New training paradigms

The theme of this book, and a growing consensus in the scientific community, is that the determinants of infectious diseases are much more complex than the traditional host-pathogen interaction, and that social, economic, ecological, and political factors are powerful forces. This is particularly well illustrated by emerging and re-emerging infectious disease problems such as HIV/AIDS, SARS, Nipah virus, malaria, antimicrobial resistant pathogens, and others. Recognition of the complexity of infectious disease determinants has led to a call for trans-disciplinary and system-based approaches to understanding and dealing with these issues. Most often, this has taken the form of assembling a collaborative multidisciplinary team to address an identified problem and develop a "common conceptual framework" or action plan. In addition to integration across the different areas of knowledge (horizontal integration), there is greater recognition of the need for vertical integration - i.e. incorporation of individual, community, and other non-academic views that add important practical, ethical, and political perspectives. Each type of integration has its value, but tends to function independently of the other. For example, the stunning success in the recognition and control of the SARS outbreak was largely accomplished by horizontal integration of the efforts of clinicians, epidemiologists, virologists, public health workers, veterinarians, and multinational organizations working in concert. However, the vertical integration of the social, economic, and ecological drivers of the disease, which have great relevance in terms of potential recurrence, received far less attention.

While there is strong consensus for transdiciplinary integration, the implications for how we train and organize the future global health workforce are much less clear. The lead in integration across academic disciplines will almost certainly come from universities (including the schools of public health and the health sciences). As an example, Duke University has made global health a university-wide priority, and is committed to building a program "that truly spans the humanities, social sciences, engineering, environment, law, and divinity as well as the life sciences." The program will include teaching, research, and services, and will be woven into both the undergraduate and graduate curricula, with special courses and certifications. More than a dozen current activities in global health will be brought together within a Duke Global Health Institute, and will build on Duke's core strengths in basic, clinical, and translational research.

On a smaller scale, the need for broadening training and perspectives is recognized by US medical students, one-third of whom overall and up to 70 percent in some medical schools now take one or more years out of the traditional training track to pursue special interests in fields like global health or research, or degrees in business, public health, or policy. Vertical integration of individual, community, political, and other special perspectives is a more difficult organizational task. However, there is increasing emphasis on diversity and lay representation in appointing advisory groups and boards of directors, and attention is given to minorities and under-represented groups in many federal grants and philanthropic activities.

The take-home message for training programs in global health is that trainees must understand the context in which they will work, and that cultural, social, economic, and other relevant areas should be included in the orientation and mentoring activities.

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