Richard Skolnik – Author of Global Health 101
One aim of teaching global health is to help students master the basic concepts and frameworks that concern our field. These include, for example, the burden of disease, tools for comparing alternative investments, cultural issues related to health, and ethical issues related to the allocation of scarce health resources. As I mentioned in several earlier blogs, we try in my introductory global health courses to enhance student understanding of key concepts by examining ‘cases’ and role playing.
One of the cases that always provokes considerable thinking among the students concerns ethical issues related to the allocation of scarce AIDS drugs. This case involves a country that is just beginning an AIDS treatment program, with US funding. The country has 20,000 people who are clinically eligible for treatment (with CD4 counts below 250 at the time) but will only be getting enough drugs to treat 5,000 of them this year. There are no other options for getting drugs in the country for now. The students are asked to meet in groups and decide who should get the drugs, why they have chosen to allocate the drugs in this manner, and what the president should announce to the country next week about the new AIDS treatment program. The student proposals have to take account of ethical concerns including: maximization of health outcomes; priority to the poor; fairness; personal responsibility, and fairness of the decision-making process. Most students have never been exposed to ethical issues that relate to the allocation of limited health resources and many students tell us that this exercise is very challenging, ‘gives them a lasting headache,’ and will surely help them keep such ethical issues in mind in the future.
We are beginning a new approach in my introductory global health course to help students become more familiar with how social and cultural issues can be taken into account in the design, implementation, and monitoring of health projects in low-income countries. First, we give the students the World Bank Project Appraisal Documents for three projects:
We ask the students to review those reports before our discussion. During the discussion, we ask the students to play the role of a group of applied anthropologists who are advising the World Bank on project design. In this capacity, the students have to design a social assessment for each of the projects. This should cover, among other things: identification of affected groups; their likely demand for the proposed investments; how the proposed investments can be most appropriate culturally; the possible impact of the intervention on the affected communities; any negative effects that might arise from the proposed investments; how the implementation of the project can be monitored and evaluated; and how affected parties can be involved in the design, monitoring and evaluation of the program. While all of our students are aware of environmental assessments, none of our students has had any prior exposure to social assessments.
We had a great deal of fun recently and a great deal of learning as well, when we held a ‘debate’ about health inequalities in Australia, Canada, and the US. Prior to the discussion, the students were assigned to read three articles on health inequalities in each of these countries. The students were asked to come to class ready to be disadvantaged groups in each country: aboriginal people in Australia, First Nations people in Canada, and very poor and rural African-Americans. In the discussion section, we divided the students into three groups – one for each country - and asked them to play the role of the group they had been assigned. We then asked them to take about 20 minutes to prepare to speak to an international conference on health inequalities. Their presentations would have to address the key health inequalities in their country, the drivers of those inequalities, and some of the steps that they wanted their government to take to reduce those inequalities so that the health of their people could be enhanced. We also asked the students to indicate why the health circumstances of their people were worse than those of the disadvantaged groups from the other two countries. All of the groups played their roles with conviction. One group, however, could have won an Academy Award for the extent to which they played their roles. In fact, we were tempted to take the blood pressure of members of that group during the ‘debate’, since they were so expressive and so ‘heated’ in making their points that we were concerned for their own well being.
This week we will be talking about cooperation in global health, the many different types of global health actors, and how they do and don’t work together effectively and efficiently. To make this topic more ‘real’ for the students, they will be asked in our to discuss 'donor coordination' in the health sector for a low-income country in West Africa that is highly aid dependent. The students will be broken into groups representing the country, the leading local NGO, the head of the international NGO group, and a number of donor agencies. They will discuss “donor coordination” from the perspective of the group they represent. We anticipate that the country representative will be thankful for the help of her development partners, but deeply concerned that she has to spend all of her time meeting them, filling out different forms for each of them, and answering the questions they raise so frequently and in ways that are not coordinated. She will no doubt ask the development partners to help reduce the transaction costs of working with them, by seeking to work with them through an agreed common approach. We anticipate that each of the development partners will express appreciation for such an approach but indicate the ways in which their taxpayers and constituents still require that the country receiving their assistance carry out some measures uniquely for them. We also anticipate that even if the development partners do agree to work more closely together, under a common umbrella, that they will still spend lots of time talking with each other about how to work together, possibly taking time away from the critical health issues they are supposed to be helping the country to address!!
Over the coming weeks, we will be preparing a variety of other ‘cases’ for my undergraduate introductory course on Global Health at Yale. In the next few months, I hope to post these cases to the teacher’s portion of the website for Global Health 101, so that any of you who are interested can use them or adapt them, as you see fit.
Thanks to Rachel Skolnik Light for her comments on a draft of this 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.