If you’ve spent time in the field of global health, you’ve probably been asked the question, “Why focus your time internationally, when there is so much need here at home?” While it is an interesting and certainly important question, I think it rests on an assumption that is fundamentally flawed. Quite simply, the question creates a dichotomy between domestic health work and international health work, presupposing that the challenges faced abroad are somehow dissimilar to the ones we face here at home. It assumes that one must choose between the international and the domestic, instead of understanding that the study of health abroad is in fact the study of health in the US. Unfortunately, this limitation is not just characteristic of the people asking the question, but also of the people answering it, as global health academics and practitioners have frequently lacked the creativity or humility to translate models of success between international and domestic contexts.
The most immediate objection to my claim is that there is a significant difference in the health burden faced by different countries around the world. More commonly known as the epidemiological transition, this argument basically holds that during the twentieth century the major health concerns of developed countries switched from infectious diseases to chronic diseases, while in the developing world they remained as infectious diseases. There is no arguing this, and in absolute terms the health crisis and burden of diseases present in the developing world are very different than they are in the US or Canada or much of Europe. For example while HIV/AIDS continues to be a horrific epidemic in many parts of Africa, the US and Europe has greatly excelled in the disease’s prevention and treatment (even greater disparities exist in the prevalence of Tuberculosis). But while the types of disease may be different, that by no means implies that the solutions are not translatable. What do I mean by this?
The most readily available example is community health workers. Over the years, community health worker models have become a staple of human resource expansions in Ministries of Health all over the developing world. They have been a vital part of increasingly stable drug retention rates, immunizations and other preventative care, as well as an invaluable link between clinics and communities. Yet despite this success abroad, very little attempt has been made to implement a similar model at home, despite structurally equivalent problems with drug retention, preventative care, and clinic to community connection.
What can we learn from this? The first is that maybe it’s time to implement a community health worker model in the US, both because it has the potential to improve health outcomes and also because under the Affordable Care Act there is a financial incentive for clinics and hospitals to engage in such preventative practices (Paul Farmer has actually recently harped on this idea). And the second is that we begin to understand that while there are degrees of scale separating the health challenges faced by certain parts of the developing world and the US that does not mean that the solutions generated abroad are compromised here at home.
In the long history of health work, the vocabulary eventually shifted from international health to global health partly because people recognized that domestic issues were always a part of international challenges. It is essential that we honor that legacy by applying many of the lessons learned far away to our problems here at home. By no means, does that mean we should adopt one-size-fits-all models to global health challenges, because cultural, geographic, political and economic context certainly matters, but it does mean that we start using the ingenuity directed abroad to solve the crisis here at home and vice versa. Development and global health are two way streets despite how much we try to act like our problems are so different than those of developing countries.
The short answer to the question of whether or not to work domestically or internationally should be that we have a responsibility to do both. Luckily that does not mean that one must split their time working on issues at home and those abroad, but rather that the field of global health must harness the genius driving international progress with the genius driving domestic progress and combine them to achieve truly global change. It’s not an easy task but one that we must seriously pursue if we are to achieve any semblance of health equity here or abroad.