with SSH awarding Geoffrey Miller, M.S., EMT-P, and Andrew Cross from Eastern Virginia Medical School the Leading Innovator Award to for their entry, Automated Intelligent Mentoring System (AIMS): Applying Game Technology to Advance Medical Education, which they presented on day two of the workshop (see Box 4-3).
Cox then described an important concept raised by Susan Scrimshaw, who remarked that learners are being prepared for a health system that no longer exists. And while Cox noted that each person or profession may have a particular way of expressing this sentiment, the fundamental essence
Automated Intelligent Mentoring System (AIMS):
Applying Game Technology to Advance Medical Educationa
AIMS came out of a dilemma that Geoffrey Miller and Andrew Cross identified, which is for learners to acquire the requisite abilities to perform clinical procedural skills and achieve competence and mastery, they need opportunities for deliberate and repetitive practice. There also needs to be an abundance of qualified faculty monitoring every learner throughout each of their skills building exercises. However, this is an unrealistic scenario. Individualized prescriptive feedback that is unique to the learner requires not only a major investment in human resources but financial resources as well. AIMS is the solution to this dilemma.
AIMS uses Microsoft Kinect, an affordable gaming technology that is readily available, and applies it to the tools and pieces that are already within medical schools and simulation centers. AIMS works by watching a person’s body movements and procedural skills, then providing feedback to the learner on how to more correctly perform the procedure. To program AIMS to do this, the team created aggregate three-dimensional time–space models of what a perfect performance looks like, and then created an interface allowing a learner to practice against the expert model while receiving real-time visual or audio feedback. This technology can also be used for assessment of learners by cataloguing what the learner did correctly and incorrectly.
a For more information, see Appendix B and visit http://iom.nationalacademies.org/futureofhpe.
of the statement is still true. Not only are students being prepared incorrectly, but large sums of money are being spent in a manner that has been described by many as wasteful. The message Cox heard repeatedly throughout the workshop presentations was a need to change the way learners are prepared that would transform the present and future workforce. A visual representation of this was offered by Christopher Olsen who described a sort of punctuated evolution. How do you get a square ball to the tipping point so it rolls over to the next side? While Cox was not convinced health professional education is yet at the a tipping point, he did believe that open, frank discussions, like those taking place at this workshop, are what is needed to begin a quiet revolution that could apply the right amount of pressure to move the metaphorical rectangle to a new side.
Global perspectives were provided by Francisco Campos from the Ministry of Health, Brazil, and Laura Magaña Valladares, from the Instituto Nacional de Salud Pública in Mexico. Campos described similarities and differences between Brazilian health care systems and others around the world, and Magaña offered her insights on the future of health professional education based on the ideas proposed in the Lancet Commission report Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World (Frenk et al., 2010).
In a panel moderated by Susan Skochelak, Arthur Kaufman, David Asprey, Elizabeth Baxley, and Terry Wolpaw, each provided a perspective on curriculum design and structure. Cox clarified that the term curriculum design is used here broadly; presenters did not offer specific curriculum designs and structure; rather, they took on the broad concept of curriculum design that blurred lines between education and practice and drew on community-based experiential opportunities for learners. Additional insight was offered by Timi Agar Barwick, who facilitated small-table discussions around educational opportunities now and in the future.
The next session demonstrated pedagogy through semistructured debating. Deborah Trautman managed the first debate on work–life balance that was further expanded on by respondents from China and Nigeria. Holly Wise ran the second debate. This one focused on the value and the risks of developing a more task-specific workforce versus expanding the roles of health professionals already providing services. Again, perspectives were offered from a Nigerian view.
Andrew Pleasant moderated the final session of day one. In it, speakers offered examples of health literacy within health professional curricula before Pleasant provided two questions for each table to discuss. These questions encouraged global thinking about the future health workforce and how health literacy concepts might be integrated into health professional education to improve communication in a globalized world.
In reflecting on the presentations, Cox described his interpretations of key messages that were presented by speakers or brought up by several participants in response to issues raised by speakers or others. The take home messages Cox identified are as follows:
- No “Xeroxing.” Cox thanked Francisco Campos for this powerful metaphor. Too many educators in health professional education clone and recreate the same curricula over and over again. This needs to stop. Educators and others have to start thinking creatively beyond just doing more of the same. No more tinkering, as Susan Skochelak encouraged through her Accelerating Change in Medical Education initiative; more radical ideas must be tested.
- There are many ways of addressing the social determinants that are and could be platforms for health professional education. This was an underlying message in the presentations of Kaufman, Campos, and Pleasant.
- A movement is afoot to place greater emphasis on broad concepts of health and well-being as opposed to only health care. Liza Goldblatt staunchly supported this emphasis for reducing hospital visits and for the benefit of the public. In descriptions of their work, speakers promoting health literacy and One Health as frameworks for education emphasized creating healthy environments. Kaufman brought up the added benefit of potential cost savings by keeping people healthy.
- There will be no new money for health professional education. This was talked about by Kaufman as a need for redistribution financing or insurer-related financing using existing dollars in a capitated system. If faculty want money for a project, program, or curriculum, what other already existing source will the funds be taken from? This will be a difficult but critical discussion, added Cox.
- Match the needs of society with the curriculum. Terry Wolpaw’s slide from Penn State showed they had achieved some balance between the biomedical component and the social determinants component of their curriculum. While commendable, Cox wondered why, if the majority of the health problems in the world have social underpinnings, then why are the social determinants not making up a majority of the curriculum? “Do not ask for equality, ask for it all,” he said. Asking for small increments will only result in obtaining small increments. Documenting the rationale and need for greater levels of funding for curricular elements that address social determinants is likely to be more effective. Cox again
referred to Skochelak’s request not to tinker around the edges of the curriculum.
- Language is important. Cox reminded the group of Andrew Pleasant’s remark about people formerly known as patients. He then took it a step further by considering whether communities might be formerly known as populations?
- Communities and community health workers can play a significant role in transforming health professional education. Numerous speakers brought up this often untapped potential. To truly involve communities in education, they should be invited to participate in the power structure—for example, serving on academic health center boards. This thought was offered by Kaufman during one of the table discussions. While Cox appreciated the idea, he wondered what would move boards from their current practice of involving one “token” community representative to one that includes multiple, and perhaps even a majority of, community members? Others may have different ideas but one that occurred to Cox was to reassess and if necessary revoke academic health centers’ tax-exempt status if they refused to comply. These centers are given 501(c)(3) tax-exempt status because they are public goods; they should be required to demonstrate this commitment by allowing more community members onto their boards.
- Task shifting may not be the best term applied to transferring responsibilities from one health professional to another. Afaf Meleis from the University of Pennsylvania School of Nursing reminded the participants that competency sharing maybe a better description of what the clinical workforce needs, Cox agreed.
- Cox also noted that it is wrong to think of community health workers as nonprofessionals. In his opinion, the people who form the base of the health pyramid worldwide should be considered professionals.
Cox finished his remarks by bundling all he had heard and the lessons he took away into a productive action-oriented package. It occurred to him when listening to the health literacy examples that maybe there is a larger construct for organizing health professional education rather than simply trying to fit ever more topics into an already constrained curriculum. Putting students in the community provides experiential learning in areas such as transportation, food, housing, and utilities. These would never be courses in a health professional school, but by placing learners in neighborhoods, students face many if not all of these issues when dealing with people’s clinical needs.
In his mind there needs to be a broad functional model for educators
to follow. This conceptual model would have to quickly capture the short attention spans of leaders who possess the power and the money to effect real change. In Cox’s view, community-based education is the broad, overarching construct from which everything else follows.
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