Virginia Rowthorn

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 Subcommittees work and proposed list of interprofessional global health competencies. METHODS After agreeing on a definition of global health to guide the Subcommittees 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.

Probiotics: Finding the Right Regulatory Balance

Some products marketed as drugs should be excused from Phase I trials, but safety and efficacy claims for dietary supplements should be more tightly regulated. Initial findings of the Human Microbiome Project (HMP), funded by the U.S. National Institutes of Health (NIH), raise important questions about the role and variation of microorganisms within individuals and across populations (1). One related area of growing research and commercial interest is the development and use of probiotics, substances containing live microorganisms that have a beneficial effect when taken in sufficient quantities (2) and “designed to intentionally manipulate microbiome and host properties” (3). We offer observations about the regulatory process for probiotics and potential areas for reform.

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.

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.

Improving regulation of microbiota transplants

Policy should balance safety, efficacy, access, and research The Human Microbiome Project and similar research has generated great interest in potential health benefits of microbiota transplantations (MTs). The use of fecal microbiota transplantation (FMT), the transfer of stool from a human donor to a human recipient, for recurrent Clostridium difficile infection (CDI) is considered by many to be standard-of-care therapy, and data on its safety and effectiveness are accumulating (1–3). Yet, although some physicians are practicing FMT using stool from donors known to the physician or patient, stool is inconsistently screened for infectious pathogens. The use of prescreened stool obtained from a stool bank and shipped to the physician is increasing, but the stool banks are not regulated. Patients who self-administer FMT using unscreened stool sourced from family or friends is also widely described. In consideration of these and other particular characteristics and challenges of MT, and the nascent regulatory landscape, we convened human microbiome researchers, legal experts, and others to explore regulatory pathways for MT (4). We believe our proposed approach is an improvement on the U.S. Food and Drug Administrations (FDA) current and proposed scheme and could provide a model for other countries that are contemplating regulatory frameworks for FMT.

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 proposed definition of microbiota transplantation for regulatory purposes

ABSTRACT 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.

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

Teaching health law.

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 CGEIs 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.