Vision for the Department of Global Health and Social Medicine
Written by Paul E. Farmer, MD, PhD, 2010
The Department of Global Health and Social Medicine (GHSM) has grown rapidly in the past few decades, usually in response to unmet needs in American medical education and to changing research paradigms. When I came to attend Harvard Medical School in 1984, and joined the faculty upon graduation from the MD-PhD program in 1990, the strengths of the department (then called the Department of Social Medicine) included the nation’s premier program in medical anthropology, small but robust programs in medical ethics and the history of medicine, and a growing series of programs in mental health. In the years following my own promotion to associate professor in 1995, I was lucky enough to help nurture programs in infectious disease and global health. These programs have been strengthened by a number of large grants to support work around the world’s leading infectious killers (AIDS, tuberculosis, and malaria). This work is carried out, not by the DGHSM directly, but by a complex set of interlocking organizations—service organizations like Partners In Health and the teaching hospitals that are the Department’s “effector arms.” I propose to integrate these “effector arms” more strongly with the DGHSM, including seeking secondary appointments for faculty whose primary appointments are in the hospitals. This will affect the way we train students, the careers those students elect, and the impact of Harvard Medical School on the world.
A key example of the programmatic implementation accomplished by the Department has been the effort to take a model of care delivery for complex and chronic disease developed in rural Haiti and scale it up in Peru, Roxbury, Russia, and four African countries. To take one prominent and promising example, the Department was awarded, in 2000, a $44m grant from the Bill and Melinda Gates Foundation, its first large “implementation” grant, to bring to scale a program to treat multidrug-resistant tuberculosis in Peru and Russia. The further purpose was to change global policies around the treatment of what had been termed an untreatable disease. To achieve these ends, such an award would necessarily be shared between HMS and ministries of health in Peru and Russia, and also with standard-setting bodies such as the World Health Organization; it would necessarily involve effector arms. The multidrug-resistant tuberculosis effort and other projects have achieved several things at once: linked research to service in the developing world (a vanishingly rare accomplishment, in spite of many claims to the contrary); created a dozen new research faculty positions (the $15m NIH grant recently awarded to our team is the direct descendant of the Gates grant); linked a Harvard Medical School department to providers of care operating in several countries; afforded mentored learning opportunities to scores of students from HMS and the School of Public Health; and led to the establishment of the world’s first board-approved residency program in global health equity. These unprecedented partnerships will be followed by others.
This complex structure created to do the right thing—both scientifically and morally—for populations facing poverty and ill health is precisely the one needed by research universities across the country and the world. The reason so many students and junior faculty seek to be involved in this department and its programs is that we have linked the standard goals of the U.S. research university (teaching and research) to service programs implanted in some of the poorest parts of the world. No compromises are involved: teaching, research, service, givers and recipients of care all benefit.
Expanding this model will change the future of medicine and public health. We have succeeded in building a structure that others emulate, but there is more to be done to truly integrate strong pedagogic and research programs (the standard fare of a basic science department) with effector arms. A department of global health must have global programs, and it is to the great benefit of our students, faculty and patients that our teaching hospital's catchment area extends over several continents. The more closely research, teaching and delivery are connected in a feedback loop, each reinforcing the other—and the more faculty, trainees and students are able to participate fully in all three—the higher will be the quality of all our work, and the greater our ability to impact the field. That is the goal demanded by so many of our students and trainees; it’s also the substance demanded by the host countries in which we work.
The stakes are higher than ever. The model outlined above took 20 years to develop and has led to significant changes in the architecture of global health. In the past years we have maintained and strengthened each of these programs, which again gave birth to novel training mechanisms, including, as noted, a board-approved program to train physicians in global health equity as well as new certificate programs in global health delivery, and several course offerings of great interest to implementers from across the globe.
As this model has been developed and refined, strategies for identifying funding for the work and for supporting the careers of the clinicians, researchers and implementers in the DGHSM have evolved. These strategies, while successful, do not together provide a comprehensive framework which will address the unique funding, organizational, academic and administrative needs of this model. A new structure is required: one which creates the flexibility in geographies, timelines and interdisciplinary pursuits which will allow students, faculty, trainees and staff to flourish in their careers without unnecessary complication; to focus on the work at hand; and to continue to innovate and refine strategies for delivering ever-better care around the globe.
We are on the cusp of great changes in medical education and, indeed, in medicine in the broadest sense. During the past five years, the U.S. Government has invested billions of dollars in global health programs such as the U.S. President’s Emergency Fund for AIDS Relief and the President’s Malaria Initiative. The Global Fund to Fight AIDS, Tuberculosis and Malaria is another giant international funding mechanism created to ensure that the fruits of advances in medicine and service delivery reach those who need them most. Others will follow, as policy makers and implementers contemplate disparities and distribution of all chronic non-communicable diseases, including cancers, diabetes, major mental illness, and complications of coronary artery disease. Medical and graduate education have not, however, kept up: there is, as yet, no significant federal funding for medical education, graduate education and post-graduate education in the arena of global health equity.
The DGHSM should remain at the forefront of the global health movement. To do so, we must: underline our commitment to teaching and research in global health equity; maintain and enhance support for “effector arms,” with a focus on implementation and delivery; strengthen models of graduate and post-graduate training, in particular through global health and social medicine residencies and fellowships; and coordinate efforts throughout Harvard to build a common agenda around global health equity.