Earlier this week, I got a call from a fellow WCMC student asking about opportunities to go abroad. We talked briefly about funding organizations, timing, and China in particular. Then, inevitably, he asked the dreaded question.
“I’ve heard that global health isn’t real research. Should I stay at Cornell and do something more rigorous?”
Being the reasonable, even-tempered person that I am, I said something to the effect of, “I cannot stand people like you.”
I wasn’t being fair, of course. I’ve struggled with the same question for a lot of my medical school life. WCMC definitely favors some types of research over others. Class of 2018ers: you and I have all felt the pressure to do “translational” research in highly specialized fields (preferably containing the words “precision medicine” or “microbiome”). I’ve heard from a lot of attendings I deeply admire that global health is a waste of time, that it doesn’t comprise serious medical research, that it doesn’t accomplish anything for anyone. If you want to do real science, join a lab at Rockefeller. If you want to do good, start at home.
So, fellow WCMCer who I likely turned off from global health forever, as an apology for lashing out, this post on global health is for you.
First, an admission: I asked that very same question my first year of medical school. In fact, if anything, I asked it in a much more presumptuous way. First year, my plan was to go to India for a summer, catch a glimpse of some cool ID cases, have the time of my life, and then come back and spend the rest of my life on “real” medicine and “real” research.
And I did have the time of my life in India (as you all know only too well). But not just because the places I visited were startling and beautiful and vibrant with life. There, I also met amazing researchers and inspiring patients. At the same time, I wrestled with some of the least efficient systems and the most appalling ethical questions I’d ever encountered. And I started to understand, for the first time, the nature of the global health market.
My understanding is still in flux. A year from now, I may feel completely differently. But for now, let me share with you my perspective on global health, why I think it exists, and why it’s important.
First, what it isn’t: global health is not a convenient stage upon which you can show off your compassion for the less fortunate. If anyone tells you that they do global health because they want to save the world, run. Despite their intentions, these people are likely to do more harm than good. Unfortunately, this is how global health traditionally gets marketed: a chance for your lord- and ladyships to save the savages! I can understand why some people, as a result, view the field with such skepticism.
So I guess it’s up to us to take the first step and say: global health is not about doing good so much as it’s about doing business.
It’s not a perfect analogy, but you can think of global health as a transaction between nations . Like any other transactional relationship, global health is based on the concept of comparative advantages. The transaction may consist of anything, but usually goes something like this: Developed nations have resources, money, research staff, and capacity for conducting high-quality research. Developing nations have circumstances. These circumstances can consist of a lot of things, including pathogens that the developed world doesn’t have; high prevalence of disease cases; environmental factors; at-risk populations; social and cultural practices; genetically unique populations. The simplest global health trade is a developed country offering money, resources, and research expertise to a developed nation in exchange for access to a set of circumstances, diseases and populations. Like any other market exchange, a global health trade is actually more efficient for everyone. In high-quality partnerships, there are positive externalities: the developing nation builds its research capabilities; the developed nation incorporates knowledge about diseases and populations previously foreign to them. Both sides gain an excellent setting for training future students. But the key output of this transaction, when successful, is a body of research that would not have been possible for either party to put out on its own.
Let me give an example. I recently met a bunch of contributors to the HPTN052 trial, which showed that consistent use of ARTs is effective in preventing HIV transmission to HIV-negative partners in serodiscordant couples. This study was done in nine countries worldwide and was sponsored by the global health department at UNC. It is now the most-cited paper in the New England Journal of Medicine. But it was only possible given US funding and research capacity, AND access to high-prevalence populations from all of the world. (Trivia: there was one couple from the US in this study because the NIH said there needed to be at least one US patient enrolled). Without US funding, this project never could’ve gotten the funding and research oversight it needed. Without access to participants from high-prevalence areas, there would never have been enough serodiscordant couples in order to sufficiently power the study.
Traditionally, a lot of global health research projects have been variations on this theme: research capacity in exchange for high-prevalence populations. But I want to mention my current research group in China, because its transaction is a bit different. Our projects often involve using crowdsourcing to promote sexual health, condom usage, or HIV testing. The US contribution is similar: funding and research expertise. But the Chinese contribution in this case, in addition to high-risk populations, is a pervasive, powerful social media app. That’s right, ladies and gentlemen: our research is utterly dependent on our friend, WeChat. I find our current project quite fascinating for this reason: it forced me to expand my definition of global health.
Of course, there is an aspect of health equity in the mix. The topics that global health researchers address are typically those that affect developing nations more than developed nations (though I might argue that the majority of health issues fall under this umbrella). And researchers from developed nations only seek to do this research in part because of their concern for populations disproportionately affected by disease. But I think it’s quite important to recognize that the actual process of global health is a cross-national exchange between two (or more) autonomous parties, each with its own interests and comparative advantages. In the future, as worldwide economic, political, and healthcare indices shift, the nature of this exchange may change dramatically. But for now, this is more or less the state of the global health market. Without it, there would simply be a lot of knowledge that we didn’t have.
Of course, like any other market, global health has its problems. In the next post, I’ll share some of the ones I’ve witnessed.
