Increasing Access to Dental and Medical Care by Allowing Greater Flexibility in Scope of Practice.

In recent years, advocates for increasing access to medical and oral health care have argued for expanding the scope of practice of dentists and physicians. Although this idea may have merit, significant legal and other barriers stand in the way of allowing dentists to do more primary health care, physicians to do more oral health care, and both professions to collaborate. State practice acts, standards of care, and professional school curricula all support the historical separation between the 2 professions. Current laws do not contemplate working across professional boundaries, leaving providers who try vulnerable to legal penalties. Here we examine the legal, regulatory, and training barriers to dental and medical professionals performing services outside their traditional scope of practice.

Measuring the Cross-Cultural Adaptability of a Graduate Student Team from a Global Immersion Experience.

BACKGROUND: Cultural competency skills for health and human services providers is important because of the growing diverse populous. Experiential learning through global immersion may promote these skills. METHODS: Using a non-randomized cohort design, there were two groups of unmatched graduate students. One reviewed an online educational module and participated in campus activities and an experience in Malawi; the other reviewed the module only. The students were assessed pre- and post-immersion using a measure of cross-cultural adaptability, a component of cultural competency skills. RESULTS: Comparing total scores on the Cross-Cultural Adaptability Inventory (CCAI™), pre-immersion (baseline), there was no significant difference between the groups. Comparing both groups' total scores pre/post-immersion, there was a significant difference. There was a significant difference for the experimental group between the pre/post-immersion total scores but not for the control group. Comparing both groups'post immersion, there was a significant difference between the groups. Comparing both groups' component scores, there was a significant difference in the Emotional Resilience and Perceptual Acuity variables for the experimental group but not for the control group. Comparing both groups' component scores, there was no significant difference in the Personal Autonomy and Flexibility Openness variables. CONCLUSION: Participation in a 6-week global immersion experience compared to education only made a greater change in the development of cross-cultural adaptability for a graduate student team.

Probiotics: achieving a better regulatory fit.

The development and marketing of new probiotic products, substances containing live microorganisms that have a beneficial effect on the human body, have dramatically increased over the last few years. This article examines how the Food and Drug Administration and Federal Trade Commission currently regulate probiotics and makes recommendations as to changes that might be made to ensure that probiotic products are made available to the general public in a way that is both safe and effective.

Global learning: A post-COVID-19 approach to advance health equity.

The COVID-19 pandemic has accelerated acceptance of learning from other countries, especially for high-income countries to learn from low- and middle-income countries, a practice known as global learning. COVID-19's rapid disease transmission underscored how connected the globe is as well as revealed stark health inequities which facilitated looking outside of one's borders for solutions. The Global Learning for Health Equity (GL4HE) Network, supported by Robert Wood Johnson Foundation, held a 3-part webinar series in December 2021 to understand the current state of global learning and explore how global learning can advance health equity in the post-COVID-19 era. This paper reflects on these cutting-edge discussions about the current state of global learning, drawing upon the highlights, perspectives, and conclusions that emerged from these webinars. The paper also comments on best practices for global learning, including adapting for context, addressing biases, funding considerations, ensuring bidirectional partnerships, community engagement, and adopting a multidisciplinary approach.

Global health reciprocal innovation: ethical, legal and regulatory considerations.

Global health reciprocal innovation (GHRI) is a recent and more formalised approach to conducting research that recognises and develops innovations (eg, medicines, devices, methodologies) from low- and middle-income countries (LMICs). At present, studies using GHRI most commonly adapt innovations from LMICs for use in high-income countries (HICs), although some develop innovations in LMICs and HICs. In this paper, we propose that GHRI implicitly makes two ethical commitments: (1) to promote health innovations from LMICs, especially in HICs, and (2) to conduct studies on health innovations from LMICs in equitable partnerships between investigators in LMICs and HICs. We argue that these commitments take a significant step towards a more equal global health research enterprise while helping to ensure that populations and investigators in LMICs receive equitable benefits from studies using GHRI. However, studies using GHRI can raise potential ethical concerns and face legal and regulatory barriers. We propose ethical, legal and regulatory considerations to help address these concerns and barriers. We hope our recommendations will allow GHRI to move the global health research enterprise forward into an era where all people are treated equally as knowers and learners, while populations in both LMICs and HICs benefit equitably from studies using GHRI.

Global Learning for Health Equity: A Survey of Five Global Learning Sites in the United States.

Global learning is the practice of adopting and adapting global ideas to local challenges. To advance the field of global learning, we performed a case study of five communities that had implemented global health models to advance health equity in a U.S. setting. Surveys were developed using a Consolidated Framework for Implementation Research (CFIR) framework, and each site completed surveys to characterize their global learning experience with respect to community context, the learning and implementation process, implementation science considerations, and health equity. The immense diversity of sites and their experiences underscored the heterogenous nature of global learning. Nonetheless, all cases highlighted core themes of addressing social determinants of health through strong community engagement. Cross-sector participation and implementation science evaluation were strategies applied by many but not all sites. We advocate for continued global learning that advances health equity and fosters equitable partnerships with mutual benefits to origination and destination sites.

Introduction to Special Collection on Decolonizing Education in Global Health.

At the heart of the decolonization of global health process lies critical analysis of the interdependent matrices of power dynamics. As characterized by the articles presented in this Special Collection, deep reform of global health can take the form of shifts in leadership structures, priority setting processes, knowledge/cognitive paradigms, power dynamics, financial arrangements, curricular innovation, and policy changes in research, education, and practice. The curation process of this Special Collection was designed to represent diverse geographies, scales, stakeholders, and themes within the decolonizing global health conversation. The unique perspectives of scholars representing the fields of pharmacy, physiotherapy, medicine, nursing, social work, law, public health, sociology, and bioethics are included in the collection. The premise of the Special Collection is the understanding that meaningful progress toward decolonization must come from within the institutions that built the field of global health in the first place, and doing so will require deep reflection on the role different disciplines - working both alone and collaboratively - can and should play to advance decolonization.

Global Learning for Health Equity: A Literature Review.

Background: In high income countries struggling with escalating health care costs and persistent lack of equity, there is growing interest in searching for innovative solutions developed outside national borders, particularly in low- and middle-income countries (LMICs). Engaging with global ideas to apply them to local health equity challenges is becoming increasingly recognized as an approach to shift the health equity landscape in the United States (US) in a significant way. No single name or set of practices yet defines the process of identifying LMIC interventions for adaptation; implementing interventions in high-income countries (HIC) settings; or evaluating the implementation of such projects. Objectives: This paper presents a review of the literature describing the practice of adapting global ideas for use in the US, particularly in the area of health equity. Specifically, the authors sought to examine; (i) the literature that advocates for, or describes, adaption of health-related innovations from LMICs to HICs, both generally and for health equity specifically, and (ii) implementation practices, strategies, and evidence-based outcomes in this field, generally and in the area of health equity specifically. The authors also propose terminology and a definition to describe the practice. Methods: The literature search included two main concepts: global learning and health equity (using these and related terms). The search consisted of text-words and database-specific terminology (e.g., MeSH, Emtree) using PubMed, Embase (Elsevier), CINAHL (Ebsco), and Scopus in March 2021. The authors also contacted relevant experts to identify grey literature. Identified sources were categorized according to theme to facilitate analysis. In addition, five key interviews with experts engaged with global ideas to promote health equity in the United States were conducted to develop additional data. Results: The literature review yielded over ninety (n = 92) sources relating to the adaptation of global ideas from low resource to higher resource settings to promote health equity (and related concepts). Identified sources range from those providing general commentaries about the value of seeking health-related innovations outside the US border to sources describing global projects implemented in the US, most without implementation or outcome measures. Other identified sources provide frameworks or guidance to help identify and/or implement global ideas in the US, and some describe the role of the World Health Organization and other international consortia in promoting a global approach to solving domestic health equity and related challenges. Conclusions: The literature review demonstrates that there are resources and commentary describing potential benefits of identifying and adapting novel global ideas to address health equity in the US, but there is a dearth of implementation and evaluation data. Terminology is required to define and frame the field. Additional research, particularly in the area of implementation science and evidence-based frameworks to support the practice of what we define as 'global learning' for health equity, is necessary to advance the practice.

Global Health Partnerships and the Brocher Declaration: Principles for Ethical Short-Term Engagements in Global Health.

Short- term experiences in global health (STEGH), also known as short-term medical missions continue to be a popular mode of engagement in global health activities for students, healthcare providers, and religious groups, driven primarily by organizations from high-income countries. While STEGH have the potential to be beneficial, a large proportion of these do not sustainably benefit the communities they intend to serve, may undermine local health systems, operate without appropriate licenses, go beyond their intended purposes, and may cause harm to patients. With heightened calls to "decolonize" global health, and to achieve ethical, sustainable, and practical engagements, there is a need to establish strong guiding principles for global health engagements. The Advocacy for Global Health Partnerships (AGHP), a multi-sectoral coalition, was established to reflect on and address the concerns relating to STEGH. Towards this end, AGHP created the Brocher Declaration to lay out six main principles that should guide ethical and appropriate STEGH practices. A variety of organizations have accepted the Declaration and are using it to provide guidance for effective implementation of appropriate global health efforts. The Declaration joins broader efforts to promote equity in global health and a critical reevaluation of volunteer-centric, charity-based missions. The current state of the world's health demands a new model of collaboration - one that sparks deep discussions of shared innovation and builds ethical partnerships to address pressing issues in global health.

Not Above the Law: A Legal and Ethical Analysis of Short-Term Experiences in Global Health.

BACKGROUND: Persons from high-income countries have multiple opportunities today to participate in "short-term experiences in global health" (STEGHs) in low-resourced countries. STEGHs are organized through religious missions, service learning, medical internships, global health education, and international electives. An issue of increasing concern in STEGHs is "hands-on" participation in clinical procedures by volunteers and students with limited or no medical training. To address these concerns, best practices and ethical standards have been developed. However, not all STEGH organizations adhere to these guidelines, and some actively or tacitly allow unethical and potentially illegal practices. OBJECTIVES: This paper considers the legal framework within which STEGHs operate. It assesses whether certain STEGH practices break laws in the US and/or host countries or violate international "soft" legal norms. Two activities of particular concern are: practicing medicine without a license and drug importation and distribution. CONCLUSIONS: Many activities undertaken in STEGHs would be illegal if they took place on US soil. In addition, these same activities are often illegal in the host countries where STEGHs operate, although compliance is unevenly enforced. Many STEGH activities violate World Health Organization guidelines for ethical conduct in humanitarian activities. RECOMMENDATIONS: This paper encourages STEGH organizations to end unethical and potentially illegal activities; urges regulatory and non-regulatory stakeholders to alter policies that motivate participation in illegal or unethical STEGH activities; and encourages host countries to enforce their local and national health laws.

The authors reply.

This is a reply to the commentary of Ossorio and Zhou.

Reconfiguring a One-Way Street: A Position Paper on Why and How to Improve Equity in Global Physician Training.

Large numbers of U.S. physicians and medical trainees engage in hands-on clinical global health experiences abroad, where they gain skills working across cultures with limited resources. Increasingly, these experiences are becoming bidirectional, with providers from low- and middle-income countries traveling to experience health care in the United States, yet the same hands-on experiences afforded stateside physicians are rarely available for foreign medical graduates or postgraduate trainees when they arrive. These physicians are typically limited to observership experiences where they cannot interact with patients in most U.S. institutions. In this article, the authors discuss this inequity in global medical education, highlighting the shortcomings of the observership training model and the legal and regulatory barriers prohibiting foreign physicians from engaging in short-term clinical training experiences. They provide concrete recommendations on regulatory modifications that would allow meaningful short-term clinical training experiences for foreign medical graduates, including the creation of a new visa category, the designation of a specific temporary licensure category by state medical boards, and guidance for U.S. host institutions supporting such experiences. By proposing this framework, the authors hope to improve equity in global health partnerships via improved access to meaningful and productive educational experiences, particularly for foreign medical graduates with commitment to using their new knowledge and training upon return to their home countries.

Building public health law capacity at the local level.

Local health officials are called upon every day to implement the programs, enforce the regulations, and take the actions that protect the health of the citizens in their districts. These responsibilities and duties are created and regulated by a complex interplay of federal, state, and local law. Not only is an understanding of these laws necessary to carry out public health activities on a daily basis, but many public health scholars and practitioners also believe that the law can be used as a tool to take proactive steps to improve public health. Unfortunately, many local public health officials do not have access to the legal assistance they need to address the various legal questions that confront them. This deficit makes it harder for them to meet their day-to-day responsibilities and makes it much more difficult for them to use the law proactively as a method to improve public health in their communities. In addition, many of the attorneys who provide legal support to public health departments do not have the time or resources to develop a thorough and up-to-date understanding of public health law. This paper examines the experience of a number of local health offices in obtaining legal advice and of attorneys who provide legal advice and assistance to local health departments and assesses different models for organizing and financing the provision of legal services to local public health officials.

A proposed definition of microbiota transplantation for regulatory purposes.

The advent of fecal microbiota transplantation (FMT) and the prospect of other types of microbiota transplants (MT), e.g. vaginal, skin, oral and nasal, are challenging regulatory agencies. Although FDA is regulating FMT (as a biologic), there is currently no widely accepted or agreed upon scientific or legal definition of FMT or MT. The authors report on discussions regarding a definition of MT that took place among a working group of stakeholders convened under a National Institutes for Allergies and Infectious Diseases grant to address the regulation of MT. In arriving at a definition, the group considered the 1) nature of the material being transplanted; 2) degree of manipulation of the transferred materials prior to implantation; 3) ability to characterize the transplanted product using external techniques; and 4) origin of the stool product (single vs multiple donors).

Legal and Regulatory Barriers to Reverse Innovation.

BACKGROUND: Reverse innovation, or the importation of new, affordable, and efficacious models to high-income countries from the developing world, has emerged as a way to improve the health care system in the United States. Reverse innovation has been identified as a key emerging trend in global health systems in part because low-resourced settings are particularly good laboratories for low-cost/high-impact innovations that are developed out of necessity. A difficult question receiving scant attention is that of legal and regulatory barriers. OBJECTIVES: The objective of this paper is to understand and elucidate the legal barriers faced by innovators bringing health interventions to the United States. METHODS: Semistructured qualitative interviews were conducted with 9 key informants who have directly participated in the introduction of global health care approaches to the United States health system. A purposive sampling scheme was employed to identify participants. Phone interviews were conducted over one week in July 2016 with each participant and lasted an average of 35 minutes each. FINDINGS: Purely legal barriers included questions surrounding tort liability, standard of care, and concerns around patient-administered self-care. Regulatory burdens included issues of international medical licensure, reimbursement, and task shifting and scope of work challenges among nonprofessionals (e.g. community health workers). Finally, perceived (i.e. not realized or experienced) legal and regulatory barriers to innovative modalities served as disincentives to bringing products or services developed outside of the United States to the United States market. CONCLUSIONS: Conflicting interests within the health care system, safety concerns, and little value placed on low-cost interventions inhibit innovation. Legal and regulatory barriers rank among, and contribute to, an anti-innovation atmosphere in healthcare for domestic and reverse innovators alike. Reverse innovation should be fostered through the thoughtful development of legal and regulatory standards that encourage the introduction and scalable adoption of successful health care innovations developed outside of the US, particularly innovations that support public health goals and do not have the benefit of a large corporate sponsor to facilitate introduction to the market.

Global/Local: What Does It Mean for Global Health Educators and How Do We Do It?

BACKGROUND: There has been dramatic growth in the number of innovative university programs that focus on social justice and teach community-based strategies that are applicable both domestically in North America and internationally. These programs often are referred to as global/local and reflect an effort to link global health and campus community engagement efforts to acknowledge that a common set of transferable skills can be adapted to work with vulnerable populations wherever they may be. However, the concepts underlying global/local education are undertheorized and universities struggle to make the global/local link without a conceptual framework to guide them in this pursuit. OBJECTIVES: This study reports on the outcomes of a 2015 national meeting of 120 global health educators convened to discuss the concepts underlying global/local education, to share models of global/local programs, and to draft a preliminary list of critical elements of a meaningful and didactically sound global/local educational program. METHODS: A qualitative analysis was conducted of the discussions that took place at the national meeting. The analysis was supported by videorecordings made of full-group discussions. Results were categorized into a preliminary list of global/local program elements. Additionally, a synthesis was developed of critical issues raised at the meeting that warrant future discussion and study. FINDINGS: A preliminary list was developed of 7 program components that global health educators consider essential to categorize a program as global/local and to ensure that such a program includes specific critical elements. CONCLUSIONS: Interest is great among global health educators to understand and teach the conceptual link between learning on both the global and community levels. Emphasis on this link has high potential to unite the siloed fields of global health and domestic community public health and the institutions, funding options, and career pathways that flow from them. Future research should focus on implementation of global/local programming and evaluation of student learning and community health outcomes related to such programs.

Putting the pieces together: creating and implementing an Interprofessional Global Health Grant Program.

In 2014, the Center for Global Education Initiatives (CGEI) at the University of Maryland, Baltimore (UMB) created an innovative Faculty and Student Interprofessional Global Health Grant Program. Under the terms of this program, a UMB faculty member can apply for up to $10,000 for an interprofessional global health project that includes at least two students from different schools. Students selected to participate in a funded project receive a grant for the travel portion of their participation. This is the first university-sponsored global health grant program in North America that conditions funding on interprofessional student participation. The program grew out of CGEI's experience creating interprofessional global health programming on a graduate campus with six schools (dentistry, law, medicine, nursing, pharmacy, and social work) and meets several critical goals identified by CGEI faculty: increased global health experiential learning opportunities, increased use of interprofessional education on campus; and support for sustainable global health programming. This case study describes the history that led to the creation of the grant program, the development and implementation process, the parameters of the grant program, and the challenges to date. The case study is designed to provide guidance to other universities that want to foster interprofessional global health on their campuses.

Identifying interprofessional global health competencies for 21st-century health professionals.

BACKGROUND: At the 2008 inaugural meeting of the Consortium of Universities for Global Health (CUGH), participants discussed the rapid expansion of global health programs and the lack of standardized competencies and curricula to guide these programs. In 2013, CUGH appointed a Global Health Competency Subcommittee and charged this subcommittee with identifying broad global health core competencies applicable across disciplines. OBJECTIVES: The purpose of this paper is to describe the Subcommittee's work and proposed list of interprofessional global health competencies. METHODS: After agreeing on a definition of global health to guide the Subcommittee's work, members conducted an extensive literature review to identify existing competencies in all fields relevant to global health. Subcommittee members initially identified 82 competencies in 12 separate domains, and proposed four different competency levels. The proposed competencies and domains were discussed during multiple conference calls, and subcommittee members voted to determine the final competencies to be included in two of the four proposed competency levels (global citizen and basic operational level - program oriented). FINDINGS: The final proposed list included a total of 13 competencies across 8 domains for the Global Citizen Level and 39 competencies across 11 domains for the Basic Operational Program-Oriented Level. CONCLUSIONS: There is a need for continued debate and dialog to validate the proposed set of competencies, and a need for further research to identify best strategies for incorporating these competencies into global health educational programs. Future research should focus on implementation and evaluation of these competencies across a range of educational programs, and further delineating the competencies needed across all four proposed competency levels.

All together now: developing a team skills competency domain for global health education.

Global health is by definition and necessity a collaborative field; one that requires diverse professionals to address the clinical, biological, social, and political factors that contribute to the health of communities, regions, and nations. While much work has been done in recent years to define the field of global health and set forth discipline-specific global health competencies, less has been done in the area of interprofessional global health education. This paper documents the results of a roundtable that was convened to study the need for an interprofessional team skills competency domain for global health students. The paper sets forth a preliminary set of team competencies based on existing scholarship and the results of the roundtable. Once an agreed upon set of competencies is defined, a valuable next task will be development of a model curriculum to teach team skills to students in global health. The preliminary competencies offered in this paper represent a good first step toward ensuring that global health professionals are able to collaborate effectively to make the field as cohesive and collaborative as the mighty task of global health demands.

A place for all at the global health table: a case study about creating an interprofessional global health project.

This essay is a reflection on the "why" and "how" of creating an interprofessional global health project, with specific focus on the challenges of incorporating law students into this type of educational activity.