How the changing demography is rendering medical education obsolete

Throughout the centuries, medicine was the profession of healing the sick, no matter the disease or the social context. Key diseases were identified and priorities were set for the well being of society, leading to diseases such as tuberculosis and leprosy being aggressively tackled. With time, the priority areas of the medical community and the ones of the ill diverged and Rudolph Virchow attempted to keep the profession from becoming increasingly isolated from the population and the root causes of illness: “Medicine is a social science, and politics are nothing but medicine at a larger scale. Physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction”.

In today’s globalized world, not only do diseases know no borders but also, migration has become ubiquitous. People are moving in greater numbers, traveling greater distances at an unprecedented pace, thus producing a new paradigm of multiculturalism and diversity within countries. Migrants, regardless of the political, economical or environmental drivers of their movement, carry with them what we call at ICMHD their “health print”. A Malian migrant settling in France will adapt to its environment relatively quickly and will even be subject to the host country’s specific health risk factors but the event of the migration does not erase this person’s past exposures to specific diseases and risk factors which he was subject to in Mali. Health professionals need to be aware of people’s migration history and take into account the impact of the risk factors and epidemiology of disease of the country of origin as well as  the migration itself. Overlooking one’s migration history can lead to erroneous diagnosis and treatment as well as poor health outcomes.

Medical students need to be exposed to the actual burden of disease of the world we live in. Today’s reality is that tuberculosis and hepatitis B, for example, are not only diseases they will encounter on their electives abroad or even when working at an inner-city clinic with vulnerable groups. A perfectly healthy migrant arriving in Switzerland might not seem to be at risk of developing tuberculosis, but if one digs a bit deeper, we might discover that this individual lives in overcrowded housing with other migrants, and that they might be carriers of active tuberculosis. Or he may every year visit his family in a high-risk tuberculosis zone. HIV in India is also a good example of the differential risk factors incurred with a particular history of migration. India has a very low HIV prevalence but is experiencing concentrated epidemics in towns where rural-to-urban migration is extensive. Among rural-to-urban migrant workers, the HIV prevalence is 10 to 20 times higher than the national average (National AIDS Control Organization, 2010). Would one think to screen a migrant worker from a rural area for HIV when HIV rates are much higher in urban settings?

To be a competent medical doctor, students need to approach the realities of migration – including its scope, magnitude, the implications for treatment and care, the effects on people’s integration in a host healthcare system and its impact on the epidemiology of disease – in a systematic and comprehensive manner. Migration is a complex and dynamic process and one can no longer predict the next major migration trend. For that reason that we believe at ICMHD that medical faculties need to include a Global Health component to their curriculum, both as an explicit course and by integrating such notions throughout the clinical rotations. Dr Piot, Director of the London School of Hygiene and Tropical Medicine, stated very bluntly the need for more Global Health education in medical curriculums in a recent New York Times article: “A very down-to-earth reason is just if you practice in the U.K. the likelihood that you will have patients who come from other places is extremely high”.

Currently, medical students all over the world are being increasingly vocal about demanding Global Health educations and courses and, because of the general unresponsiveness of medical faculties to any demands in this field, they themselves are taking the lead and learning by themselves, peer-educating each other about Global Health and creating their own programs (see New York Times article).

Yet again medicine is at a crossroads. We can no longer dismiss the health needs of migrants, who now represent the 5th largest country in the world, or the vast impact migration has on the population. Medicine needs to reconnect with its roots and address the needs of the population, know effectively a global one.

Alexandre Lefebvre

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