Richard Skolnik – Author of Global Health 101
My students have always appreciated a focus on learning key concepts and frameworks that concern Global Health and the opportunity to apply them in class to “real life” situations. Given both student interest and my own experience working with low- and middle-income countries on policy issues, my classes have always had a heavy policy focus. I want to ensure that my students learn to understand problems, what can be done about them in the most cost-effective ways, and how to make choices among various investments in resource-constrained settings.
I set the stage for this policy focus early in the term. In the first session, for example, I introduce the students to several policy “lenses” that I ask them to wear throughout the course. I tell them in the first session:
- It is important to think about health as if you were the Minister of Finance of a low-income country, rather than the Minister of Health, since so many determinants of health are outside the health sector.
- It is essential to continuously ask yourself – “if you could only spend $100 to improve the health of people in your country” – how would you spend it and why?
- In many respects, the goal of low-income countries with poor health status is to “bury old people instead of young people, make the transition as fast as possible, and do this at the least possible cost.” In other words, how do you go in health status from being Senegal, to Sri Lanka, to Denmark as fast as possible, and at least cost?
As my introductory courses get going, we do a lot of role-playing. For the ethics session, for example, the students form groups, each of which is an Advisory Committee to the President on AIDS drugs. The country we are discussing has AIDS drugs for only 1/3 of the people who are clinically eligible to receive them. After meeting in small groups for 40 minutes, each Advisory Committee must brief the Committee as a whole about the non-clinical criteria they would use to decide who should get the drugs and the rationale for their proposal. As they outline their proposals, they must make specific reference to the ethical principles that we are studying. We then discuss the various proposals as a class to try to understand which one – or combination of proposals - might be most appropriate for our country.
For the discussion of Water, Sanitation, and Hygiene, we form teams of Advisors. First, I very briefly describe a low-income country. The students then meet in small groups for 40 minutes to formulate an approach to enhancing health in low-income rural areas at the least cost by improving water supply, sanitation, handwashing with soap, and cooking practices. As the students present their proposals, they must relate the steps they would take to the risk factors they would address. They must also indicate the relative costs and benefits of each element. We end the class with an assessment of the proposals and examples of how low-cost solutions, such as pit latrines and covered wells with hand pumps, may not be very “convenient” but can nonetheless lead to substantial health benefits.
We place a major “policy focus” on our sessions that cover women’s health, children’s health, communicable diseases, and non-communicable diseases. For a typical class of this type, I will act for the whole session as the Minister of Health of a low- or middle-income country.
First, I briefly introduce the students to the country. Then I seek their advice on a number of questions that can help us understand the current problem and guide our formulation of measures to address it. These are the same questions that I have them address in the policy briefs I assign, about which I wrote last month:
What is the nature and magnitude of the problem?
Who gets the problem?
What are the risk factors for this problem?
Why should the Minister of Finance and the President care about this problem?
What can be done, at least cost, to address this problem and enhance the health of our people?
Generally, the students will quickly list the most important burdens of disease in response to the first question. If the topic were women’s health, for example, the students will indicate their biggest concerns about the health burdens women face, including: undernutrition; HIV; depression; cardiovascular disease; maternal morbidities and mortality, including obstetric fistula; domestic violence; and unsafe abortion.
By this time in the course, the students are also be very good at identifying high-risk groups—the poor, rural and uneducated, as well as marginalized ethnic groups.
The students are also able to articulate specific risk factors for each of the health burdens they raised. For maternal mortality, they would raise, for example, malaria, anemia, young age at first birth, the lack of access to family planning, giving birth without a skilled birth attendant, and limited referral and transport to a hospital where C-sections can be performed for women with complications of pregnancy.
I try to ensure that all of my students could give the “30 second elevator speech” to the President or Minister of Finance on all of the key topics that we cover. Here, when they have to indicate why the President and the Minister of Finance should care about this problem, I expect them to talk about the costs to the country of the health burden, the availability of a manageable program to address the problem, and the high economic returns that will come from tackling it.
In some respects, the discussion of what to do about the problem is the most interesting and the most fun part of the discussion. First, we look at what can be done in the most effective way to address each of the health burdens that were raised initially. Then, I remind the students that we are a very poor country, with limited technical and managerial capacity, and that we cannot possibly do all that needs to be done. For the rest of the session, we wrestle with making choices among the many measures that deserve to be taken, since there are limited resources.
It would be wonderful if we lived in a world with sufficient financial resources to attend to all critical health needs and other needs. However, this is never the case. Thus, an important part of my teaching always focuses on understanding key issues and learning to make decisions about getting the most value per dollar spent, especially in poor countries, with high disease burdens.
Thanks to Rachel Skolnik Light for her helpful comments on a draft of the blog.
Richard Skolnik is a Lecturer at the Yale School of Public Health, where he teaches global health courses at the undergraduate and graduate levels. Richard was previously an Instructor in Global Health at The George Washington University, the Vice President for International Programs at the Population Reference Bureau, and the Executive Director of the Harvard School of Public Health PEPFAR program. Richard worked at the World Bank from 1976 to 2001, last serving as the Director for Health and Education for South Asia. Richard is the author of Global Health 101 a comprehensive, introductory text on global health.