Global public health starts at home: upstream approaches to global health training
Authors: Tolu Oni, John S Yudkin, Sharon Fonn, Philip Adongo, Margaret Kaseje, Ademola Ajuwon, Lesley Doyal, Leslie London
Journal: The Lancet Global Health (2019)

The interconnectedness of today's globalised world brings with it challenges and inequality in the health of populations. But all too often health professionals' training focuses on downstream individual intervention approaches (eg, smoking cessation, diet improvement), at the expense of upstream determinants (eg, food marketing, trade agreements). A crop of global health degrees has emerged aimed at explaining and understanding diseases of global importance. However, these courses are largely taught from a position of assumed power in which those from the wealthy nations have greater leverage than their counterparts from low-income and middle-income countries (LMICs). We set out to challenge the philosophies and approaches for action that are taught in global health training courses, which have been slow to tackle more foundational issues. Highlighting trade agreements and the political economy of health as examples, we stress the need for a greater emphasis on intervening in the upstream social, economic, and commercial determinants of health. Although we recognise that the terms "global north" and "global south" are an oversimplification of the global distribution of power and resources that do not comprehensively capture the heterogeneity of the global south, we merely use these terms to scaffold discussion on power asymmetries and dynamics that influence health. First, global health courses, almost exclusively taught in the north, focus on diseases of relevance to LMICs based on the global burden of disease borne by these countries to prepare graduates to work in those contexts. However, often missing is an understanding of global inequality; that poverty in the global south is a consequence of trade and political systems that create wealth and power in the north. Poor health outcomes are not merely due to chance, disasters, dictators, and fate. To ignore this, leaves a critical gap in global health training. Second, current public health training focuses mainly on actions from within the health sector. However, there is a need to include other sectors such as education, economics, agriculture, and sustainable environments to address the interrelatedness of global and local systems that drive health inequities. This change requires the capacity to engage beyond the health sector, and beyond local, national, and regional borders. In particular, it requires challenges to "unfair terms of global trade agreements and the international financial systems undermining capacity for equitable growth"1Rabbani F Shipton L White F et al.Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?.BMC Pub Health. 2016; 16: 941Crossref PubMed Scopus (27) Google Scholar in order to confront the root causes of ill health and inequity everywhere, not just elsewhere (or for "other" people). Therefore, there is a need to review the curriculum required for global public health professionals to ensure that it includes: (1) a broader knowledge base and skill set including leadership and teamwork skills, negotiation, and diplomacy; (2) training of students from diverse disciplines relevant to health and its upstream determinants; and (3) recognition that these students should be equipped with the skills required for action focused on upstream determinants where they originate (not simply addressing the negative consequences of skewed global systems), a greater engagement by the global health community with social and political sciences, and a readiness to act politically and challenge the status quo. Finally, global public health training requires a shift from consequences to causes. Increased wealth and power come at the expense of exacerbating inequality affecting others, both near and far. In the name of economic growth and free trade, risks and exposures related to non-communicable diseases (NCDs) often go unchecked as they put people at risk of obesity and related diseases. In particular, understanding global trade liberalisation and the marketing practices of multinationals2Moodley G Christofides N Norris SA Achia T Hofman KJ Obesogenic environments: access to and advertising of sugar-sweetened beverages in Soweto, South Africa, 2013.Prev Chronic Dis. 2015; 12: 140559Crossref Scopus (28) Google Scholar, 3Schram A Labonté R Sanders D Urbanization and international trade and investment policies as determinants of noncommunicable diseases in Sub-Saharan Africa.Prog Cardiovasc Dis. 2013; 56: 281-301Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 4Rayner G Hawkes C Lang T Bello W Trade liberalization and the diet transition: a public health response.Health Promot Int. 2006; 21: 67-74Crossref PubMed Scopus (82) Google Scholar, 5Freudenberg N Lethal but legal: corporations, consumption, and protecting public health. Oxford University Press, New York2014Google Scholar will allow those interested in global health to act locally yet influence how multinationals operate globally, including their impact on health. This understanding would shift the primary focus from individual health education and behaviour change, which falls well short of population level prevention, to a focus on policy levers,6Cabrera Escobar MA Veerman JL Tollman SM Bertram MY Hofman KJ Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a meta-analysis.BMC Pub Health. 2013; 13: 1072Crossref PubMed Scopus (213) Google Scholar and structural factors including regulations and control of industry behaviour. Such upstream interventions aim to address the balance of power in a global context, and to challenge the inter-related system of systems beyond national boundaries, with skills to challenge and effect change in national and global systems and structures that drive ill health and inequity (appendix). Such training should be equitably distributed globally, to address the skewed and narrow perspectives from which global public health is currently taught.7Yan Liu Ying Zhang Zhaolan Liu JianLi Wang Gaps in studies of global health education: an empirical literature review.Glob Health Action. 2015; 8: 25709Crossref PubMed Scopus (49) Google Scholar An example of global health training text that incorporates a global public health approach is the recently updated Textbook of Global Health.8Birn A-E Pillay Y Holtz TH Textbook of global health.4th edn. Oxford University Press, Oxford2017Crossref Google Scholar This text locates global health in the context of changing world orders. It provides an important focus on the political economy of health and highlights the importance of a social-justice approach, incorporating the social and political economies of LMICs, to building healthy societies. In conclusion, improving population health across the globe requires an application of global concepts and approaches to local contexts through the agency of those trained to effect change. We must therefore challenge approaches to Global Public Health training that fail to recognise global inequalities of power, unsustainable economic growth, and ever-widening inequity. We must advocate for training that provides the skills to apply theories to inter-relationships between factors that influence health across different global regions at the local and global levels and to critically examine failures and successes in the global north and south. We envisage this new cadre of global public health professionals would lead different kinds of public health research (with strong social justice and equity values), become leaders in multilateral organisations, governmental positions (eg, in health, finance, trade), and community-driven organisations. The under-representation of academic institutions within Africa and other LMICs offering Global Public Health training courses and degrees is an opportunity to incorporate a new voice in training curricula. We propose that curricula are reviewed and altered through a coordinated approach, that would: (1) explore alternative knowledge sources that incorporate local and regional contexts that influence health; (2) examine barriers to the provision of global public health training in the global south; (3) explore models of true bilateral exchange for shared, not simply transferred, learning that value different discourses on health from a variety of settings and disciplines; and (4) highlight the importance of evaluating the outcomes and impact of this training. We declare no competing interests. Download .pdf (.23 MB) Help with pdf files Supplementary appendix