Abstract
Global health education and health promotion have the potential to engage students, scholars, and practitioners in ways that go beyond the classroom teaching routine. This engagement in global communities, can range from reflection on continuing deep-seated questions about human rights and civic responsibility to the use of health education and promotion–related theoretical, intellectual, and practical skills. In the arena of global health education and promotion, these skills also range from leadership and advocacy to decision making, critical and creative thinking, teamwork, and problem solving. In recent times, there has been a growing interest in cross-cultural collaborations and educational initiatives to improve stakeholder’s understanding of global health principles and practices, to enrich the experiences of health professionals, and to improve the lives of those who are disenfranchised and live across borders. In this article of Health Promotion Practice, we highlight two unique cases of cross-national collaborations and provide a glimpse of the various shapes and forms taken by cross-cultural educational initiatives for global health education and promotion. We summarize the history, philosophy, and current working practices relevant to these collaborations, keeping in view the global health domains, competencies, and activities. In addition, we also compare the key components and activities of these two case studies from Rwanda and Mexico, wherein communities in these two countries collaborated with academic institutions and health professionals in the United States.
Keywords
Introduction
The increasing cultural, racial, and ethnic diversity in the United States compels the health profession to emphasize cultural understanding as an important educational component in preprofessional and professional training. It is essential that health educators and other health professionals have a clear understanding of the cultures within which they work to be effective educators and health change agents. Global health experiential learning opportunities can provide students with unique opportunities to experience and work with various cultures and to develop cross-cultural awareness, self-confidence, and self-efficacy, leading to potentially enhanced cultural competency. Global service experiential learning initiatives have been shown to influence cultural awareness and culturally sensitive health care for nursing and medical students (Holmes, Zayas, & Koyfman, 2012; Jones, Ivanoff, Wallace, & VonCannon, 2010). The demand for global health education by health science students has greatly increased recently (Global Health Education Consortium, 2012; Khan, Pietroni, & Cravioto, 2010; Khubchandani & Simmons, 2012). Global health education in-country immersion programs have shown to increase awareness of one’s own cultural beliefs, values, and biases; increase understanding of culture and health of the local population; and promote understanding of local cultural nutrition and food traditions, among other benefits (Bill & Tucker, 2004; Gilboy & Bill, 2011). There is a growing need for culturally appropriate student learning experiences to complement university-based global health education.
This article highlights two service-learning global health promotion immersion programs in Rwanda and Mexico organized through two U.S. universities, Thomas Jefferson University (TJU), a private health science university in Philadelphia, Pennsylvania, and San José State University (SJSU), a public state-supported university in San José, California. Though both face different global health challenges, there is a synergy across both programs in their health and social missions and values to provide a sustained, respectful, and equitable relationship with the individuals, communities, and organizations they serve.
Case Study 1: A Student-Led Global Health Promotion Service-Learning Experience—the Rwanda Health and Healing Project
At TJU and Jefferson Medical College, the Department of Family and Community Medicine and the Center for Urban Health (CUH) provide health professional students and residents with opportunities to serve communities at both the local and the global levels through partnerships with community-based organizations. In 2005, the CUH was invited to partner with one such organization, Barefoot Artists (Barefoot Artists, 2012), on the Rwanda Healing Project in Rugerero, a village in Northwest Rwanda, near the border with the Democratic Republic of the Congo. Barefoot Artists is a community-based organization that “works with poor communities around the globe to help people heal and thrive through self-expression and action.” The CUH have been working with Barefoot Artists in North Philadelphia on a multidimensional community building project—The Village of Arts and Humanities (The Village of Arts and Humanities, 2012).
The Rwanda Healing Project began in 2004, as a 2-year multidimensional art project that expanded the boundaries of art as a vehicle for social change. Through the initial stages of the Rwanda Healing Project, it became evident to Barefoot Artists that there was an urgent need for health assessment and programming in the community. In response, the Department of Family and Community Medicine and Jefferson Medical College students created a student organization, Jeff HEALTH (Helping Africans Link to Health), and mobilized a team of faculty and students to design a community health assessment in the Survivors Village in Rugerero (one of the many constructed in 1997 throughout Rwanda by the Rwandan Government to provide housing for people rendered homeless during the 1994 genocide). The goal was to integrate basic public health practice into Barefoot Artist’s holistic philosophy of healing and community building.
In 2006, the first team of TJU medical and nursing students and faculty traveled to Rwanda in order to explore the feasibility of student-driven health projects in the Survivors Village. The overall goals of this initial trip to Rwanda were to (a) provide basic public health hygiene and sanitation training for the Survivors Village, based on input from Barefoot Artist’s staff; (b) further document the needs of community members through key informant interviews and focus groups; (c) evaluate and document health resources currently available through site visits and semistructured interviews; and (d) better understand community health needs in context of the cultural, social, and political history of Rwanda.
Through several months of concentrated community building, resource mapping, and partnership building with established organizations in Rwanda, Jeff HEALTH built the foundation for what has become the student-run, interdisciplinary, public health–oriented Rwanda Health and Healing Project (RHHP). Over the past 7 years, the RHHP has expanded into a second village, Akarambi, and has implemented longitudinal, interdisciplinary programming in health and hygiene, nutrition, village gardens, helminthic prevention, HIV/AIDS education and support groups, and family planning. Most educational activities have been implemented with the assistance of local health committees and use a train-the-trainer model to empower and train community members and ensure program sustainability. Additionally, with initial Jeff HEALTH funding, several income-generating projects have been started, including rabbit rearing, mushroom farming, and beekeeping.
The RHHP has also formed partnerships with two nonprofit organizations, the Mid-Atlantic Chapter of Engineers Without Borders and the Thirst Relief International, to rebuild latrines and improve access to potable drinking water in Rugerero. Finally, through partnership with a Rwandan medical student organization, the Rwanda Village Concept Project (RVCP; http://rwanda-vcp.org), RHHP has worked with the National University of Rwanda to develop an exchange program for Rwandan medical students. To date, Jefferson has hosted 17 Rwandan medical students as part of a 2-month clinical experience during which students attend public health courses, complete observatory clinical rotations in pediatrics and family medicine, make physical diagnosis, and participate in community outreach activities. From its inception, RHHP has created longitudinal, sustainable public health programs that address specific community-identified health needs. To ensure the continuity of community relationships and health projects, new participants are dependent on the collective memory of the organization. Yearly recruitment efforts involve multiple cohorts of Jeff HEALTH participants, who provide a longitudinal perspective of the successes and failures of past and existing projects to inform future efforts.
Since 2011, RHHP has become an important global health experience for Jefferson medical students participating in the recently developed College Within a College program, a 4-year interprofessional primary care cocurricular elective program with education tracks in population health and community health. Through involvement in the College within a College program, students traveling to Rwanda participate in formal didactic training in public health prior to travel and are required to use the problem-solving paradigm in public health to rigorously consider, evaluate, and report on their global health immersion experience in Rwanda. Although RHHP has continued to be a grassroots, student-driven project, the inclusion of the project experience as part of a formal educational curriculum in medicine and public health has strengthened the education and professional value of the immersion experience for participating students.
To prepare for their Rwandan immersion experience, new Jeff HEALTH members, which now include public health and other health science students, form teams based on interest areas, participate in regular meetings with current and past members, and are provided readings on the history, culture, and current health care climate of Rwanda. An essential part of preparation is working with participating Rwandan exchange students while they are on campus. Through activities that facilitate cultural brokerage, new Jeff HEALTH students gain a greater understanding of and appreciation for cultural and social norms in Rwanda prior to arrival. These preimmersion experiences are essential to the goal of providing culturally and socially sensitive health programming across different years of student involvement.
The central mission of the RHHP is rooted in continuity and sustainability with the goal of community independence, with continuous monitoring of existing projects and community empowerment. As with many global health projects, the availability of reliable funding is a continuous challenge. Through an international travel fellowship program at TJU, students can apply for funding for international travel (to date, 59 students have been granted more than $63,000 in funding for travel to Rwanda). In its second year, Jeff HEALTH received 501c status for fund-raising purposes. Jeff HEALTH has also been the recipient of more than $30,000 in local and national grant funding. Although Jeff HEALTH members typically only spend 1 to 2 months in Rwanda during the summer, the organization continuously monitors existing projects through its partnership with the RVCP and its participating Rwandan medical students. RVCP members selected for the Jeff HEALTH exchange program perform monthly visits and assessments of village health and income-generating projects. The continual monitoring of projects by local representatives who help villagers problem solve, address challenges, and recognize opportunities for improvement has been invaluable to the continuity and sustainability of Jeff HEALTH projects and the organizational relationship with the participating villages. The involvement of the RVCP students has also been critical in identifying key community informants and instrumental in providing and facilitating translation services in French and Kinyarwandan.
To date, 65 students from the fields of medicine, public health, nursing, pharmacy, occupational therapy, and physical therapy have traveled to Rwanda as part of Jeff HEALTH and RHHP. The Jeff HEALTH interdisciplinary model of global health has provided participating students with unique and invaluable experiences in the development of global health competencies (Association of Schools of Public Health, 2011). These competencies are summarized in Table 1. Through required postexperience processing, including a formal written report and presentation to the TJU community by all Jeff HEALTH members, the work of Jeff HEALTH is widely disseminated with the goal of continued discourse around the role of interdisciplinary health sciences efforts both at the global level and at the institutional level. A summary of the key aspects of the Rwanda Health and Healing Project is listed in Table 1.
Key Components and Global Health Competencies of Service Learning Health Immersion Programs in Rwanda and Mexico
As the RHHP experience becomes more integrated with a formalized global health curriculum at TJU, there is an increasing emphasis on supporting scholarly activity among returning students. As a result, more students are designing, implementing, and presenting institutional review board–approved research projects related to their work in Rwanda. Developing the research capacity and infrastructure for TJU Jeff HEALTH members and Rwandan RVCP members is an ongoing process involving transnational, cross-institutional, and cross-cultural consideration of feasibility, accountability, and ethics. Although challenging, program evaluation and research are seen as an essential part of professional development for both U.S. and Rwandan students and helps ensure the sustainability and continuity of RHHP’s projects.
In an effort to informally evaluate the impact of the RHHP on student educational and professional development, general outcome data have been collected on all participating members to date. Student participants in the project have entered a variety of fields of medicine, and participants’ career paths have included working for the organization Partners in Health in Rwanda and Haiti, pursuing advanced degrees in public health and global health fellowship training, and developing a resident-driven nonprofit organization for emergency medicine, and ultrasound training in Rwanda (Physicians Ultrasound in Rwanda Education Initiative, 2012). As an organization, Jeff HEALTH is in the process of expanding the RHHP into a sustainable and interdisciplinary opportunity for advanced health profession students, residents, and faculty that focuses on reciprocal education and the integration of current public health initiatives with clinical medicine. Over the past 7 years, RHHP has provided students with a unique, interdisciplinary, community-focused global health immersion experience. With its focus on developing team-based, sustainable programming around public health, economic development, and community empowerment, the project provides the opportunity for students to become involved in an experience that is longitudinal in scope and practice. Individual student experiences become part of the collective organizational experience and its relationship to the partnering Rwandan villages. This feature of the RHHP is a key factor in overcoming the notable challenges facing students participating in global health immersion programs, such as relevant preparation, multiple national and international partners, continuity, language, sociocultural barriers, and sustainability.
Future plans for the RHHP project include the following: (a) continuing to seek opportunities for sustainability, (b) ensuring interdisciplinary students are prepared for the challenges of global work, (c) integrating global health competencies into local and regional projects involving diverse communities such as immigrants and refugees, (d) involving more faculty in developing faculty enrichment activities, (e) consolidating more clinically focused rotation opportunities.
Case Study 2: Intercambio! A Mutual and Sustainable Service Learning Partnership between the Health Science Department of a California Public University and an Artisan Association in a Small Pueblo of Oaxaca, Mexico
The Department of Health Science at SJSU in California and the Association of Ecoalebrijes Artisans of Arrazola, Oaxaca, Mexico, have been engaged in an unusual, unexpected, and thriving health promotion partnership, since 2005. The organizing center of the relationship is the annual Spring Break service-learning trip to Arrazola by 20 to 25 SJSU Health Science students, alumni, and faculty. In the 8 years of this partnership to date, the Intercambio (interchange) has become an integral part of the calendar, rhythm, priorities, and cultures of both SJSU and the Mexican pueblo. How that happened, how this unique design is protected and what it contributes to the emerging mix of health immersion models are discussed below.
SJSU is a large, public university located in the culturally rich and dynamic Silicon Valley. The unique geographic setting and strong campus diversity, particularly with Hispanic and Asian populations, have long placed global citizenship and intercultural understanding in the mission and strategic vision of SJSU. Recently, administrative enthusiasm for international experiences has encouraged faculty and students to explore opportunities for study abroad, faculty-led programs, and alternative spring break service trips. The Intercambio emerged from a faculty member’s interest in potential service-learning sites in Mexico, a seed grant to support an exploratory trip, and unexpected opportunities that can arise from the interaction of people from different cultures and places.
The initial trip included 24 travelers (students and faculty members). The faculty organizer worked with Enlaces Comunitarios (Community Links), a group based in Oaxaca that organized traditional immersion trips for U.S. universities. The Enlaces staff led a remarkable week of site visits for the delegation, introducing travelers to the culture, history, food, environmental commitments, and health concerns of the vibrant yet very poor region around the capital city of Oaxaca. By chance, the community group that had planned to host the delegation overnight had to cancel at the last minute. The Enlaces staff quickly contacted a group of local people to see if they could host 24 Californians in their homes the next day. In less than a day, 12 pueblo families graciously opened their homes to strangers from SJSU. When traveler–host assignments were made through random drawing, the Chair of the SJSU Health Science Department was matched with the Director of the Artisans Association. The friendship, respect, and family connection forged in just 24 hours became the seed that would later form the Intercambio.
The story of this random beginning was critical to the structure and commitments of the binational and bicultural organization. Typically, a service-learning health immersion program brings resources, energy, and skills from the university for a focused period of time to address health needs or priorities in the other country. Faculty and student interests and skills make invaluable contributions to important assessment, research, intervention, and evaluation activities, many of which could not occur without the infusion of outside resources or expertise. The Intercambio, however, was not founded on a Mexican health problem, faculty research interest, or a community-identified need. The two groups met because the SJSU delegation needed a place to stay. That simple but powerful reality established the relationship from the very start as one of equals, born of graciousness, and confident in the power of unplanned experiences informed by shared values and health promotion imagination.
The Mexican hosts were the 18 families of the Association of Ecoalebrije Artisans (Ecoalebrije Artisan Association & The Intercambio, 2012). Alebrijes (see Figure 1) are hand-carved and beautifully painted wooden figures that are made in only a few places in Southern Mexico. The pueblo of Arrazola, a few miles southeast of the city of Oaxaca and at the base of the ruins of the Zapotec civilization’s majestic Monte Alban, is home to many alebrije artisans. With almost no other work available in the area, the art and promotion of the alebrije has become central to the sustainability of economic and family life in this community. Among the many artisans in Arrazola, a small group led by Saúl Aragón formed a collective in 2005 dedicated to the art of the alebrije and sustaining the native copal forest that provides the wood. Families called ecoalebrijes work on the figures—but also work together in ongoing reforestation projects that link their imaginations and formidable artistry to the land. Adults and children work together on the best ways to cultivate the eroded soil, nurture seedlings, and grow new trees to replace those they use for the ecoalebrijes. Their work is progressive, difficult, and, with the first new forest maturing after 7 years, very promising. It was immediately clear that there is much that 21st-century college students and faculty can learn about sustainability, community action, the environment, community organizing, and an expanded definition of health from the people of this pueblo.
Alebrije Made by the Artisans of the Ecoalebrijes Association
The exploratory trip led to the first official service-learning immersion trip. In the spirit of partnership, SJSU worked to secure travel visas for community members to visit us in California before we brought our first group to Mexico. This established that individuals were true partners, equally willing to share their homes, lives, families, and communities. Now, every year in March, a group of 20 to 25 SJSU students and faculty go to Mexico for a week of service, learning, immersion, and reflection in the homes and communities in Arrazola. Each October, 2 to 3 of the Oaxacan colleagues—artisans and sometimes children—also visit SJSU for 2 weeks of service, learning, immersion, and reflection. In January, a small group from SJSU travels to Arrazola to plan the March trip.
During the Intercambio, SJSU students spend a full morning of reforestation work alongside the artisans, composting, clearing brush, planting seeds, transplanting seedlings, or finally putting the small trees into the ground on the slope of Monte Alban. Working alongside the artisan families, the group learns about traditional methods of agriculture, Zapotec sustainability, and the new ideas of the organic farming communities of Oaxaca. Students also work alongside Mexican public health workers from the local health center, inspecting home water storage, taking blood pressures, and vaccinating cats and dogs in the pueblo and outer colonias. Through these activities, they observe extreme differences in rural living conditions, the critical importance of primary prevention, and the low-tech but highly effective ways in which community and personal health data are carefully collected and monitored at the local level. Student teams also work at the Food Bank and spend a day at community-based organizations or children’s service programs, learning outreach, service, and systems change strategies that are conceived of and implemented without formal training or resources.
Building on their health education skills, the SJSU group provides health topic workshops each year in schools in Arrazola and Oaxaca, from kindergarten through adult education. With input from the local health center director and the artisan families, the students prepare interactive workshops and presentations—in Spanish—on topics such as healthy eating, physical activity, hygiene (personal, home, and animal), oral health, sexual health, mental health, depression, contraception, violence prevention, and health literacy.
The reciprocal nature of the Intercambio is evidenced by SJSU’s most ambitious project: the Health Fair. As visiting artisans participated in SJSU’s community-based projects with Mexican immigrant families, they began imagining how they could do there what we do in the United States. The result was the first annual Intercambio Health Fair, in 2010, serving more than 400 child and adult community members, complete with 10 interactive stations on different health topics, with prizes, food, dancing, live music, and local dignitaries. The SJSU team brings the health expertise, the activities, the materials, and the prizes; the Arrazola team provides the outreach and publicity, the food, the tents and chairs, the decorations, and the performers. When the artisans visit SJSU, the Intercambio’s location changes, but the spirit is the same. Students who have travelled to Arrazola host the Mexican colleagues in their own homes, introducing them to their families, cuisines, and daily routines. The artisans provide countless hours of presentations on the art of the alebrije and on environmental sustainability in college and community classrooms. They participate in the SJSU project Salud Familiar en McKinley, where Mexican immigrant families welcome them as returning relatives. Throughout the year, the SJSU team of past and future travelers seeks venues for ecoalebrije demonstrations and exhibitions so that the artisans can reach new markets when they are in California.
Since the beginning, this partnership has resisted the temptation and pressure to organize the Intercambio around a disease or problem in order to attract funding or other support. The organizers prefer instead to keep costs low, travel modestly, and retain control of the purpose, manner, and dynamics of the experience. No student is ever turned away because he or she cannot afford the trip, nor is any artisan who wants to travel to San José denied that opportunity. The Intercambio is supported through selling the alebrijes (Figure 2) and numerous fund-raisers. Indeed, without a health problem to address, a disaster to mitigate, or a research question to pursue, the unique partnership between the pueblo and the university was free to emerge carefully, respectfully, and consistent with the core values of our different settings and traditions. The Intercambio embraces traditional Mexican and Zapotec values of respeto, familia, comunidad, trabajo, tequio, and la naturaleza (roughly—and imperfectly—translated as respect, family, community, work, community service, and nature, respectively) and enduring higher education and health promotion values of self-determination, partnership, lifelong learning, social ecology, equity, cultural humility, and hope.
To date, more than 100 public health and health science students have traveled seven times to Arrazola (25% have returned for at least a second trip), and the partnership has hosted eight trips by artisans to California. Table 1 summarizes some of the key components of the Intercambio service-learning project and the global health domains and competencies it addresses (Association of Schools of Public Health, 2012).
The challenges are those facing any grassroots initiative desiring stability and independence, in this case, the funding and the freedom to travel between the United States and Mexico. The partnership’s history, the intergenerational leadership that has emerged, and the multilayered immersion in each other’s cultural, organizational, and community contexts bode well for the future of this Intercambio.
Conclusions
Immersive learning about global health issues provides an ideal opportunity to engage students, scholars, and communities in addressing existing problems faced by individuals and groups across nations. This requires critical analyses of physical, social, economic, and political factors in the concerned communities. Frequently, immersive learning aimed at developing locally sustainable solutions does not have a targeted strategy or evidence-based best practice, as highlighted by the fluid and dynamic nature of the aforementioned successful interventions in Rwanda and Mexico. In addition, it is also critical for cross-cultural immersive learning experience aspirants to appreciate the value of respecting historical and cultural contexts that surround health related issues in communities of interest that become viable targets for an intervention. In the two cases discussed above, stakeholders used an integrative approach of adapting traditional classroom learning to novel learning strategies with an emphasis on immersive learning, community engagement, and continued rethinking and redesigning of service activities. It can be gathered from the Rwanda and Mexico projects that engaged individuals had a win–win situation: an enriching global health education and promotion experience for U.S. collaborators and a feasible solution to address community problems for individuals in Rwanda and Mexico.