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COVID-19, Racial Injustice, and Medical Student Engagement with Global Health: A Single Institution Survey

Published:November 15, 2022DOI:https://doi.org/10.1016/j.jss.2022.11.020

      Abstract

      Background

      United States (US) medical schools continue to respond to student interest in global health (GH) and the evolution of the field through strengthening related curricula. The COVID-19 pandemic and superimposed racial justice movements exposed chasms in the US healthcare system. We sought to explore the possible relationship between the pandemic, US racial justice movements, and medical student interest in GH to inform future academic offerings that best meet student needs.

      Methods

      A novel, mixed-methods 30-question Qualtrics survey was disseminated twice (May-August 2021) through email and social media to all current students. Data underwent descriptive and thematic analysis.

      Findings

      Twenty students who self-identified as interested in GH responded to the survey. Most (N=13, 65%) were in preclinical training, and half were women (N=10, 50%). Five (25%) selected GH definitions with paternalistic undertones, 11 (55%) defined GH as noncontingent on geography, and 12 (60%) said the pandemic and US racial justice movement altered their definitions to include themes of equity and racial justice. Eighteen (90%) became interested in GH before medical school through primarily volunteering (N=8, 40%). Twelve (60%) students plan to incorporate GH into their careers.

      Conclusion

      Our survey showed most respondents entered medical school with GH interest. Nearly all endorsed a changed perspective since enrollment, with a paradigm shift towards equity and racial justice. Shifts were potentially accelerated by the global pandemic, which uncovered disparities at home and abroad. These results highlight the importance of faculty and curricula that address global needs and how this might critically impact medical students.

      Keywords

      Introduction

      In 2009 Koplan et al. defined global health as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care.”
      • Koplan J.P.
      • Bond T.C.
      • Merson M.H.
      • et al.
      Towards a common definition of global health.
      Given an increasingly globalized and interconnected world, medical students and faculty alike have called for medical training curricula to reflect this evolving context, which will prepare students for diseases and health challenges that cross national borders.
      • Bandyopadhyay S.
      • Thomas H.S.
      • Gurung B.
      • et al.
      Global health education in medical schools (GHEMS): a national, collaborative study of medical curricula.
      • Stigler F.L.
      • Duvivier R.J.
      • Weggemans M.
      • Salzer H.J.
      Health professionals for the 21st century: a students’ view.
      • Martineau F.
      • Johnson O.
      • Rowson M.
      • Willott C.
      • Yudkin J.S.
      International health graduates—career path experience.
      In response to this request, medical schools across the United States (US) increased their focus on ethics training, strengthened partnerships between international schools, and increased exposure to the role of new specialties in global health training, including surgery and anesthesiology.
      • Mehta A.
      • Xu T.
      • Murray M.
      • Casey K.M.
      Medical Student Perceptions of Global Surgery at an Academic Institution: Identifying Gaps in Global Health Education.
      • Tissingh E.K.
      Medical education, global health and travel medicine: a modern student’s experience.
      • Martin B.M.
      • Love T.P.
      • Srinivasan J.
      • et al.
      Designing an ethics curriculum to support global health experiences in surgery.
      The global COVID-19 pandemic and its impact on travel, coupled with the United States (US) racial justice movements, pivoted focus towards domestic health challenges and inequities as the virus exposed huge chasms in the US healthcare system.
      • Azar K.M.J.
      • Shen Z.
      • Romanelli R.J.
      • et al.
      Disparities In Outcomes Among COVID-19 Patients In A Large Health Care System In California.
      In many ways COVID-19 has been a ‘stress-test’ for health systems around the world. In the US, hospitals have been overwhelmed to the point that ambulances have nowhere to deliver patients to,

      Fuller T, Fernandez M. Surging Virus Exposes California’s Weak Spot: A Lack of Hospital Beds and Staff. The New York Times. https://www.nytimes.com/2020/12/01/us/california-hospital-bed-shortage.html. Published December 2, 2020. Accessed December 9, 2021.

      an occurrence all too familiar in many Low- and Middle-Income countries (LMICs).
      • Tansley G.
      • Stewart B.
      • Zakariah A.
      • et al.
      Population-level Spatial Access to Prehospital Care by the National Ambulance Service in Ghana.
      These stresses have changed the way healthcare is provided in both HICs and LMICs, such as increased telemedicine.
      • Monaghesh E.
      • Hajizadeh A.
      The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence.
      ,
      • Miller P.
      • Owolabi E.
      • Chu K.
      We Asked the Experts: The Promises and Challenges of Surgical Telehealth in Low Resourced Settings.
      Although the pandemic has prevented many from engaging in global health through historical pathways like international missions and volunteering to provide direct healthcare and education, in some cases the pandemic spurred increased international cooperation, such as through vaccine development, and advocacy for equitable access to treatment and preventative measures. However in others, COVID-19 has made evident continued glaring inequities between countries such as in vaccine availability and access.
      • Maxmen A.
      The fight to manufacture COVID vaccines in lower-income countries.
      ,

      Vaccine Manufacturing | Launch and Scale Speedometer. Accessed December 9, 2021. https://launchandscalefaster.org/covid-19/vaccinemanufacturing

      Thus, COVID-19 has placed a renewed emphasis on the interconnectedness of our health and the common challenges facing all communities around the world.
      While many have considered the profound impact the pandemic has had on core elements of medical school curricula, little work has been done to assess how COVID-19 has affected how medical students envision their future careers, particularly in global health.
      • Sharma D.
      • Bhaskar S.
      Addressing the Covid-19 Burden on Medical Education and Training: The Role of Telemedicine and Tele-Education During and Beyond the Pandemic.
      ,
      • Nnamani Silva O.N.
      • Hernandez S.
      • Kim A.S.
      • et al.
      Where Do We Go From Here? Assessing Medical Students’ Surgery Clerkship Preparedness During COVID-19.
      COVID-19 has challenged many elements of our health systems and has underscored the need for a medical workforce that is trained in global collaboration and interconnected leadership.
      • Reid M.
      • Abdool-Karim Q.
      • Geng E.
      • Goosby E.
      How will COVID-19 transform global health post-pandemic? Defining research and investment opportunities and priorities.
      In order to better meet the educational needs of students in this changing landscape, we queried medical student global health knowledge and experience prior to and during the COVID-19 pandemic. We also investigated the interplay between the pandemic, US racial justice movements, and student interest in global health, to inform future offerings that best meet student interests. We hypothesized that the pandemic and racial justice movements may have played a role in shaping perceptions of global health among medical students.

      Methods

      This was a cross-sectional study to evaluate perceived definitions of global health and the potential interaction between COVID-19, the US racial justice movements, and global health’s role in medical training and research. Medical students from a single institution were surveyed via an electronic questionnaire after the University of California San Francisco (UCSF) institutional review board (IRB) deemed the study to be exempt. We received a waiver of signed consent from the IRB and communicated the research purpose of the survey through our recruitment materials, and respondents consented to participate in the study by electing to proceed with the survey via the provided link. All surveys were de-identified and both quantitative and qualitative data were collected.
      A novel 30-question survey, informed by a previous global health interest survey
      • Jayaraman S.P.
      • Ayzengart A.L.
      • Goetz L.H.
      • Ozgediz D.
      • Farmer D.L.
      Global Health in General Surgery Residency: A National Survey.
      with adaptations to reflect current interactions between health and racial inequities, was developed to evaluate medical student understanding of and participation in global health. Students answered a variety of multiple choice, true/false, and free-text questions.
      The survey was piloted with a cohort of UCSF medical students and a global health department administrator, who provided written feedback regarding question clarity, survey content, and completeness that was subsequently incorporated. Upon completion of this cycle, all pilot participants reported that the revised survey was easy to comprehend and adequately addressed the intended topic of medical student understanding of and interest in global health.
      The survey was administered from June to August 2021. Recipients were actively enrolled UCSF School of Medicine students, which included gap year and research students. Pre-clinical students were in their first two years of medical school before beginning their clinical rotations. Clinical students were in the latter two years of medical school. The survey was distributed three times via email to all relevant UCSF listservs and shared once on an exclusive UCSF medical student Facebook group, which have significant overlap. In total, 715 students were actively enrolled at the time of survey dissemination. Our target population was students who self-identified as interested in global health. Global health interest is not routinely measured at UCSF but is estimated to be approximately 20 students per year based on UCSF global health elective enrollment data. Based on this estimate, we believe our target population was approximately 80 students, with a survey response rate of 25%. Participation in the survey was voluntary and anonymous. The survey and recruitment materials are included in the supplement.
      Data underwent descriptive and thematic analysis. Quantitative results underwent descriptive analysis to examine proportions by demographic characteristics. Non-responders to individual questions were excluded from the analysis of those questions. Anonymous free-text responses were read by two of seven authors (PM and RL) who familiarized themselves with the responses and undertook open coding of all responses. Authors (PM and RL) met to agree on a series of thematic codes that described several categories and subcategories.

      Strauss A, Corbin J. In: Corbin J, Editor. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage Publications; 1998.

      Results

      Twenty students responded to the survey, with an even distribution between men and women (50%, N=10, respectively) and the majority in the preclinical phase of training (65%, N=13). Most identified as Asian or Pacific Islander (30%, N=6), and many planned to specialize in either Internal Medicine (25%, N=5) or General Surgery (20%, N=4) (Table 1). Nearly all respondents (90%, N=18) became interested in global health before medical school, and the most common initial exposure was volunteer experiences (40%, N=8) (Table 2). Despite the pandemic, many students still planned to incorporate global health into their careers (60%, N=12).
      Table 1Demographics and Characteristics of Survey Respondents
      N (%)
      Phase of Training(N=20)
       Pre-clinical13 (65%)
       Clinical2 (10%)
       Research5 (25%)
      Gender Identity
       Male10 (50%)
       Female10 (50%)
      Race/Ethnicity
       Asian or Pacific Islander6 (30%)
       Black or African American1 (5%)
       Hispanic or Latino2 (10%)
       White or Caucasian5 (25%)
       Multiracial or Biracial5 (25%)
       Other1 (5%)
      Intended Specialty
       Emergency Medicine2 (10%)
       General Surgery4 (20%)
       Internal Medicine5 (25%)
       OBGYN2 (10%)
       Pediatrics2 (10%)
       Other2 (10%)
       Undecided2 (10%)
      Table 2Exposure to and Experience in Global Health
      N=20
      N (%)
      Time of Initial Interest in Global Health
       High school or before10 (50%)
       College6 (30%)
       Gap year2 (10%)
       Medical school1 (5%)
       Other1 (5%)
      Initial Exposure to Global Health
       Volunteer8 (40%)
       Work2 (10%)
       Research2 (10%)
       Study abroad2 (10%)
       Family/personal4 (20%)
       Other2 (10%)
      Avenues for Learning about Global Health
      • Martineau F.
      • Johnson O.
      • Rowson M.
      • Willott C.
      • Yudkin J.S.
      International health graduates—career path experience.
       Student-led10 (50%)
       Medical School Faculty-led17 (85%)
       Non-Medical School Faculty-led4 (20%)
       Public Health Faculty-led5 (25%)
       Research Project11 (55%)
      Plans to Incorporate Global Health into Career
       Strongly or Somewhat Agree12 (60%)
       Neither Agree nor Disagree6 (30%)
       Strongly or Somewhat Disagree2 (10%)
      Notes:4.Participants could select more than one option; therefore, totals exceed 100%.
      Once in medical school, students transitioned to more academic engagement with global health frequently through research, which took place during the summer between first and second year (60%, N=12), during dedicated fourth year research time (15%, N=3), and/or as part of a master’s or external degree (35%, N=7). Cumulatively participants identified 30 discrete global health related research experiences during medical school from 2019-2021, 23% (N=7) of which were conducted internationally. Of the projects that were ongoing at the onset of COVID-19 (N=25), 32% (N=8) were impacted by the pandemic by an inability to travel (50%), change in research question (38%), or difficulty planning with community partners (12%) (Table 3).
      Table 3Global Health Experiences and Impact of COVID-19
      Research during Medical School5Research for a Thesis or External DegreeClinical Electives
      N (%)N (%)N (%)
      Experience Pre-COVID41Not assessed
       Domestic2(50%)0Not assessed
       International2(50%)1(100%)Not assessed
      Experience During COVID19619
       Domestic17 (89%)6 (100%)Not assessed
       Affected by COVID6(35%)1(17%)5(26%)
       International4 (21%)0Not assessed
       Affected by COVID2 (50%)0Not assessed
      Notes:5Participants could designate an experience as domestic and/or international, therefore, total exceeds 100%

      Domain 1: Definitions of global health

      Theme 1: Global Health means bringing expertise to low-income settings

      Respondents described global health as an act of providing services to those in need. One described global health as “[the] alleviation of suffering from health on a societal and international level in a culturally competent manner” (Asian/Pacific Islander Preclinical Male). Another participant wrote that “[global health means] distributing high quality medical services to patients who live in underserved areas or who are underserved for other reasons” (White Research Male).

      Theme 2: Low-resource settings within both low- and high-income countries

      We observed a range of perspectives on whether low-resourced settings within high income countries were part of respondents’ definitions of global health. One respondent wrote that “[global health is] health around the world, with a particular emphasis on health in underdeveloped nations” (Hispanic/Latino Preclinical Male). Similarly, another respondent described global health as “thinking and working towards improving the health of those in LMIC[s]” (Black/AA Preclinical Female). While others described global health as inclusive of local disparities and as noncontingent on geography. Statements for this theme focused on infrastructure: “[Global health is the] practice of medicine that believes everyone, regardless of geography or nationality, deserves access to quality healthcare, and endeavors to provide it by engaging in transnational information and resource sharing” (White Clinical Male). Similarly respondents placed global health on a continuum of capacity building in low-, middle- and high-income countries: “[Global health means] addressing health inequities on the global scale, distributing resources and expertise and helping to build local capacity in places that have inadequate healthcare infrastructure” (White Research Male) and “[Global health] is healthcare without regard for national boundaries” (Black/White Biracial Preclinical Female).

      Theme 3: Global health involves interconnected international public health responses

      One respondent acknowledged that “[Global health means] practicing medicine and formulating public health responses with acknowledgement of internationally connected systems” (Multiracial or Biracial Research Male). Other respondents noted that global health encompasses evolving dynamics and partnerships: “[Global health is] health and wellness within a global context, taking into consideration shifting cultural and social dynamics” (Asian or Pacific Islander Clinical Male) or “[Global health is] health and healthcare provision, infrastructure, and research in any non-domestic setting, which means that global health in the US means something slightly different than it does in France or Vietnam” (White Research Female).

      Domain 2: The potential role of the pandemic and US racial justice movements in shaping students’ perceptions of global health.

      Theme 4: Global Health refers to the connectivity of health systems and their dependence on each other regardless of geography

      Some respondents shifted their perspectives due to inequities in vaccine distribution: “I've definitely thought more about vaccine distribution and how healthcare in one country can impact other countries when there are limited resources” (Black/AA/White/Biracial Preclinical Female). A separate respondent wrote: “Global health now includes a broader definition of policy and resource allocation. The vaccine distribution is an example of how having poor global health policy and unequal distribution of resources can affect the health of many” (Black/AA Preclinical Female). But many focused on our collective connectivity in the wake of the pandemic: “[The] pandemic has made it clearer than ever that our individual health depends upon our collective health” (White Clinical Male). Similarly the theme of borderless health equity is inclusive of all resource deprived communities: “I’ve realized that “global health” encompasses domestic health, as well - so global health now [includes] the health (and healthcare infrastructure provision etc […]) of the entire global interrelated system” (White Research Female). Global health is interconnected with domestic health: “[I have] more recognition that the "global health" perspective can be applied within the United States and within San Francisco” (White Research Male).

      Theme 5: Global Health encompasses the consequences of systemic racial oppression and health injustices.

      One respondent observed that “anti-racist movements helped [to] shed more light on violence and systematic oppression inherent [to] the settler-colonialist past of so many of the industrialized nations, including the US, and that racism [and] poverty [are] feature[s] of this system” (White Clinical Male). Another respondent wrote “Anti-racism and anti-oppression impact community health, both mentally and physically. I …now pay more attention to discrimination, racism, and oppression as a public health risk” (Hispanic/Latino Preclinical Male). The relationship between racial justice and health justice emerged during the pandemic because of stark health disparities: “[I] think the recent pandemic and highlighting of racial inequities helps me to remember to include in my definition the interactions between nations and between groups of differing power and with differing access to resources” (White Research Male).

      Discussion

      Our aim was to describe definitions of global health amongst medical trainees and to identify the potential association between the COVID-19 pandemic and recent US racial justice movements on perceptions of global health and its role in medical education. We found that students remained interested and committed to global health, and that prior to the pandemic, medical school represented an important opportunity to pivot from a volunteerism mindset to a more academic or research focused approach. Two domains with five thematic subgroups emerged from our analysis. We found some students retained limited definitions of global health as bringing expertise to other countries. However, many others considered global health to be a continuum focused on addressing local disparities, which seemed to derive from and connect to how racial disparities and COVID-19 impacted their definitions. The diversity in responses from students at the same institution highlights the potential variability that still exists in how people define global health.
      The dual challenges of racial injustice and a global pandemic have not deterred medical students' interest in global health. We hypothesized that in the same way COVID-19 has disrupted medical education, shifting classes online and limiting away rotations, engagement in global health would seem less feasible to students. Rather, we found students continue to want future careers in global health, consistent with pre-pandemic interest and the increased demand over the past decade for medical schools to provide more global health education.
      • Drain P.K.
      • Primack A.
      • Hunt D.D.
      • Fawzi W.W.
      • Holmes K.K.
      • Gardner P.
      Global health in medical education: a call for more training and opportunities.
      The continued interest reflected in our survey spanned stages of training, gender identities, racial and ethnic backgrounds, and career interests, which may mirror the increased inclusion and diversity of global health, such as welcoming specialties like surgery and anesthesiology. However, the pandemic and US racial justice movements challenged some respondents’ prior perceptions of global health. Interestingly, more respondents cited racism as the primary driver of their shifting definition of global health; many cited racial justice as synonymous with health justice. Vaccine distribution was also cited as an important example of health inequity both globally and domestically, which was a shift in perspective for many respondents. The pandemic expanded their understanding of global health from an isolated international experience to include local phenomena
      • Galvin S.
      • Neubauer L.C.
      • Leonard W.R.
      • Doobay-Persaud A.
      Reassessing Global Health Education in the Age of COVID-19.
      and perhaps strengthened interest in studying and integrating global health into their clinical, pre-clinical, and research curricula.
      However, many students faulted the pandemic for causing a gap in global health education rather than a reimagination of how students might engage, with some needing to modify their research projects or cancel international clinical rotations. Rabin et al. noted how the COVID-19 pandemic has highlighted the importance of bidirectional educational exchange and the inter-reliance of HIC and LMIC health systems, arguing that this pause in typical global health engagement was an opportunity to reexamine educational relationships with partner institutions.
      • Rabin T.L.
      • Mayanja-Kizza H.
      • Barry M.
      Global Health Education in the Time of COVID-19: An Opportunity to Restructure Relationships and Address Supremacy.
      The demand and funding for US-based students to visit partners in LMICs has grown quickly but does not always align with partner priorities, needs, and preferences. Similarly, the reciprocity for LMIC partner engagement at US-based institutions is far from equitable.

      Crane JT. Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science. Cornell University Press; 2013. doi:10.7591/9780801469060

      LMICs are seeking more opportunities and more equitable experiences for their trainees. One existing example, provided by Weine et al. is collaboration between students in the University of Illinois at Chicago Global Medicine program and the Federation of African Medical Students’ Associations who jointly developed an online intervention for mental health and psychosocial support.

      Weine S, Bosland M, Rao C, et al. Global Health Education Amidst COVID-19: Disruptions and Opportunities. Ann Glob Health. 87(1):12. doi:10.5334/aogh.3088

      Using this break as an opportunity to ensure mutually beneficial goals and contributions are established could be critical to improving the quality and equity of global health partnerships going forward.
      • Adams L.V.
      • Wagner C.M.
      • Nutt C.T.
      • Binagwaho A.
      The future of global health education: training for equity in global health.
      While students described the pandemic limiting travel and closing doors to certain activities, it conversely opened a promising window for global health curricula and engagement with the expansion of virtual tools. Investing in online platforms might facilitate the creation of more accessible, formalized global health curricula that can be incorporated into medical didactics and protected education time, while also enabling global health departments with similar goals to join.
      • Sherif Y.A.
      • Hassan M.A.
      • Thuy Vu M.
      • Rosengart T.K.
      • Davis R.W.
      Twelve Tips on enhancing global health education in graduate medical training programs.
      The opportunity to develop novel online curricula is a chance to pivot towards more ethics training and evidence-based methods of global health engagement.
      • Adams L.V.
      • Wagner C.M.
      • Nutt C.T.
      • Binagwaho A.
      The future of global health education: training for equity in global health.
      ,
      • Merchant A.I.
      • Walters C.B.
      • Valenzuela J.
      • McQueen K.A.
      • May A.K.
      Creating a Global Acute Care Surgery Fellowship to Meet International Need.
      These well-established recommendations for enhanced global health education could be more aptly mobilized during this period where global travel has decreased but students want to continue to engage in this work.
      Our study was limited by a small sample size, however the size of the target population is not routinely quantified, preventing the calculation of a precise response rate. This small sample size might reflect an overall diminished interest in global health or a core group of global health focused students who were highly motivated to participate in this study. Additionally, as a single-institution survey at a US medical school, our results were constrained to the perspectives of US medical students, potentially limiting external validity. Our qualitative analysis may also be limited by self-selection bias and the potential bias of researcher perspectives, although two separate reviewers met to agree on themes and sub-themes to mitigate this. Despite these limitations, our findings are congruent with themes emerging in current global health and medical education literature, suggesting they can be extrapolated more broadly. We also anticipate further studies on student perceptions of global health, ideally both in the US and abroad, to add to our findings.

      Conclusions

      Our study found that the dual forces of a global pandemic and racial justice movement provided a unique opportunity for global health education. The 2021 Black Lives Matter protests, rising in the wake of the deaths of George Floyd and many others, created space for medical students and educators interested in global health to grapple with a history of racism and colonialism that continues to permeate the field to this day.

      Weine S, Bosland M, Rao C, et al. Global Health Education Amidst COVID-19: Disruptions and Opportunities. Ann Glob Health. 87(1):12. doi:10.5334/aogh.3088

      The pandemic simultaneously revealed inequities not only in the US, where there was a greater impact on lower socioeconomic status communities and racial minorities, but also across the world, where there have been disparities in access to resources such as medical supplies and vaccines.
      • Maxmen A.
      The fight to manufacture COVID vaccines in lower-income countries.
      ,
      • Antúnez-Montes O.Y.
      • Escamilla M.I.
      • Figueroa-Uribe A.F.
      • et al.
      COVID-19 and Multisystem Inflammatory Syndrome in Latin American Children: A Multinational Study.
      While our survey showed COVID-19 forced many engaged with global health both clinically and through research to either change or restrict their focus, most survey respondents also endorsed a perspective change as a result of the pandemic. We found that for many medical students, the societal effects of the pandemic catalyzed a shift to a ‘global is local mindset’
      • Hinchman A.
      • Ali D.
      • Goodwin B.W.
      • Gillie M.
      • Boudreaux J.
      • Laborde Y.
      Global Health Is Local Health: A Multidisciplinary Perspective of COVID-19.
      rather than stymying it. We propose that global health educators seize upon this enhanced focus to make necessary changes to global health curricula and engagement that focuses on true equity, inclusion, and bilateral benefit, regardless of geography.

      Disclosure

      The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article

      Author Contributions

      Phoebe Miller: Developed and tested survey tools, oversaw data analysis and primarily responsible for manuscript writing, Ruth Laverde: Contributed to the development and testing of survey tools, data analysis and manuscript writing, Avery Thomas: Contributed to the development and testing of survey tools, data analysis and manuscript writing, Paul Park: Contributed to the development and testing of survey tools, data analysis and manuscript writing, Doruk Ozgediz: Provided substantial feedback on survey tool and manuscript writing, Marissa Boeck: Senior and corresponding author, provided substantial feedback on survey tool, data analysis and manuscript writing

      References

        • Koplan J.P.
        • Bond T.C.
        • Merson M.H.
        • et al.
        Towards a common definition of global health.
        The Lancet. 2009; 373: 1993-1995https://doi.org/10.1016/S0140-6736(09)60332-9
        • Bandyopadhyay S.
        • Thomas H.S.
        • Gurung B.
        • et al.
        Global health education in medical schools (GHEMS): a national, collaborative study of medical curricula.
        BMC Medical Education. 2020; 20: 389https://doi.org/10.1186/s12909-020-02315-x
        • Stigler F.L.
        • Duvivier R.J.
        • Weggemans M.
        • Salzer H.J.
        Health professionals for the 21st century: a students’ view.
        The Lancet. 2010; 376: 1877-1878https://doi.org/10.1016/S0140-6736(10)61968-X
        • Martineau F.
        • Johnson O.
        • Rowson M.
        • Willott C.
        • Yudkin J.S.
        International health graduates—career path experience.
        The Lancet. 2012; 379: 2051-2052https://doi.org/10.1016/S0140-6736(12)60893-9
        • Mehta A.
        • Xu T.
        • Murray M.
        • Casey K.M.
        Medical Student Perceptions of Global Surgery at an Academic Institution: Identifying Gaps in Global Health Education.
        Acad Med. 2017; 92: 1749-1756https://doi.org/10.1097/ACM.0000000000001832
        • Tissingh E.K.
        Medical education, global health and travel medicine: a modern student’s experience.
        Travel Med Infect Dis. 2009; 7: 15-18https://doi.org/10.1016/j.tmaid.2008.12.001
        • Martin B.M.
        • Love T.P.
        • Srinivasan J.
        • et al.
        Designing an ethics curriculum to support global health experiences in surgery.
        Journal of Surgical Research. 2014; 187: 367-370https://doi.org/10.1016/j.jss.2013.06.013
        • Azar K.M.J.
        • Shen Z.
        • Romanelli R.J.
        • et al.
        Disparities In Outcomes Among COVID-19 Patients In A Large Health Care System In California.
        Health Aff (Millwood). 2020; 39: 1253-1262https://doi.org/10.1377/hlthaff.2020.00598
      1. Fuller T, Fernandez M. Surging Virus Exposes California’s Weak Spot: A Lack of Hospital Beds and Staff. The New York Times. https://www.nytimes.com/2020/12/01/us/california-hospital-bed-shortage.html. Published December 2, 2020. Accessed December 9, 2021.

        • Tansley G.
        • Stewart B.
        • Zakariah A.
        • et al.
        Population-level Spatial Access to Prehospital Care by the National Ambulance Service in Ghana.
        Prehospital Emergency Care. 2016; 20: 768-775https://doi.org/10.3109/10903127.2016.1164775
        • Monaghesh E.
        • Hajizadeh A.
        The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence.
        BMC Public Health. 2020; 20: 1193https://doi.org/10.1186/s12889-020-09301-4
        • Miller P.
        • Owolabi E.
        • Chu K.
        We Asked the Experts: The Promises and Challenges of Surgical Telehealth in Low Resourced Settings.
        World J Surg. September 26, 2021; (Published online)https://doi.org/10.1007/s00268-021-06318-7
        • Maxmen A.
        The fight to manufacture COVID vaccines in lower-income countries.
        Nature. 2021; 597: 455-457https://doi.org/10.1038/d41586-021-02383-z
      2. Vaccine Manufacturing | Launch and Scale Speedometer. Accessed December 9, 2021. https://launchandscalefaster.org/covid-19/vaccinemanufacturing

        • Sharma D.
        • Bhaskar S.
        Addressing the Covid-19 Burden on Medical Education and Training: The Role of Telemedicine and Tele-Education During and Beyond the Pandemic.
        Front Public Health. 2020; 8589669https://doi.org/10.3389/fpubh.2020.589669
        • Nnamani Silva O.N.
        • Hernandez S.
        • Kim A.S.
        • et al.
        Where Do We Go From Here? Assessing Medical Students’ Surgery Clerkship Preparedness During COVID-19.
        J Surg Educ. 2021; 78: 1574-1582https://doi.org/10.1016/j.jsurg.2021.01.010
        • Reid M.
        • Abdool-Karim Q.
        • Geng E.
        • Goosby E.
        How will COVID-19 transform global health post-pandemic? Defining research and investment opportunities and priorities.
        PLOS Medicine. 2021; 18e1003564https://doi.org/10.1371/journal.pmed.1003564
        • Jayaraman S.P.
        • Ayzengart A.L.
        • Goetz L.H.
        • Ozgediz D.
        • Farmer D.L.
        Global Health in General Surgery Residency: A National Survey.
        Journal of the American College of Surgeons. 2009; 208: 426-433https://doi.org/10.1016/j.jamcollsurg.2008.11.014
      3. Strauss A, Corbin J. In: Corbin J, Editor. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage Publications; 1998.

        • Drain P.K.
        • Primack A.
        • Hunt D.D.
        • Fawzi W.W.
        • Holmes K.K.
        • Gardner P.
        Global health in medical education: a call for more training and opportunities.
        Acad Med. 2007; 82: 226-230https://doi.org/10.1097/ACM.0b013e3180305cf9
        • Galvin S.
        • Neubauer L.C.
        • Leonard W.R.
        • Doobay-Persaud A.
        Reassessing Global Health Education in the Age of COVID-19.
        Academic Medicine. 2021; 96e20https://doi.org/10.1097/ACM.0000000000003879
        • Rabin T.L.
        • Mayanja-Kizza H.
        • Barry M.
        Global Health Education in the Time of COVID-19: An Opportunity to Restructure Relationships and Address Supremacy.
        Acad Med. 2021; 96: 795-797https://doi.org/10.1097/ACM.0000000000003911
      4. Crane JT. Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science. Cornell University Press; 2013. doi:10.7591/9780801469060

      5. Weine S, Bosland M, Rao C, et al. Global Health Education Amidst COVID-19: Disruptions and Opportunities. Ann Glob Health. 87(1):12. doi:10.5334/aogh.3088

        • Adams L.V.
        • Wagner C.M.
        • Nutt C.T.
        • Binagwaho A.
        The future of global health education: training for equity in global health.
        BMC Med Educ. 2016; 16: 296https://doi.org/10.1186/s12909-016-0820-0
        • Sherif Y.A.
        • Hassan M.A.
        • Thuy Vu M.
        • Rosengart T.K.
        • Davis R.W.
        Twelve Tips on enhancing global health education in graduate medical training programs.
        Medical Teacher. 2021; 43: 142-147https://doi.org/10.1080/0142159X.2020.1762033
        • Merchant A.I.
        • Walters C.B.
        • Valenzuela J.
        • McQueen K.A.
        • May A.K.
        Creating a Global Acute Care Surgery Fellowship to Meet International Need.
        Journal of Surgical Education. 2017; 74: 780-786https://doi.org/10.1016/j.jsurg.2017.01.012
        • Antúnez-Montes O.Y.
        • Escamilla M.I.
        • Figueroa-Uribe A.F.
        • et al.
        COVID-19 and Multisystem Inflammatory Syndrome in Latin American Children: A Multinational Study.
        The Pediatric Infectious Disease Journal. 2021; 40: e1https://doi.org/10.1097/INF.0000000000002949
        • Hinchman A.
        • Ali D.
        • Goodwin B.W.
        • Gillie M.
        • Boudreaux J.
        • Laborde Y.
        Global Health Is Local Health: A Multidisciplinary Perspective of COVID-19.
        Ochsner J. 2020; 20: 123-133https://doi.org/10.31486/toj.20.0059