Obstacles and Avenues for Medical Students Interested in Global Health Work

In 2012, the Association of American Medical Colleges reported that nearly 30% of graduating medical students participated in a global health elective at some point during their training.¹ In our current M1 class of 203 students, that is approximately 41 students who will potentially train abroad. But of those 41, how many will be able to pursue a career in global health? In a survey of medical graduates from global health–related programs, only 41% reported participating in global health work after graduation. Of these physicians, most spent less than 10% of their total professional time on global health.² At Georgetown, that correlates to fewer than 4 students in the class of 2026 who will spend significant time practicing internationally. As someone whose primary pursuit in medicine is to work in global health, this discrepancy is distressing. While many of us have likely been inspired by Physician and medical anthropologist Paul Farmer, or participated in international service trips or medical missions, the pathway to establishing a long-term career in global health is not guaranteed. Thus, it is important to understand the obstacles in the way of pursuing a career in global health medicine and to consider recommendations for students interested in committing their careers to international health care.

Before beginning, I want to be intentional in acknowledging that practicing in international health care, especially coming from the Global North, is a delicate commitment. I can only chase a dream of participating in global health as a result of longstanding historic inequities and gross injustices that have disempowered and disenfranchised the Global South for centuries. While there are ways to participate in short-term international service that are culturally informed and sensitive to the needs of diverse communities, the line between longitudinal service and medical voluntourism is gray. When I consider my own participation in short medical missions and international work alongside the potential roles I may have in the future, I am reminded of a passage from Edward Said’s Orientalism: “the relationship between the Occident [Global North] and the Orient [Global South] is a relationship of power, of domination, of varying degrees of a complex hegemony…” in which “the Westerner [is situated] in a whole series of possible relationships with the Orient without ever losing him the relative upper hand.”³ Ultimately, the goal of global health medicine is that these jobs will one day cease to exist, as we empower communities to develop health care infrastructure for their unique needs and decolonize the medicine of the future. However, our present challenge is to improve the system we have. Currently, it is not set up for US-trained physicians to participate in global health in a personally, professionally, nor financially feasible manner. Current obstacles to global health practice include financial constraints due to student loans and volunteer expenses, as well as risks of sacrificing professional establishment.

Perhaps the most substantial and increasingly intensified factor limiting one’s transition into global medicine is the financial constraints. Not only are young physicians often crippled with student loans, but even established, well-compensated physicians in the US face what scholars refer to as the “global health tax,” often paying out of pocket to practice internationally. In 2019, the average medical student graduated with $200 000 of medical student loan debt, not including debt from undergraduate or graduate school.⁴ Here at Georgetown, the estimated cost of attendance for 4 years of medical school is $280 228 for tuition and fees alone, so most leave our institution with closer to $400 000 of debt.⁵ Residents earn $60 942 on average in their first year, with pay increasing annually to not more than $80 000.⁶ While pay increases significantly after residency, it takes nearly a decade to even begin to reach a traditional physician’s salary, most of which is shunted toward paying back loans. Primary care physicians, who are desperately needed in the US and in global health care, work in the lowest paid specialty despite their value, leaving many with the skills and interest in global health care too financially crippled to seek jobs outside of the US.

Some physicians wait until later in their careers to begin global health work, but even after paying back loans and earning financial stability through domestic practice, these physicians struggle to finance their work abroad. This global health tax can be seen as physicians fund their own supplies, travel, and staff for pro bono work. Many use vacation days or take a pay cut from domestic positions to make the time to practice internationally.⁷ One study of hospitalists in global health revealed that 78% did not receive any funding for their work.⁸ Other physicians and residents may receive small stipends of a few thousand dollars, but this usually never contributes to airfare, nor does it cover a majority of expenses.⁹ Health Volunteers Overseas, for example, holds volunteers responsible for funding airfare and accommodations, with some grant opportunities for specific specialties. At Health Volunteers Overseas, only 28% of volunteers received partial funding to support their overseas work in 2018.⁹ Hence, the global health tax is dependent on a pro bono model that is not sustainable to encourage the long-term service roles that global health requires. These financial constraints encourage transient voluntourism and prevent sustainable community engagement and trust. Thus, while this work is valuable and altruistic, it is not the best model for providing consistent care to a community, training local staff, nor ensuring adequate health care infrastructure and service—the ultimate goals of global health work.

Finally, US and international physicians working in nonprofit and global health work often feel stunted in their professional development because avenues for research, teaching, and publication are not prevalent in global health medicine but are considered the standard for advancing a career in academic medicine.¹⁰ Physicians who participate in affecting change in international health care often do not have the academic paper trail of publications to receive professional advancement in domestic health care positions later in life. The expectation of academic medicine stunts international scholarship, both for physicians from the Global North and the Global South, despite the credibility and impact of their work and the history of medical experimentation and clinical trials on oppressed communities in the Global South.

Despite the obstacles, many physicians have paved unique routes for careers in global health care and are piloting programs to make this work more feasible for other physicians. Several residency and fellowship programs offer diverse international opportunities. Harvard Medical School and Brigham and Women’s Hospital offer global health residencies and fellowships that include long-term international training positions consisting of stays of more than 1 year or that last nearly the entire duration of the training program. Other hospitals including Georgetown, the University of Pennsylvania, and Johns Hopkins University have created global health “tracks” that provide academic training in global health work domestically in conjunction with short-term international training programs such as month-long electives. While this short-term service model is more prevalent currently for residencies and fellowships, the opportunity to train almost exclusively internationally as with Harvard Medical School and Brigham and Women’s Hospital is encouraging. As future residents and fellows, it is important that we think critically about the ways our training could perpetuate transient care models or be in service of long-term participation and partnership in communities. We must advocate for the programs in which we hope to participate.

Aside from pursuing training opportunities in global health, physicians have the option to seek out careers with established global health institutions such as Partners In Health, Médecins Sans Frontières, or the World Health Organization. While the obstacles for compensation and professional establishment still remain, these institutions generally are mindful of supporting long-term employment for physicians all over the world and compensating them fairly.¹¹ Still, larger conversations regarding the cost of medical school, loan forgiveness opportunities, residency and primary care salaries, and the limitations of academic medicine remain relatively untouched but offer rich avenues for opening physician participation in global health.¹²

As a medical student, I am training to be the most prepared, knowledgeable, and attentive physician I can be to each and every one of my patients, regardless of their place on the globe. Should my future practice reach only those on US soil, I would be immensely privileged. However, I hope to use my positionality as a Georgetown medical student to call attention to the deficits in appropriate and feasible global health training and employment opportunities. I seek a future where students like me have the opportunity to serve the communities to which they feel called.