Editorial: Research and discussions in critical discourses and remedies in global health education

Editorial on the Research Topic
Research and discussions in critical discourses and remedies in global health education

1 Introduction

The field of Global Health has evolved as an interprofessional and interdisciplinary approach to understanding and addressing the socio-economic, political and environmental factors that impact health around the world. Defined by Koplan et al. (2009) as distinct from both public health and international health, the field has continued to evolve together with dedicated frameworks for global health education that aim to promote equitable learning opportunities and social accountability for academic institutions. And academic communities of practice and partnerships have emerged along the way among institutions of varying income levels (high-income countries, middle-income countries, and low-income countries), diverse cultural beliefs and social circumstances with a goal of eliminating health disparities worldwide.

However, there is widespread concern that activities conducted under the auspices of Global Health often run counter to their intended objectives due to deeply ingrained colonial assumptions, racism, elitism, mistrust and other forms of bias entrenched in systems, institutions, and individuals. This Research Topic, “Research and discussions in critical discourses and remedies in global health education,” seeks to delve into the frameworks and practices of Global Health Education to explore and address these historically reinforced ideologies. In the 19 papers that follow, the authors critically examine the impact of these historical biases and—importantly—provide examples of new pathways forward, focusing on bidirectional learning and partnerships, community engagement and power shifting, decolonizing dimensions and human dignity, and proposing new platforms for learning.

1.1 Decolonizing dimensions and human dignity

The legacy of colonialism in high-income countries (HICs) has influenced power structures, resource distribution, and priorities in health systems around the world. This has led to entrenched biases (both implicit and explicit) and mistrust between HIC-based and lower-middle-income-country (LMIC)-based institutions. Additionally, in many countries, medical education and global health collaborations are conducted in English when local languages are spoken by patients and providers. Similarly, biomedical explanatory models are prioritized over indigenous perspectives on health and healing both in teaching providers and treating patients. Therefore, even the language of educational instruction in many LMICs still reflect traces of HIC colonization, leading to knowledge hierarchies that may devalue indigenous expertise and with resulting impacts on local healthcare delivery and education frameworks. Decolonization of health and clinical education systems is crucial for promoting equitable interventions that prioritize human dignity with the ultimate goal of providing optimal health for all. Institutions, stakeholders, community actors, and beneficiaries must raise awareness and promote practices that uphold gender equity and social inclusion of historically minoritized groups.

There are seven articles in this Research Topic that specifically address the issue of decolonization across a spectrum of interventions. Kalbarczyk et al. delved into existing global health education programs in search of data about the current incorporation of learning opportunities related to the colonial history of global health (including information about the spectrum of teaching strategies, support for faculty curricular design efforts, and institutional barriers related to implementation). Ngaruiya et al. used an implementation science framework to provide guidance on assessing and developing decolonization efforts within global health research endeavors and, importantly, evaluated four geographic axes of power dynamics across which decolonization might occur: Global North-Global South, Global South-South, Local Global South, and Local Global North. The remaining five articles in this section provide examples of proactive approaches toward decolonization of global health education. Hawks et al. undertook a review of experiential educational theory and best practices to develop an interactive framework to guide curricular development by highlighting key aims, barriers, and potential unintended consequences. Collins et al. describe the implementation and assessment of the impact of a global health book club within an undergraduate public health course. And three of the articles specifically address issues related to clinical global health education:

• Ratner et al. describe the development and assessment of a pilot course for medical students focusing on promoting knowledge and skills about decolonizing global health;

• Martin et al. describe their 10-year experience in implementing an immersive, month-long global health course for senior medical students, evaluating the impact of the course according to the four principles in Melby et al. (2016) Guidelines for Implementing Short-term Experiences in Global Health;

• Dozois et al. describe the end-result of a workshop that the Global Emergency Medicine Academy ran at the 2022 Society of Academic Emergency Medicine Annual Meeting, focused on addressing inequalities and increasing diversity in Global Emergency Medicine education—a toolkit containing strategies for addressing historical power dynamics, which highlights five key themes: access to educational opportunities; awareness and cultural humility; the use of language/vocabulary that avoids perpetuating colonial power structures; the importance of representation and valuing diverse expertise and lived experiences in designing education and research programs; and enhancing the global visibility of emergency medicine as a specialty and the recognition of the scholarly contributions of LMIC partners.

1.2 Bidirectional learning and partnerships

Many in the Global Health Education community have been shifting from historical knowledge-transfer frameworks that are HIC-learner centric, toward partnerships that incorporate bidirectional learning and bilateral institutional benefit. These newer partnership models respect local contexts and expertise while leveraging the resources of each institution to achieve shared objectives. They embody principles of equity, community focus, social inclusion, mutual respect, and benefit, emphasizing the value of engaging all stakeholders and community actors.

This Research Topic includes four articles which speak to the principles of bidirectional benefit and equitable partnerships. Achana et al. leverage the results of literature review and the lived experience of the authors as Global South educators and researchers, to highlight the critical role of Global North partners in promoting equitable global health research collaborations. The authors propose specific actions related to the assignment of key roles on grant proposals and authorship positions on publications; increased training of Global North students, faculty funders, and politicians about the importance of equitable partnerships; and a focus on increasing capacity building efforts within LMIC institutions with a goal of developing independent, sustainable research and mentorship infrastructure. In a similar vein, Rose et al. report on the results of a qualitative study examining the lived experiences of LMIC health researchers who collaborate with HIC partners, and used these findings to develop a set of five key recommendations aimed at helping HIC researchers and funders improve the collaborative nature of and prioritize bidirectional benefits within research partnerships.

With respect to the implementation of best practices, Rosenbaum et al. describe the relevance of the six principles of the Brocher Declaration (Prasad et al., 2022) to short-term experiences in global health for dental students, ensuring that these clinical learning opportunities are conducted ethically, sustainably, and are aligned with the priorities of host communities. This approach underscores the significance of mutual partnership, community empowerment, and capacity building, ensuring that global health engagements are impactful and rooted in bidirectional learning and collaboration. Importantly this effort encompasses governmental, non-governmental, academic, faith, and secular stakeholders.

Lastly, Li et al. use the example of the State University of New York (SUNY)-University of the West Indies (UWI) Health Research Consortium as a best practice example of a bidirectionally beneficial relationship that has built collaborative programs to address research, population health, and patient care capacity building needs to address a diverse array of public health priorities in the Caribbean. This consortium has a focus on both infrastructure/technology development, as well as multidisciplinary programs that are focused on specific clinical issues, ranging from infectious diseases to diabetes/nutrition and a spectrum of neurologic issues.

1.3 Community engagement and power shifting

Another aspect of the evolution of Global Health Education is a recognition of the importance of community voices and expertise in educational and scholarly endeavors. These approaches call for a transformative shift toward ethical, sustainable, and impactful engagements with global communities, foregrounding the principles of power shifting, sustainability, and centering community-led development. These principles mark a departure from traditional academic center-driven, top-down approaches, advocating instead for initiatives that are both ethical in their conception, driven by co-creation, and sustainable in their execution.

Kalyesubula et al. describe the educational model at the African Community Center for Social Sustainability (ACCESS), a community-based organization in rural Uganda which prioritizes the needs and empowerment of the local community through education, healthcare, and economic promotion, and invites HIC academic partners to align with community-based projects. This model leverages the resources of the HIC partners, along with the energy and skills of individual HIC students and faculty, to address the community needs while providing high quality educational experiences for HIC learners, as well as local learners in the ACCESS Community Health Worker training program, the Nurses and Midwifery School, and the Grace's Promise preschool.

Palazuelos et al. describe the experience of Compañeros En Salud (CES), the Mexico branch of Partners in Health, in developing a rural public health and clinical care delivery system in Chiapas, Mexico. This program similarly leverages relationships with academic institutions (in the United States, Mexico, and Europe) to provide educational opportunities for global health learners, but with a primary focus on sustainability and addressing the community priority of revitalizing the government healthcare infrastructure, in part by incentivizing Mexican physicians to do their mandatory, post-medical school social service year in communities in Chiapas, and then providing opportunities for some to stay on in various roles with CES (among other initiatives).

As a third example of power shifting, Goldberg et al. describe the experience and impact of a program focused on increasing research mentorship capacity in Nigeria and Tanzania by training local faculty to serve as facilitators of mentorship training. As the authors describe, the facilitation approach is designed to guide learners in constructing their own knowledge that is contextualized to their own experience and needs, representing a departure from the traditional transmission-based educational framework which is more common around the world (and can be seen as a vestige of colonial learning strategies). This example uses the idea of learner-centered education to explore concepts of power and positionality, which the authors reported as themes that resonated with the program participants. And, per the evaluation described in the article, these ideas were seen as acceptable and practical to the participants.

1.4 Platforms for learning

Conversations about Global Health Education theoretical and best practice developments naturally lead to practical discussions about the mechanics of implementing new learning strategies via learning platforms. Following the rapid transition to virtual modes of teaching and knowledge transfer that occurred as a result of the early years of the COVID-19 pandemic, three of the five articles in this category focus on technological developments, while the remaining two describe educational programs.

As the first technology-focused article in the Research Topic, Gicheru and Mwangi sought to explore the facilitators of and barriers to medical school faculty use of a digital learning platform at an academic institution in Kenya. While the majority of faculty reported having access to personal computers and internet at work, slightly more than half were even aware that they had an account on the institution's learning management system (LMS), and only a minority of those faculty reported feeling confident in having the skills needed to engage with learners on the LMS. As the authors describe, this case report demonstrates the importance of academic institutions seeking to understand and address this “digital divide” in the use of educational strategies, and note that this is an area in which various types of institutional partnerships may be able to provide solutions.

Botha et al. describe the benefits of simulation training as a strategy to improve infection prevention and control skills within undergraduate nursing education, with a specific focus on virtual reality as an untapped educational modality in LMIC. The authors note that virtual reality trainings can be constructed to optimize the development of critical thinking and clinical reasoning skills and have tremendous potential to standardize infection prevention and control training across communities and countries. Additionally, they describe specific adaptations to promote equitable access to virtual reality by minimizing the costs and technological infrastructure required, such as cell phone-based programs that use low-cost data modes or are fully downloadable and do not require access to cell data.

On a larger scale, Dykens et al. describe the development and launch of the Consortium of Universities for Global Health Capacity Strengthening Platform (CUGH-CPS). This novel web-based platform seeks to address a variety of inequities related to global health capacity building partnerships, including issues of unequal access to potential institutional capacity building partners and lack of transparency around institutional training priorities. Thus, the CUGH-CPS serves as a conduit for connecting institutions and programs that have specific healthcare workforce capacity gaps, with individuals and institutions around the world that have the expertise to provide assistance. This free, online resource demonstrates the revolutionary potential of global matching platforms in transforming training and education for healthcare workers in resource-constrained settings.

With respect to educational programs that serve as learning platforms, Nawagi et al. describe the experiences of African health professions students (medicine, nursing, and pharmacy) participating in the GEMx Regional Elective Exchange Program. By facilitating South-to-South exchanges within Africa, the program underscores the importance of intra-continental collaboration, supported by international financial and technological assistance and other expertise when necessary. This initiative not only enhances the accessibility of international electives but also fosters a culture of knowledge sharing and sustainable healthcare practices among future healthcare professionals from a variety of disciplines. This approach highlights the program's commitment to promoting mutual understanding and cooperation.

Lastly, Shah et al. report on the results of a survey of new African medical schools (defined as having been established with in the prior 20 years) which collated information about a host of characteristics, including demographics, operational details (e.g., admissions policies, evaluation and accreditation, faculty development), curricula and assessment, research capacity, and postgraduate training opportunities. Relevant to the prior discussions of the incorporation (or lack thereof) of instruction technology, it is notable that more than 75% of the survey respondents reported using electronic platforms and information technologies for instruction.

2 Conclusion

In the quest to engage in critical discourses and develop evidence-based guidance to remove supremacy in global health practice and dismantle systems built upon colonial frameworks (Abimbola and Pai, 2020), several key principles and models emerge as guiding lights, which unsurprisingly are foundational to decolonization. The Brocher Declaration, for instance, provides an ethical compass for global health initiatives, underscoring the importance of mutual partnerships and community empowerment. Similarly, the ACCESS and CES models champion local needs, robust partnerships, and community engagement as the bedrock of sustainable improvements in health, education, and overall community wellbeing.

However, the journey toward decolonization in global health practice necessitates confronting and mitigating the impact of colonialist/supremacist biases in Global Health Education. This is a prerequisite for aligning the development of the field with its defined practice directions. The insights offered by the articles in this Research Topic are invaluable for educators striving to build more equitable practice communities and eliminate deep-rooted colonialist assumptions, racism, elitism, and other forms of bias within institutions and individuals.

Scholarship that centers the power, perspective, expertise, and ownership of traditionally disempowered or resource-deprived stakeholders can provide frameworks for anti-colonial and anti-racist global health. This paves the way for the development and implementation of initiatives that genuinely enhance the diversity, equity, and inclusivity of Global Health Education resources and programs. Together, the programs, resources, and information that have been selected for this Research Topic, outline a roadmap toward global health education frameworks and partnerships where sustainable capacity building and bidirectional benefit transition from being mere aspirations to tangible realities.

Author contributions

AD-P: Writing – review & editing. MA: Writing – review & editing. ZZ: Writing – original draft. JE: Writing – review & editing. BM: Writing – review & editing. TR: Writing – review & editing.

Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

Abimbola, S., and Pai, M. (2020). Will global health survive its decolonisation? Lancet 396, 1627–1628. doi: 10.1016/S0140-6736(20)32417-X

PubMed Abstract | Crossref Full Text | Google Scholar

Koplan, J. P., Bond, T. C., Merson, M. H., Reddy, K. S., Rodriguez, M. H., Sewankambo, N. K., et al. (2009). Towards a common definition of global health. Lancet 373, 1993–1995. doi: 10.1016/S0140-6736(09)60332-9

PubMed Abstract | Crossref Full Text | Google Scholar

Melby, M. K., Loh, L. C., Evert, J., Prater, C., Lin, H., and Khan, O. A. (2016). Beyond medical “missions” to impact-driven short-term experiences in global health (STEGHs): ethical principles to optimize community benefit and learner experience. Acad. Med. 91, 633–638. doi: 10.1097/ACM.0000000000001009

PubMed Abstract | Crossref Full Text | Google Scholar

Prasad, S., Aldrink, M., Compton, B., Lasker, J., Donkor, P., Weakliam, D., et al. (2022). Global health partnerships and the brocher declaration: principles for ethical short-term engagements in global health. Ann. Global Health 88:31. doi: 10.5334/aogh.3577

PubMed Abstract | Crossref Full Text | Google Scholar