Global Health: Career Options & Specialization
Physicians and other health professionals-in-training considering a possible full- or part-time career in global health* (GH) often ask about career opportunities and the need for post-basic training or specialization. This section, prepared for the Global Health Education Consortium (GHEC), may provide help answering these questions. First, several basic questions and considerations. (*See end of document for explanation as to why "global health" is now preferred over "international health.")
Consider your personality. Living abroad has many, many attractions but also can imply difficult living and working conditions, strange foods, language challenges, frustrations, uncertainties, and risks of disease and physical harm (road accidents are a greater risk than violence). If you have doubts about how you’ll fare abroad give yourself a several month ‘field test’ before making a firm decision about a career in GH.
Consider your motivations. These may include: altruism; faith‑based service to others; opportunity to learn new skills and about diverse cultures; travel and adventure; "escape" from perceived problems of the U.S.; improving language skills; and a search for ancestral roots. Most will have several motives with some more important than others. Remember, too, that your motivations are likely to change with time; travel, adventure and youthful altruism may fade, to be replaced by either a deeper commitment to serve the disadvantaged, wherever they are, or to the practical goals of paying off debts, raising a family and professional advancement. Your reasons for considering GH work, and their stability over time, will have bearing on choices regarding specialization, type of work, sponsor, and time spent overseas.
What do you want to do in GH? — The broad choices include practitioner, educator, researcher, grant or contract maker (i.e., a philanthropist with foundation or government money) or what might be termed “change agent.” This last choice, usually inherent in any of the other options, works primarily to change the attitudes, behaviors and practices of organizations or groups of individuals? Where you are on the continuum between one extreme and the other will have important implications for your postbasic training program, implications that will become clear in the discussion of training and work options described below.
Use your elective and vacation time. Go abroad and sample specialties of potential interest. Spend time with established practitioners to learn about these fields of practice, their benefits, limitations, relevance for overseas work, and the market for qualified specialists. Consider taking or designing an elective “concentration in global health” where you can develop a professional approach to solving the major GH problems through research, service, and education.
Choose a specialty of interest to you. Most specialties can have a role in GH but some offer far more points of entry than others. Be strategic in your choices. Start with a list of specialties that might appeal to you and then review them carefully as to their compatibility with a GH career. Career opportunities in GH are now far more numerous than in the past but skill requirements are also more demanding and specialized. Narrow your specialty choices to those that provide reasonable prospects of a GH career consistent with other criteria such as long- vs. short-term, clinical vs. non-clinical, ability to re-enter practice in the United States, and so forth.
Consider the timing for overseas work. There are several aspects to this important question, including especially those of children, career, and level of commitment to GH. For children, the easiest time is when they are young or, of course, after they have left home. When young, domestic help is abundant and inexpensive, young children sop up languages like a sponge, peer norms and pressures are not as important as in later years, and local school deficiencies will be less harmful than later on. By the time your children reach the last several years of high school you need to think about possible adverse effects on their education if you remain in a country with deficient schools. It will also be harder for them to leave their friends if they have been raised in the U.S. and then taken abroad as teenagers. For careers, you need to consider your longer‑term objectives as noted earlier. Those choosing to be away from the U.S. for several years while committed to a U.S.‑based career may experience slower career progression and/or difficulty finding a job on re‑entry. If you have a strong commitment and have already had enough GH experience while a student to know what it is like, then your choice is easy; start working in GH as soon as you can and don't worry about other considerations. If, however, you are unsure about your degree of interest in GH, try it out soon after completing your studies. After several years of GH work you will either be ready to commit to a career with significant GH work or you will decide that additional GH work is not for you. In this latter case the time commitment will have been small, you were at the start of your career, and your several‑year delay won't prejudice further advancement.
Consider the wishes of your spouse or partner. If you are not alone in your GH work this is a very important consideration! Given all the special problems you will encounter including language, cultural differences, jobs, work permits, personal safety and health risks, acquired debt and perhaps low earnings, child care and educational options, separation from friends and family, communications, etc., you need to ensure that you and your partner are in agreement about GH work. Living abroad can be enormously fulfilling for a family, e.g., closer bonding, warm friendships, less outside distractions, foreign travel, etc., but the potential for stress is there too. This is especially the case in those countries where the gender differential regarding jobs, authority, roles and expectations is much greater than in the U.S. If both partners are not already somewhat experienced in international living and equally committed to the experience, best you plan a trial period of a few months or several years before deciding on a GH career. One additional caution: Quite a few Americans working overseas have married persons native to the country in which they worked. Many such marriages work out fine but problems may arise if there have been significant differences in the cultural and social upbringing of the spouses. An American‑born woman who marries a man from a culture in which male‑female expectations and opportunities are very different from those in America is at special risk. After the glow of courtship and the marriage ceremony pass, early cultural patterning can infuse their way into the relationship such that the American wife finds herself constrained by the expectations of her husband and perhaps her husband's family.
Summarizing, be reflective and be strategic. Know yourself, your motives, your skills, personality and constraints. Test your GH inclinations during medical school and if firmly committed to a career in GH, plan your postbasic training accordingly. And if uncertain, be more cautious about major training commitments. Mentors and role models can help with your decision but only you will have to make, and live, with what you decide. To help you narrow your range of choices regarding training and specialization we have listed below frequently asked questions along with possible answers.
What types of jobs are available in GH? — Major job options are listed below along with a qualitative appreciation of job availability and expectations of prior training and experience. While the number of health professionals working in GH will likely increase substantially, the increase in jobs for physicians may be slower. Many low income countries now have a substantial medical workforce, there are fewer opportunities for American doctors to do clinical work (except in faith-based NGOs), and a high proportion of GH jobs call for persons with public health training, with or without a medical degree. An excellent resource is the book, Finding Work in Global Health: A Practical Guide for Job—Seekers or Anyone Who Wants to Make the World a Healthier Place, by Garth Osborn and Patricia Ohmans, 2005, and available for online purchase from Amazon.com or the Global Health Council. Student memberships in the Council are inexpensive and as a member you can review the "Jobs" section to get an idea of the hundreds of job and volunteer opportunities available. Many other information sources are available such as the “Resource” section of GHEC ( www.globalhealth-ec.org) and the GH interest groups of professional organizations such as the American Academy of Family Physicians.
International, or multilateral organizations — World Health Organization, World Bank, UNICEF, FAO, UNDP, etc. — These organizations usually require specialization and prior experience at a progressively responsible level. Postgraduate degree training in disciplines such as public health, business, economics and social or behavioral sciences is valuable, and advanced clinical skills are generally not utilized. Though some ‘internship’ arrangements are available, most international organizations do not hire staff right out of training. American citizenship can sometimes be a liability since these organizations tend to have national quotas, and the "industrialized country" slots are often oversubscribed. Salaries and benefits are among the best for GH work, travel can be extensive, and a career with these organizations can be rewarding, though at times frustrating due to bureaucracy and the inherent problems of international development. Short‑term consultations with the World Bank and regional development banks can pay adequately while much of the short‑term work with WHO will be without honorarium or only with nominal payment.
Bilateral governmental organizations — U.S. Agency for International Development (USAID), the Department of Health and Human Services (DHHS) through the U.S. Public Health Service, the Centers for Disease Prevention and Control, and the other DHHS agencies, the Peace Corps, U.S. embassies abroad, and various other national foreign assistance organizations. Job requirements are similar though somewhat less demanding than in the case of the international organizations. There are more opportunities for internships and entry-level positions, especially in the CDC, which offers training (including fourth year U.S.-based electives) both domestically and abroad. Several years of training and service in the CDC's Epidemic Intelligence Service (EIS) is especially appropriate as an entry level position with the U.S. Government for international service. This is basically a two-year fellowship in epidemiology, available after full clinical training, to MDs, RNs, PhDs, and other health professionals. A Preventive Medicine Residency, available at many public health training and service institutions, is one option, but full clinical training in primary care, with possible subspecialization in infectious disease, is a common career track. Since U.S. international aid organizations contract out many of their activities, direct hires are relatively few and determined more by retirements than agency growth. For example USAID contracts to numerous for‑profit and not‑for‑profit agencies (mainly located in the Washington, DC, area) to implement programs abroad; it is these organizations that most entry-level positions for new graduates.
Academic institutions — An increasing number of academic institutions are developing GH programs and when adequately funded, these can provide the usual opportunities of job stability, academic advancement and teaching, research and consultation with a GH focus. However, such institutions are still very much in the minority and for most faculty with GH interests it is a matter of squeezing part-time GH activities in between the normal clinical, teaching, research and administrative responsibilities. GHEC has some 300 members from ~50 North and Central American medical schools, and the GHEC website <http://www.globalhealthedu.org/> provides a good description of medical school entry points.
Not-for-profit non-governmental service organizations — There are many such organizations that fall into several broad categories. (1) Specialized services and/or training. These are provided by medical specialty societies that conduct short-term service trips for cataract surgery, cleft palate repairs, orthopedic and rehabilitation services, etc., while at the same time providing training to local health personnel. The American Academy of Family Physicians and the American Society of Tropical Medicine and Hygiene both publish and maintain lists of overseas opportunities. (2) Emergency relief and rehabilitation. Organizations such as Doctors Without Borders (MSF), International Red Cross, CARE, etc., help with famines, refugee crises of the sort that occurred in Rwanda, Bosnia, Kosovo, Afghanistan and the Horn of Africa region. Non-physicians hold most permanent staff positions, while fully qualified physicians do much of the short-term work. The opportunities for students to gain experience in these types of organizations is generally limited and requirements for acceptance should be carefully reviewed.
For-profit and not-for-profit consultant organizations — Recent decades have seen rapid growth in the number, size and complexity of GH consultant organizations due to the trend toward government contracting for the provision of assistance. Such organizations, especially large ones such as Management Sciences for Health, John Snow, Inc., University Research Corporation, and Family Health International, can provide a good opportunity for new graduates, especially those with public health skills, with or without medical training. Pay and benefits are usually good, and there are opportunities both for long- and short-term overseas assignments.
Faith-based organizations — Numerous denominational charities and health facilities exist including large ones such as Church World Service, the Aga Khan Foundation, Catholic charities and World Vision. Except for short‑term assignments, most faith-based organizations expect their regular staff to be a member of the sponsoring denomination. Many jobs with faith‑based organizations are clinical or associated with relief services, and may offer a pay scale well below stateside norms. Some small organizations, such as the American Friends Service Committee, have positions for persons irrespective of denomination.
What type of postbasic training is most appropriate? — Postbasic clinical training is essential for clinical or clinical research. If, however, you tend more toward working in a change agent role, you may want to consider public health or perhaps other non‑clinical training, either in place of or in addition to, clinical training. The two major paths are:
(1) Clinical training
What clinical specialties are most appropriate? — The more frequent clinical specializations are family medicine, infectious disease, tropical and/or travel medicine, pediatrics, OB/Gyn, emergency medicine, internal medicine, public health (with many subspecialties available), and psychiatry/mental health. Among clinical specialties, family medicine and emergency medicine offer some advantages. Both fields treat all patients, young, old, pregnant, medical and surgical, and thus provide clinical versatility advantageous both at home and abroad. For those considering short GH assignments, emergency medicine has the advantage of time flexibility. Short-term assignments can readily be arranged with NGOs working on refugee and humanitarian crisis situations and U.S. hospitals are always in need of EM doctors or locums, arrangements that are more difficult in specialties that emphasize continuity of care. Those trained in a surgical specialty may find it difficult to find employment in a long term assignment but have many opportunities for short term visits as part of a fly-in surgical team that both operates and trains local surgeons. Examples of specialties with well established contributions include ophthalmology, otolaryngology, orthopedics and plastic surgery.
How important is board certification? — Though board certification is not essential for most non-academic international positions, it is very desirable and potential employers are likely to give substantial preference to those certified in a clinical specialty.
Are there clinical residencies in GH? — Yes, though not many. The GHEC website has nascent but growing list of residencies offering overseas experience. An especially useful guide is the 326 pp. document, International Health Care Opportunities in Family Medicine: A Guide for Practicing Family Physicians, Family Practice Residents & Medical Students, published by the American Academy of Family Physicians in 2000. The guide lists many programs, either based overseas or with GH relevance. Though most residency time is actually spent in the U.S., some supervised overseas time can be credited towards completion of residency requirements. Additionally, these residencies usually provide structured activities and offerings that will help residents prepare for overseas work. The AAFP website also provides substantial information on International Family Medicine (http://www.aafp.org/x13825.xml).
(2) Public health or other non-clinical training
Does a public health degree increase chances of employment? — For persons working in short term assignments or primarily as clinicians, a public health degree adds little. However, for extended assignments and for jobs concerned with population-based research, training and for jobs involving program development, implementation and evaluation, a public health degree can be valuable. Your field of concentration will have some bearing on employability but not as much as the mere possession of a public health degree. This degree gives evidence of basic training in the core disciplines provided by most schools of public health, i.e., epidemiology, biostatistics, program planning and management, and one or more of the important programmatic content areas such as maternal and child health, health education, and environmental health. Many schools of public health offer the option of completing a preventive medicine residency in conjunction with an academic degree. This residency, by itself, probably has limited relevance to the most GH positions.
Which schools of public health offer GH programs? — At least 10 of the 37 accredited schools now offer concentrations in GH, though programs vary widely in scope, content and faculty strength. One of the oldest and largest programs is the Johns Hopkins Bloomberg School of Public Health (Baltimore, MD). Other strong programs, in alphabetical order, are at Boston University, Columbia, Emory, Harvard, Tulane, Univ. of California (at Berkeley, and at Los Angeles), Univ. of Michigan, Univ. of North Carolina at Chapel Hill, Univ. of Washington, and Yale. Full details can be obtained from GHEC’s list of annotated websites and from the Assoc. of Schools of Public Health ( www.asph.org/). Most schools offer one‑year MPH programs for those with a prior health degree (vs. two years for those coming directly out of college). The one year course saves time and money but limits the number of second level courses that can be taken. Two other fine options are: the two‑year "Epidemic Intelligence Service" program offered by CDC; and for those interested in training abroad, the world‑renowned London School of Hygiene and Tropical Medicine or a public health program in Canada or France.
What public health disciplines are most relevant? — Depending on your interests, the following concentrations are likely to be relevant: maternal and child health (MCH); population / family planning / demography; epidemiology; biostatistics; communicable and/or tropical disease; public health administration, management, finance and policy; environmental health; occupational health and safety, and/or injury prevention; nutrition; and, health education and promotion.
When should I get my public health training? — Should it be during or immediately after medical school, during residency, or after residency? There are advantages and disadvantages to each. The easiest, if the option is available, is to do your MPH degree concurrently with your medical training, perhaps after your second or third year. You are still in the "student mode," the benefits of a PH orientation and PH contacts will serve you in good stead later on, you are less likely to have spousal and child responsibilities, and you won't risk interrupting your postgraduate clinical training. But, easiest is not always best. A PH degree will probably mean more to you after a few years of clinical work and “health system maturity.” If you are not yet sure about your commitment to a GH career, best wait awhile before deciding to invest in another degree.
What about other types of non-clinical training — Increasing numbers of persons working in GH have postbasic training, occasionally leading to a degree, in law, economics, business, education, sociology, psychology, informatics, development studies, and medical anthropology. Physicians with training in such disciplines can make an especially valuable contribution to GH.
Are short, non-degree or certification GH programs available? Numerous language immersion programs are available, especially in Spanish, and language is always a valuable skill abroad. In addition, many short pre‑ and post‑graduation courses are available to help prepare physicians for clinical, public health and other aspects of GH. For example, certificate programs in tropical medicine (DTM&H, 3-6 months) provide excellent didactic and clinical training for handling tropical diseases. Short courses in epidemiology and public health are very useful in understanding population‑based approaches to GH problems. Such courses may be creditable towards a later degree and will definitely add to your armamentarium above and beyond clinical training. The GHEC website (<http://www.globalhealthedu.org/>) is a good place to start your search.
*For decades the predominant term has been "international health," conveying the image of high income countries sending people, equipment and funds to the developing world. In recent years the rapid evolution of air travel, commerce and electronic communications has effectively served to make the world smaller and the health risks and problems truly global. The evolving term "global health" better captures the sense of our commonality across borders — and of our common commitment to improve human health throughout the world.
Prepared for the Global Health Education Consortium by Thomas L. Hall. This revision has benefited greatly from suggestions made by colleagues and students from the U.S. and Canada. Send corrections and suggestions for improvement to email@example.com. File updated on 1 February 2006.