Q&A Guidance for Persons Considering a Global Health Career

International Health: Career Options & Specialization

Physicians-in-training considering a possible full- or part-time career in international health (IH) often ask about career opportunities and the need for postbasic training or specialization. This section, prepared for the Global Health Education Consortium (GHEC), seeks to provide some help for answering these questions.

First, a few important and obvious principles:

Consider carefully your motivations for international health work.
There are many reasons for considering IH work. These include: altruism towards disadvantaged peoples; faith-based service to others; the opportunity to learn about and from diverse cultures; travel and adventure; learning new skills; “escape” from perceived problems of the US; improving language skills; and a search for ancestral roots. For most it will be a combination of several reasons, with some more important than others. Many students entered medical training motivated by a desire to help people and certainly IH work will provide them ample opportunity to help those most in need. Approximately 40% of the world’s population lives on less than $2/day and 20% on less than $1/day. To sense the power of comforting suffering and the joy of making a small difference in the lives of the poor, consider reading books such as, The City of Joy by Dominique LaPierre, and Mountains Beyond Mountains by Tracy Kidder. Your own reasons for considering IH work will affect your choices regarding type of work, type of sponsor, and the amount of time you will want to spend in the field. These choices, in turn, will have important bearing on your choice of specialty.

Do not consider a specialty just because it may be more useful in finding a job in IH! Life is too short, you will have already spent many years and much money obtaining your professional degree, and you don’t want to spend additional time and money in a field that is not otherwise of much interest to you.

Use your medical school undergraduate elective options to sample specialties of potential interest. Spend some time with established practitioners in these fields to learn about these fields of practice, their benefits, limitations, and the market for qualified specialists.

Consider the effect of foreign living on your lifetime career plans. Living and working abroad has many life-enriching benefits for both you and your family. Even if your time abroad is limited, it can help you become a better doctor in whatever field you choose enter. However, there are some career risks you should keep in mind. For potential future U.S.-based employers will your time abroad be a plus or a minus as they evaluate your resume? Sadly, unless you choose your position wisely, it could be more the latter than the former. Some jobs in the U.S. will give you “credit” towards advancement for your work overseas, eg, with some government, academic and consultant organizations. For others, however, you may find that on return to the U.S. your peers in the U.S. have advanced farther in their careers than you have. This may not be a serious consideration for those with a strong commitment to IH and who wish to have a lifetime IH career, but is something to think about. If your preference is for just a few years of IH work, and if you want to reach the highest level possible in your chosen career, think about the possible effect of spending time away from the U.S. Will this absence enhance or hurt your reputation and chances for advancement? Can you compensate for your absence through professional publications or periodic returns to the U.S? Would the IH experience more than compensate for a somewhat slower pace of advancement in your primary career? Would it be better to do your IH work early, before your career is well established and then return, or would it be preferable to become well established and then, after your children have left home, to go overseas?

Finally, and to state the obvious, you, and only you can decide what is right for you. However, to help you narrow your range of choices we have listed below frequently asked questions along with possible answers.

International Health Careers
~ A Q&A Session with GHEC ~

• How important is the reputation of my postbasic training institution? — The answer is somewhat different depending on the type of organization you would like to work with. Major U.S. employers (eg, universities, centers, institutes, consultative organizations) and multilateral organization (eg, WHO, World Bank), will likely consider both the reputation of your postbasic training institution and the relevance of your training program to the job position for which you are being recruited. Faculty contacts you make in these first rank institutions can also be very helpful in your search for a job. Most other employers, eg, smaller NGOs, faith-based organizations, and foreign employers will probably give little weight to your training institution. Persons in most foreign countries are not too familiar with the relative reputations of U.S. universities and residencies, and over the long run, your own skills, personality, and performance will be much more important in determining your success than where you received your postbasic training.

• Are short, non-degree or certification programs available to help me prepare for international work? — Most definitely yes! Numerous language immersion programs are available, especially in Spanish, and short pre- and post-graduation courses are available to help prepare physicians for clinical and other aspects of IH. The GHEC website () is a good place to start your search.

• What types of jobs are available in IH? — There are many different options. Major options are listed below along with a qualitative appreciation of the ease of getting a job and typical expectations of prior training and experience. While the total number of health professionals working in IH will likely increase substantially in the future, the increase in jobs for physicians may increase more slowly. Many low income countries now have a substantial medical workforce, there are relatively fewer opportunities for American doctors to do clinical work (except in faith-based NGOs), and a high proportion of the IH jobs call for persons with public health training, with or without a medical degree. The more common fields of work include family planning, maternal and child health, malaria, nutrition, TB and HIV/AIDS. While it would appear that specialization in infectious disease would be an attractive field to work in, adult ID is now mostly concerned with opportunistic infections in the immuno-compromised patient. Pediatric ID can, however, can be more relevant.

International, or multilateral organizations — Examples: WHO, World Bank, UNICEF — These organizations usually require specialization and prior work experience at a progressively responsible level; postgraduate degree training in disciplines such as public health, business, economic, development studies, and social or behavioral sciences is valuable; American citizenship can be an asset for some jobs but may be a liability since these organizations tend to have quotas and the “American” and “industrialized country” slots are often filled. Salaries and benefits are among the best for IH 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 assistance. Short-term consultations with the banks can be lots of fun and they pay adequately; much of the short-term work with WHO will be without honorarium or only with a nominal payment.

Bilateral, governmental organizations — Examples: USAID, DHHS (through the Public Health Service and/or Centers for Disease Control, and the Office of International Health), the Peace Corps, U.S. embassies abroad, and various other national foreign assistance organizations — Job requirements are similar though probably somewhat less demanding than in the case of the international organizations. There will be more opportunities for internships and entry-level positions, especially in the CDC, which offers training (including fourth year U.S.-based electives) in both the U.S. and abroad. Several years of training and service in the CDC’s Epidemic Intelligence Service as an EIS officer would be an especially good way to enter international government service while receiving excellent training in the process. A preventive medicine residency, available at many public health training and service institutions, is another good option. U.S. international aid organizations have tended to contract out many of their activities so direct hires are relatively few and are mainly determined by retirements rather than agency growth. Career positions will have all the joys, relatively good remuneration packages, and sorrows inherent in large agency employment

Academic institutions — Examples: Schools of medicine, nursing and public health — For those interested in academia this is a good option since it provides a home base, opportunities for progression up the academic ladder, and if the right departmental base is found, you can get “credit” for your IH activities. Besides teaching, work options in academic institutions will usually be field research, clinical or public health activities, and/or short consultations abroad in your field of specialty. GHEC has some 300 members from ~60 North and Central American medical schools, and the GHEC website provides a good entry to this resource as regards medical schools.

Not-for-profit non-governmental service organizations — There are many such organizations that fall into several broad categories. Specialized health services and/or training: Examples include many medical specialty societies that hold short-term “service camps” 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. Emergency relief and rehabilitation: Organizations such as Doctors without Borders, 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. Probably non-physicians hold most permanent staff positions, while physicians do much of the short-term work.

For- and not-for-profit consultant organizations — Examples: Management Sciences for Health, John Snow, Inc., University Research Corporation, Family Health International — Recent decades have seen a rapid growth in the number, size and complexity of IH consultant organizations due to the trend toward government contracting for the provision of IH assistance. Such organizations often 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 — Examples: Church World Service; Aga Khan Foundation; Catholic charities; Project Hope; numerous denominational charities and health facilities — Except for short-term assignments, most such organizations will expect you to be a member of the sponsoring denomination. Most jobs with faith-based organizations will be clinical or associated with relief services, and usually offer a pay scale well below usual norms. Some small organizations such as the American Friends Service Committee will have positions for persons irrespective of denomination.

For-profit commercial organizations — Examples: Pharmaceutical and medical equipment companies. — Many such companies market their products and even conduct research in overseas locations. These jobs will be among the best paid but in some cases may result in employees feeling compromised by their need to maximize sales, even when company products are ill-suited to the perceived main health needs of the country.

• What do you want to do in IH? — Do you see yourself primarily working as a “practitioner” or as a “change agent?” Practitioners spend most of their time working one-on-one with patients, while change agents work primarily to change the attitudes, behaviors and practices of organizations or groups of individuals? In real life most persons working in IH combine elements of both roles but where you are on the continuum between one extreme and the other will have important implications for your postbasic training program.

• At what stage in your working career do you want to do your IH-related work? — Early in your career while you and your children, if any, are young? Or later on, after you have become established in your chosen field? Children in their teens are more difficult to move away from friends and classmates, and their educational requirements are more demanding and critical as regards application to college.

• Where do you want to spend most of your IH time? — During your IH career do you primarily want to live overseas, or primarily in the U.S., with short-term (weeks to several months) visits to overseas locations?

• What type of postbasic training is most appropriate? — This will depend on your preferred type of work. Postbasic clinical training will be essential if your primary role is clinical and/or in 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. Either way, some international experience before you start postbasic training will help you determine what type of training will be most relevant to your future career. The two major paths, Clinical Training, and Public Health or Other non-Clinical Training, are outlined below:

(1) Clinical Training

What clinical specialties are most appropriate for IH work? — Anecdotal information suggests that most physicians working in IH are specialized in one of the following fields: family medicine, pediatrics, OB/Gyn, emergency medicine, internal medicine, public health (with many specialties available in this field), and psychiatry/mental health. The fields of internal medicine and pediatrics also offer subspecialization in infectious disease, which can be very useful in some settings. We do not have quantitative information on the distribution by specialty of those actually working in IH, and in any event, this would vary widely depending on the type of work being done. Among the clinical specialties family medicine and emergency medicine offer certain advantages. In both fields you see all patients – young, old, pregnant, medical and surgical – and thus you will have a clinical versatility that is advantageous both overseas and in the U.S. For those considering short IH assignments, emergency medicine has the advantage of a high degree 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. Such arrangements are more difficult in those specialties that emphasize continuity of patient care.

How important is it to have a clinical specialty? To be board certified? — A clinical specialty, including family medicine, will definitely be important if you plan to work primarily in a clinical role, and will probably be essential if you plan to teach and/or return to the U.S. to practice after your international work is complete. Though board certification may not be essential for most non-academic international positions, it is very desirable and indeed many potential employers are likely to give substantial preference to those who are certified in a clinical specialty.

Are there clinical residencies in IH? — Yes, though not a large number. These may be accessed through the GHEC website. 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 IH 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

Will a public health degree increase chances of employment? — The answer is, of course, “it depends.” It depends on what you want to do. For persons engaged in short term IH assignments or who are working primarily as clinicians, a public health degree adds little. However, for substantial IH assignments and for a wide variety of jobs concerned with field research, overseas training, and especially, in jobs concerned with program development, implementation and evaluation, a public health degree can be valuable. The field of concentration will have some bearing on your employability, but probably not as much as the mere possession of a public health degree. This degree gives evidence that you have had basic training in the core disciplines provided by most schools of public health, viz, epidemiology, biostatistics, elements of 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, will probably have limited relevance to the most IH positions.

Which schools of public health offer IH programs? — At least 10 of the 34 accredited schools now offer concentrations in IH, though the programs vary widely in scope, content, and faculty strength. Probably the oldest and largest formal program is in the Dept. of International Health at the Johns Hopkins Bloomberg School of Public Health ( Baltimore, MD). With four distinct IH tracks and more than 100 Masters and doctoral students in that department alone, plus several other departments with substantial international orientation, Johns Hopkins provides an exceptionally strong IH program. 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 their websites (see www.globalhealth-ec.org and www.asph.org/) and catalogs. Most schools now offer a one-year MPH program for those with a prior health degree as compared with their usual two-year program for those coming directly out of college. While this offers health professional graduates with a time and money advantage, it greatly reduces the number of elective and second-level courses that can be taken. Another consideration for those who graduate with a large indebtedness is the cost differential between public and private schools, typically ~$15,000 vs. ~$30,000 per year. Two other training options are: the excellent two-year “Epidemic Intelligence Service” program offered by the Centers for Disease Control; 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 areas of public health concentration are most relevant to IH? — While the specific choice will, of course, depend largely on your job preferences, some general observations may be useful:

Maternal and child health . With more than 50% of developing country populations constituted by reproductive age women and children, this is obviously an important field. It is especially appropriate for pediatricians and Ob/Gyn specialists. For those with a particular interest in women’s issues, reproductive health services are receiving increased attention.

Population / family planning / demography. Some schools combine these fields with MCH while others offer a distinct program. Since many low income country populations are growing at a fast and unsustainable rate, this specialty area is highly relevant to IH.

Epidemiology, biostatistics, and/or communicable / tropical disease. For those interested in research, academic work, or involvement in programs concerned with infectious disease, this specialty can be very useful. All schools offer courses in the disciplines of epidemiology and biostatistics, and a few offer courses in communicable disease and tropical medicine.

Public health administration, management and policy. This broad and increasingly important area of concentration, going under many names, is variously concerned with the program planning, management, evaluation, economics and financing, and policymaking.

Environmental health. Air, water, soil and food contamination are very prevalent in developing countries so this field has much relevance.

Occupational health and safety. Developing country working conditions are often hazardous, and with the increasing use of pesticides, toxic chemicals and industrial machinery, this field is very relevant.

Nutrition. Malnutrition is a major problem in developing countries and hence this discipline is highly relevant. Most schools offer concentrations both in the laboratory research and programmatic aspects of nutrition.

Health education / promotion. Of necessity, most programs have a high educational component so skills in education, the behavioral sciences, and medical anthropology can be very useful.

When should I do my public health training? — Should PH training be during medical school, immediately after graduation or during a year taken mid-residency, or after the residency? There are advantages and disadvantages to each but probably 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. An early MPH year has the several advantages: you are still in the “student mode” and hence it may be psychologically easier to continue with the usual student chores; the benefits of a PH orientation and PH contacts will serve you in good stead as you complete your clinical training; you are less likely to have spouse and child responsibilities to further complicate your life; you won’t have the potential risks of interrupting your postgraduate clinical training, including that of obtaining a leave of absence without penalty; and after completing your public health training you will probably know better what type of IH work you would like to pursue, and hence the most appropriate clinical or other specialization. On the other hand, if you are not yet very sure about either IH as a career or the potential relevance of PH training for what you want to do, a delay may be best. This way you minimize the risk of spending a year of your life and accumulating more debt to get a degree you may not find useful.

What about other types of non-clinical training — There are significant and increasing numbers of health professionals working in IH who have postbasic training, occasionally leading to a degree, in such fields as law, economics, business, education, sociology, psychology, development studies, and medical anthropology. Physicians with training in these other disciplines can make an especially valuable contribution

• Consider when would be the best time to spend a few years overseas? There are several aspects to this important question, including especially those of children, career, and level of commitment to IH. 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 2-3 years of high school you will need to think about possible adverse effects on their education if you continue to remain in a country with a deficient school system. It will also be much harder for them to leave their friends if they have been raised in the U.S. and then are taken abroad during their teens. For careers, you will need to consider your longer-term objectives as noted in a preceding section. Those choosing to absent themselves from the U.S. for several years at a time while on the track of a U.S.-based career not designed around IH may experience slower career progression and/or difficulty finding a job on re-entry. By level of commitment we refer to the importance you attach to IH work. If you have a strong commitment and have already had enough IH experience while a student to know what it is like, then your choice is easy; start working in IH as soon as you can and don’t worry about other considerations. If, however, you are unsure about your degree of interest in IH, try it out soon after completing your studies. After several years of IH work you will either be enthusiastic to the point that you can then decide to plan a career that includes significant IH work, or you will decide that additional IH work is not for you. If you remain enthusiastic, success in your initial international experience will be a powerful assist in getting your next international job because it shows that you can really do it. And if on the contrary you decide that IH work is not for you, your time commitment up to now will have been small, you were at the start of your career, and your several-year delay will not prejudice further advancement.

• Take into account the wishes of your spouse or “significant other.” If you will not be alone in your IH work this is a very important consideration! It is hardly necessary to stress that unless both partners can find fulfillment in the special opportunities, challenges and compromises of foreign living, the partnership will likely run into big trouble. Given all the special problems you will encounter including language, cultural differences, jobs, work permits, separation from friends and family, communications, etc., you need to ensure that you and your partner are in agreement about any potential foreign assignment. Living abroad can be enormously fulfilling for a family, eg, closer bonding, warm friendships, less outside distractions, foreign travel, etc., but the potential for stress is there too. This can especially be 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 an IH career. One additional caution: There are lots of Americans working in IH who have married persons native to the country in which they worked. Many such marriages work out fine, but there are quite a few where in time problems arise due to 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 that exist in America is at special risk. In time early cultural patterning can infuse their way into the relationship such that the American wife finds herself constrained by her husband’s expectations.