 Good afternoon, on behalf of the McLean Center for Clinical Medical Ethics, the Department of Obstetrics and Gynecology, and the Bucksbaum Institute, I'm delighted to welcome you to our ninth lecture in the 2016-17 series on reproductive ethics. It is now my pleasure to introduce today's speaker, Tim Johnson. Dr. Johnson is the Bates Professor of the Diseases of Women and Children at the University of Michigan, where he is the Chair of the Department of Obstetrics and Gynecology. Dr. Johnson received his MD at the University of Virginia School of Medicine at his residency at Michigan and completed a fellowship in maternal fetal medicine at Johns Hopkins. Dr. Johnson is active in international teaching and training with a particular focus in Ghana and is an honorary fellow of the West African College of Surgeons, an honorary fellow of the Ghana College of Physicians and Surgeons, and an honorary fellow of the International College of Surgeons. Dr. Johnson is the author of more than 300 articles, chapters, and books, has served on numerous editorial boards, study sections, professional committees, societies. Dr. Johnson is an elected member of the Institute of Medicine of the National Academy of Sciences. In 2005, Dr. Johnson was awarded the Distinguished Service Award, the highest honor of ACOG. He's past president of the Association of Professors of Gynecology and Obstetrics, editor of the Association of Professors of Gynecology, of the Journal of Professors of Gynecology and Obstetrics, and the editor of the International Journal of Gynecology and Obstetrics. Recently, Dr. Johnson received the University of Michigan's Leadership Award for Support of Women in Health Care. Today, Dr. Johnson's talk is entitled, as you see behind me, Global Women's Health Ethics, Academic Engagement in Global Health. It is the light to welcome Tim Johnson. Tim. Thank you very much. It's my pleasure to be here today. And I'm going to be talking about a responsible academic engagement in global health. Why this relates to women's health is that globally women's health issues are often major issues in societies, that maternal mortality, infant mortality, long-term issues in women's health, HIV, the disproportionate burden that women have with both infectious and non-infectious chronic diseases across the world, makes women's global health really one of the central issues in global health entirely. And what I want to talk about today is my personal journey through this topic. As a faculty member at the University of Michigan, I have to say that I have no specific conflict of interest. I'm going to talk a little bit about a postgraduate training program that we established in Ghana in 1989 that was funded for several years by the Carnegie Corporation of New York. I'm going to talk about a grant that was funded by the Gates Corporation. And we currently have a large center for reproductive health in the Department of OBGYN that's funded by a generous grant from an anonymous private foundation. So in terms of thinking about global women's health, I'm going to be talking about clinical issues and educational issues in global health and also about leadership in academic global health. And specifically today I'm going to be focusing on the academy in scholarship and leadership and I'll be talking more about those later. I'm not going to be talking at all about kind of the conduct of research in the global health environment. That's an entirely different several-hour talk about how one engages ethically in research in low-income countries and with cultural disparities and financial disparities. And while it's an important topic, today I'm going to be really talking about educational activities and clinical activities. So I think there's, for me at least, there's several frameworks to think about global women's health and I'm informed by kind of my personal journey. I've been, in addition to being a professor in the medical school for the last 23 years, I've had an appointment in the Department of Women's Studies at the University of Michigan. In fact, I was the first man to have an appointment in the Department of Women's Studies. And the Women's Studies Department at the University of Michigan is one of the outstanding women's studies departments in the country. It was very interesting being the first man and facing some interesting interactions, I would say. I guess discrimination would not be the right word. But it was very uncomfortable both for me and for the 50-some women in the Department when I went to the first faculty meeting. And so in my academic career, I've been able to face reverse discrimination in some interesting ways that I think have informed my journey. Because I've been teaching a Women's Studies course to undergraduates for 23 years, I've spent a lot of time thinking about feminist theory and feminist practice and clearly those initiatives have had a major influence on my thinking. So I'm going to talk a little bit about women's studies and how the issues of women's studies frame a discussion around global women's health ethics. Then I'm going to talk a little bit about a topology of global health, then describe why me an obstetrician gynecologist and a high-risk obstetrician is allowed to come to this distinguished group and a little intimidating here to sit in front of Mark Siggler and talk about ethics. Why should I even have the temerity to do that? And I guess I'm comfortable because I'm going to be describing a personal journey that has been increasingly through time but increasingly recently been fraught with issues around ethics. I'm going to talk a little bit about my personal journey in Ghana and talk about a charter for collaboration that was really an ethical construct that we were engaged in with as part of the Ghana partnership. And I'm going to end with what I'm going to be describing as ethically informed academic engagement in global health and that's important because more and more universities are being involved in global health. We were having dinner last night talking about the University of Chicago's engagement in global health. Everybody who's applying to college in 2016, everybody who's applying to medical school in 2016 is interested in doing global health as part of their lives. And we as faculty and we as administrators need to kind of address this issue with our students and think about how are we going to meet this need. This year it's estimated that somewhere around 70% of the graduates of the University of Michigan will have done at least one year in some type of a global engagement during their four years of medical school. And we were joking the other day that at least half of the incoming freshmen had started at NGO as an undergraduate. And unless you've started at NGO, you're really not competitive to get into medical school in 2016, which is really not too far from the truth. So in terms of thinking about women's health from a feminist perspective, obviously today we're going to be talking about women's health and gender as a category of analysis becomes really important. But obviously the feminist insights that it's not just about gender, but other disparities that have to do with race and ethnicity and class and intersectionality are important issues. And for me at least, having become comfortable talking about race and ethnicity in class, when one starts doing global health, one starts dealing with issues of tribalism and other kinds of disparities that are culturally real in low income countries. Global health is an important issue obviously from a feminist perspective. And has informed my thinking as I became engaged in global health. And finally, reproductive justice as a description of kind of feminist approach has been increasingly important. We have at Michigan a center for the study of sexual or study for the center for sexual rights and reproductive justice. And I have six faculty members in my department who are MD, JDs, MD, PhDs, MD, MPHs, JD, masters and ethics who are engaged in a discussion around sexual rights and reproductive justice. And specifically around this concept of reproductive justice which has defined as allowing women to make decisions about when to have a baby, when not to have a baby. And to allowing individuals and partners to parent children with the necessary social support to be safe and work in healthy communities without fear of violence. And I think we're gonna be hearing a lot about reproductive justice as a thought in the next four to five years. As I think of doing analysis from a women's health perspective and so I mean, thinking of how kind of feminist theory and feminist practice works. And many of you in this room are used to doing an ethical analysis of a problem. And for me at least I begin with a feminist analysis before I can do an ethical analysis and before I can do other kinds of things. And so we end up with these matrices of perspectives. From a feminist point of view, obviously looking at who's been left out, who's been included, analyze our own relationships to those kinds of issues. What does it feel like to be the first man in the women's studies department? What does it feel like to be a marginalized group in a larger society? Issues with women's agency, the social construction of gender. Especially how gender affects power relationships. And I think most importantly for me, feminist analysis and feminist theory has allowed me to think of power relationships in a different way. And as I start talking about high income, low income, middle income countries, the power relationship between institutions and individuals in high income countries compared to the people they're trying to partner with in low and middle income countries gives pretty significant. There are intellectual power differences. There are academic power differences. There are economic power differences. And so this disparity in terms of the agency of individuals and institutions between high and low income countries becomes something very important as we start talking about global health. I mean, we now think about these power disparities in communities in the United States, but suddenly we start talking about transnational communities, transcultural communities, and translational communities where linguistic challenges become also an important part of some of the challenges. And again, power plays through this in very, very interesting ways. And then obviously, the social construction of these issues are something that those of us who do medicine have had to learn about. Obviously, you all have been interested in the humanities and the social sciences and how they play through for medicine. But that's not a traditional medical focus. So let me talk for a moment then about the topology of global health. When people talk about global health, what are they really talking about? And I think it's important to kind of think about the different ways that people construct global health in their own ideas. First of all, missionary work where people do service and where people do proselytization has been going on for ages. It was, you know, the Albert Schweitzer, all of us who were of a certain age wanted to grow up and be like Albert Schweitzer and play the organ in Europe and then take care of poor people in Africa. And that kind of service that was often linked to proselytization continues today. Obviously, there are churches who provide missionary service and this is linked with this kind of proselytization in interesting ways. Missionaries for years were very important in low income countries and identifying the best and brightest students, bringing them to Europe for their training and having them go back to do that kind of work. And I think that's been going on obviously for hundreds if not thousands of years that this kind of kind of missionary zeal is part of what we talk about. Secondly, there are service learning trips and if you go on the internet, there are all kinds of opportunities and students are actually getting bombarded with these requests from companies who are set up that on a fee for service basis will arrange for you to have a global health experience. And if you have the resources, then you can just sign up and you can have a wonderful trip that's often kind of a learning trip and not really a service trip. And these are often during the summertime. And the paid organizers, I looked on the web the other day and there are at least 40 or 50 sites that you can find very, very easily that organize these type of global health opportunities. And they will take kind of students with no preparation and send them over with groups of students. And obviously the people on both sides are making a lot of money on this, but if you think about who can afford to do this. I mean, these are people with a certain degree of wealth and a certain degree of the ability to pay for these service learning trips. And there are very few low income countries that are offered service learning trips to the United States. And so let me just kind of begin with this concept of bilaterality that I'm gonna be talking about. And that is, as you think about doing global work, one of the important things to think about is would it look okay to us if somebody from a low income country was doing the same thing in the United States? And I'll come back and give you an example of that here in a second. So medical tourism is another thing that people talk about. And there are two types of medical tourism. The medical tourism where you go to some place to get an inexpensive heart bypass. And then there's medical tourism where you pay and you get to go and you get to visit hospitals and you get to see poor people and you get to see people in terrible clinical situations. And you come back with this kind of interesting view of the terrible things that are happening in low income countries. That really is kind of a voyeuristic opportunity and one that I wanna issue today. Then there are these professional ear changes. And many of us that are senior get these things in the mail where for only $10,000 you can join a group of prominent whatever, internist, surgeons, OBGYNs. And you can take a crew of Russia or China. And these are usually high level physicians from the United States who are visiting high level physicians in these other countries. And these tend to be very male dominant situations where you kind of get rich white doctors from the United States visiting rich white doctors who are doing ENT in plastics and heart surgery in high and low middle income countries. And these are also very interesting. And it points out kind of the level at which this happens, these professional interchanges, but also some of the gender disparities. If any of you studied the history of medical education in Russia, you would know that since the Russian revolution, the large majority of physicians trained as physicians in Russia were in fact women. Since 1917, 80% of the physicians that have been trained in medical school in Russia are women. Not very many people know that. Almost all of those women functioned as primary care physicians. They provide services that are fairly inexpensive and fairly poorly compensated. And almost none of those women are directors of the major institutes. Almost none of them are heart surgeons. Almost none of them are neurosurgeons. Almost none of them are orthopedic surgeons. Those positions at the elite institutes in the predominant cities are almost always men. And that's one of the reasons that women's health services in Russia have actually been fairly good for a long period of time. And that's because you've got a large numbers of poorly paid women generalists providing services. Until recently in Russia, it was cheaper to get a first trimester surgical abortion than it was to pay for condoms. It cost about $5 to have an abortion if you had to pay anything at all, and condoms were more expensive than that. So I don't know how many of you've seen Russian expats, but it's very common for women who moved to the United States to have eight or 10 or 12 elective terminations. And they received those from women who were fairly poorly paid or paid almost nothing for these services as part of kind of the routine health services where condoms, IUDs, birth control pills were not accessible, but poorly paid women physicians were available to do first trimester medical terminations. And so the kind of the gender disparities and the economic disparities in these professional interchanges is something that's worthy of some critique as well. Then there are these surgical programs that we all know about operation smile and operation hope and these ships that go in and they provide, you know, they fix cleft lifts and cleft pallets usually. Sometimes they'll fix craniofacial abnormalities and these programs kind of drop in, they do wonderful things for a week or two and then they leave. And for those of us who've spent time in low-income countries, we know that the complications they leave behind are really pretty substantial. I was in a meeting one time and one of the, a British plastic surgeon who'd been in Kenya for years said it's always a disaster when these people leave because as soon as they leave, then you start seeing the complications from the breakdowns of the cleft lift and the cleft pallets and he said in the last year, he'd seen four babies for young children that had had draining who'd had, as part of their cleft cleft pallet, they'd gotten into their sebril finus fluid and they now had draining CSF through their mouths. And so he was really saying it's not, they really don't do much help. That I mean the cosmetic immediate result is wonderful but the long-term societal benefit from these surgical programs is really problematic, especially the more complicated surgery they do. And then there are the NGOs. Now the NGOs have been kind of the major provider of global health services for a number of years. Obviously Partners in Health, Paul Farmer's famous program has been well recognized and has been going on in Haiti and now has expanded to other countries. Jepago, John Snow and Gender Health, we were just talking about in Gender Health are all major programs that are independent, non-governmental organizations that receive money, sometimes from USAID, sometimes from private philanthropy to do work in low and middle income countries, generally working by setting up their own clinics or working with government organizations but almost never partnering with academic organizations because if you listen to NGOs, academic organizations are impossible to deal with because they're bureaucratic and they're difficult and they're rigid and we can't do the kinds of things that we wanna do and they require us to have bureaucratic and other kinds of activities and responsibilities that we're not willing to undertake. And so there's been this kind of dynamic tension between academic institutions in low and middle income countries and the no NGOs and the NGOs who tend to kind of work outside of that. If you can imagine in the United States, if you had NGOs from Russia that came into Chicago and started working in neighborhood health clinics and bypassed the traditional health system and bypassed Northwestern and the University of Chicago and the regular healthcare providers, how we as academics would feel about those NGOs. And then there are these medical student kind of white coat adventures. And these are kind of medical students who put on white coats and go to other countries often as M1s and M2s where they go to clinics and take blood pressure and listen to hearts and tell people about diabetes and kind of really kind of initiate kind of what they think is white coat activities. I'll give you an example of how this operationalized at Michigan. We have a program called Global Reach that is our medical school umbrella organization. And for a while I was the interim director of Global Reach and when I took it over, they said, well, we're having some trouble with some of our M1 and our M2 rotations. And I said, it'll explain to me just what exactly is going on. And they said, well, we have M1s and M2s that go to Central and South America during their summer vacations and they work in clinics and they check patients for blood pressure and they do clinical exams and they do screening. And I said, so just exactly how does that work? And they said, well, before they go, the M3s give the M1s and the M2s a one week how to take a blood pressure, how to listen to hearts thing. And then they go and they do that. And this gets back to my earlier example of what would we think if we had medical students, first year medical students from the University of Chile coming to Hyde Park and doing blood pressure screening in our patients without any kind of clinical context. And so this gets to kind of the feminist approach of let's think about what it would look like if we switched places. What would it look like if there were people from low and middle income countries doing what we're doing in those countries and what's developmentally appropriate for our medical students is also an issue that I'm gonna be talking about as well. But this, so you wouldn't be surprised to hear that those projects stopped immediately. I said, we're simply not gonna let our M1s and M2s do things in another country that we wouldn't let them do in our own country. That until you've taken introduction to the patient given by the medical school, you're not allowed to touch patients just like as an M2 at the University of Michigan, you're not allowed to go on the wards until you've completed introduction to the patient. And introduction to the patient cannot be taught by M3s, it has to be taught by faculty members in some kind of a rigorous fashion. And so it got us thinking about kind of what are the appropriate medical student experiences. There are appropriate experiences for M1s and M2s, but clinical opportunities until they've taken kind of the clinical basics is really not one of them. So what we really need to think about what is pedagogically and developmentally appropriate. And as we think about how we professionalize and socialize medical students as M1s and M2s we're giving them basic science information, we're teaching them about medical education, we're teaching about how to talk to your patients, we're teaching about how to interact with their patients, we're teaching them about evidence-based practice to some extent and talking and introducing them to the basics of research. And so having students doing patient education and having them engage in research at the M1 and M2 level is probably appropriate. But it's really not until they've completed introduction to the patient and kind of the clinical training that it's appropriate for them to go and do in Ethiopia or Chile or Ghana or whatever, China, what we would not let our own medical students do. And so one of the things I think we really need to think about is what is it that our students are prepared in terms of their own professional development to do? And we do not often enough think about how we professionalize our own medical students. I mean we've all, those of us who are physicians went to medical school in the first two years of basic science in the third year was clinical, things are getting shifted around with the new curriculum. But there's a very rigorous way that medical schools for the last 100 years since Flexner have educated medical students with a similar paradigm in almost all the medical schools. And a couple years ago I taught a course on literature and medicine to fourth year medical students and one of their final great options was to reread their medical school essay application and reflect on it. And virtually to a person, everyone who reread their medical student essay said, I don't recognize the person who wrote that. I'm no longer that person. And I wish I were more like the person who wrote that than I am the person who I am now, which I think is an interesting indictment. I mean it was 30 medical students wrote the same thing. I don't recognize that person. I wish I were more like that person and I don't like the person I've become after four years in medical school. And I think maybe as academic educators we need to do some reflection around what we do to medical students during the four years as well. But it's pretty clear that at the end of four years we turn out something that is a pretty good product and we don't wanna throw out the baby with a bath water. And so again these issues of how we do global health and how we think about doing global education allow us to think about how we do our domestic work I think as well. The other issue for me was bilateral equality and you'll hear me talk about that. If we're sending our medical students over there then we need to make sure that we accept their medical students over here. If we're sending our residents over there we need to accept their residents over here. And we need to make sure that there's a certain equipoise in terms of what we do. So the nice thing about medical students is that when we send our medical students to Ghana they're allowed to see patients, operate on patients, scrub with patients, be with attendings, do deliveries and engage in patient care just like their students who come here are allowed to do that. So the University of Michigan allows Ghanaian medical students to go to clinic, to see patients, to write in the electronic medical record, to scrub in the operating room, to do all the things that our third and fourth year medical students do. But when residents come from Ghana because they don't have a license they can't do any of those things. And so we need to be very careful as we think about kind of what are equivalent roles and we tend to make sure that our residents who go over there don't think that they're gonna be able to do a whole lot of official operations when we take their residents here they really not allowed to do those kinds of things. So again, this kind of thinking about power and equalization. So again, as we think about how we professionalize our physicians, we teach medical facts, epidemiology and education to M1s and M2s, teaching medical students about doing research in low income countries as a real benefit because we're teaching them as M2s and M3s how to do evidence based medicine and learning how we collect evidence, learning how that evidence is analyzed is actually a real plus. When I was in medical school, nobody ever taught me about clinical research, nobody ever taught me about how we move from evidence to practice and that's something now, I think that people really benefit from. So if you're thinking about a global experience for first and second year medical students, giving them an experience, seeing how research is done in low income countries because it's very similar to how it's done over here gives them an insight into how we collect evidence and how that evidence could in fact be utilized in clinical practice in what people today call evidence based clinical practice. I love that term. I love it that people today say we use evidence based practice and suggest that when you and I were residents we used voodoo based practice. It's just that the quality of the evidence that we have is much better because the quality of the clinical trials that we're doing is much better and often we get definitive answers. And then finally, third and fourth year medical students are able to kind of demonstrate their clinical skills and kind of function a medicalized world. They've learned the lingo, they've seen how we operate professionally as physicians and they've had introduction to the patient, they've had physical diagnosis and they've had the things that we expect our medical students to have and so as our students go over there and as their students go over here, it's really quite remarkable when we do a post-visit interviews of our students and ask them to do reflective pieces that those reflexive pieces are almost identical to the reflexive pieces that Ghanaian students do when they come to the United States. And then finally with this changing medical education paradigm, I'm a little bit unsure what the new curriculums are gonna look like. I don't know about you here at the University of Chicago but we have a new curriculum at the University of Michigan where the first year is basic science. The second year is clinical science and the third and fourth year are now discovery opportunities to wander. So we've taken what used to be a wasted fourth year and made it now wasted in third and fourth year. But this kind of shift of kind of clinical activities to the second year may change some of these activities. But I think we need as academic educators and as academic clinicians, we need to pay attention to what our paradigm is here and how that paradigm might apply in low and middle income countries that may be 20 or 30 or 40 years away from us in adopting these kinds of paradigms. In the United States, we started talking about ethics in the 1970s. It's only now that many low income country medical schools are starting to introduce the concepts of ethics into their curriculum. We've been talking about professionalism now for 20 years. In many low income countries, talking about professionalism is relatively new. Patient safety, patient quality are things that we've been talking about in the United States for 20 years. Those concepts have not been introduced in the low income countries yet because they're still dealing with kind of chaos and high mortality from medical complications and surgical complications and OB complications. So we need to be very cognizant of kind of the local environment in terms of where they are in terms of the ontogeny of medical education. And we can't impose kind of, we need to can't go over and say, well it's time for you to do informed consent in a country where they haven't even started talking about the importance of ethics and autonomy and beneficence and non-maleficence and even raised those issues yet and to go over and impose kind of this Western paradigm of IRBs. Which isn't to say that we shouldn't demand those kinds of rigor, but we need to be very careful that we're not, those of you who are Star Trek fans, the prime directive is not to interfere in the local culture. And we need to be very careful that the local culture is ready to take up the ideas that we have because it takes a certain degree of preparedness. I mean, we didn't go from one day to the next in the United States of having not informed consent and having informed consent, it was a process. And that cultural process is one that we need to be very cognizant of as we work in low income countries. So let me talk about my ethical journey. So I was a medical student at the University of Virginia in 1975, which was a very, very interesting time. Thomas Hunter was the former dean of the medical school and as part of his retirement package from the vice president for medical affairs, Ked Crispell, he was given some money to start a clinical ethics program which he did with Joseph Fletcher. And as a medical student, the two coolest things that we did were medical grand rounds, which was basically a CPC that was held weekly. And then a weekly clinical ethics conference that Dr. Hunter and Dr. Fletcher ran. And so it was very important for me to kind of hear about ethics and listen to ethics on an ongoing basis. And I think I was pretty profoundly affected by it. I think, again, this idea about you need to infect people early with the ideas and the concepts and they continue to kind of grow through their lives. At least for me was an important one. After my residency, after my fellowship, after my time in the Air Force at 1985, I went back to Johns Hopkins. And believe it or not, in 1985 was the first time that there was a formal medical ethics course that was taught at Johns Hopkins. And it was taught by Peter Dans, who you must know, Mark. Peter, most everybody in the noble know him for a couple of reasons. One, he was taught clinical ethics at Hopkins. Number two, he opened an office for medical practice evaluation, which was one of the first offices of kind of medical practice evaluation, excellence, patient safety in the country. And most of us know Peter Dans because he was, for many years, the movie critic for Inferos. Remember the doctor, through those of you who are members of AOA, the quarterly magazine, The Feros, has got a section on doctors at the movies. And Peter Dans was a movie buff and in fact wrote a book about movies with physicians in them. And when I was a young faculty member at Hopkins, Peter asked me to be a small group leader for this ethics class. And so I would, you know, every week have 10 or 12 medical students and we would talk about ethical problems and we would use the four quadrant framework that already then was the national paradigm for how to think about ethics and has informed how I think about ethics forever. And then finally, in 2009, at kind of midway through the work that we were doing in Africa, we had what was called a charter grant. We received money from the Gates Foundation as part of a large initiative on collaborative research and teaching in Ghana. The goal was to kind of expand capacity in many specialties to do research training but also to think about how one would collaborate between high income and low income country. So we had specific money to set aside to develop a document to guide the collaboration between the University of Michigan and our partners in Africa and I'll come back and talk about that in a second. So my personal journey in global health began in 1986. I was a perinatologist. I was, my interest was in fetal therapy and diagnosis which in 1986 was becoming very exciting. Ultrasound was becoming ubiquitous and we were starting to do fetal interventional therapy. I was the division chief of MFM at Hopkins. I was the residency program director. I was the fellowship director. I was the medical student clerkship coordinator. I had a wife, I had three children and those were the days and I didn't get salary support for any of those things. That's when you just did those things out of the goodness of your heart. And I had no intention and no interest of doing global health. It was not something that was on my radar screen and one of my colleagues came in and said I was supposed to give a talk in Ghana in a couple of months but I can't go, would you be willing to go? And I said yes and it was a transformative experience for me. So in 1986 I visited Ghana at a time when the relationship between the US and Ghana was opening up. Remember this was just after the fall of the Soviet Union. The money which had been going to Ghana had been mostly Russian money and Cuban money up until 1986. That money was quickly drying up and the government of Ghana said, boy, we better find a new partner. Maybe we should open up the borders to the United States. And so USID sponsored a trip over there to reestablish the OBGYN Society of Ghana and I got to go over there and give some talks. This was an important time from a global women's health point of view because in 1985 the Safe Motherhood Initiative had been launched by Alan Rosenfield who was the Dean of the School of Public Health at Columbia and he published this very important article in the Lancet on where is the MNMCH. And basically Alan and Deborah Mayne made the case that infant mortality had been coming down worldwide in the previous 25 years because of immunizations and oral rehydration therapy and there had been an almost 50% reduction in infant mortality even in low income countries. But in low income countries maternal mortality had been flat. And so this was really the clearing call that led to the United Nations and WHO declaring a Safe Motherhood Initiative which was a focus on maternal mortality. And so in 1886 I was interested in maternal mortality. I went to Ghana and so there was this kind of confluence of things that made this the perfect timing. This is actually a picture that I took at the University of Ghana Teaching Hospital in 1986. In 1986 Ghana had a teaching hospital, two teaching hospitals. This was the University of Ghana Teaching Hospital. They did about 18,000 deliveries a year. The maternal mortality was about 900 per 100,000 which compared to the United States maternal mortality of 11 per 100,000 at the same time was a pretty significant difference. And there weren't enough beds for all the patients. These are several of the patients. Actually when you made rounds at this hospital you would stand next to the bed and one patient would get in the bed and you'd examine her and then she would go out of the bed and the next patient would get in the bed and you'd examine her and she'd get out of the bed and the next patient would get in the bed and get out of the bed. So for me it was a very, very interesting a very, very interesting experience. This was the operating room at the University of Ghana Hospital. As I mentioned they were doing over 15,000 deliveries. The day, well the month that I was there the OR was closed so they were not allowed they could not do caesarean sections because they did not have any anesthesia. This was a gas tank and it was empty. So they had no inhalational agents. They were out of lidocaine. They were unable to give a spinal anesthetic. They were unable to give a local anesthetic and so they were simply unable to do a caesarean section. And that was even during the time that the anesthesiologists were there. So at this teaching hospital anesthesia came in at 11 o'clock in the morning and they left at three in the afternoon. Subsequently when they got the gases they were only able to give gases between 11 and three. So this is the kind of environment that was happening in 1986. The Ghana government in 1986 had sent 26 physicians out of the country to train to be OBGYNs. Most of them had gone to the UK. Some of them had gone to Germany and two had come to the United States. And over those 26, zero, none had come back to Ghana. And so the Ministry of Health was a little bit wary about sending people out of the country because none of them were returning. And there were lots and lots of young medical school graduates from these two medical schools who were interested in training an OBGYN. And they were like, where can we start? When can we start getting a job? How can we get a job? How can we get a residency? We want to be OBGYNs. And in 1986, it was pretty clear that those opportunities for students in Ghana, at least, were not going to be there. So since I'm an academic and since I was involved in residency education and since I train residents and fellows as a living, obviously, and since it's like surgeons, if you have a hammer, then you're going to find a lot of nails. I'm a medical educator, an academic medical educator. So I thought, well, gee, why don't we set up a residency training program in Ghana? And people over there thought that was a great idea. So I came back to the United States and I picked up the phone and I called the Executive Director of the American College of OBGYN and said, has ACOG ever supported resident training in Ghana? They really, they're ready for resident education. Is that something that we could help them with? And he said, well, you know, we've never done that. That's not something that we would ever think about doing, but it just so happens that last week, the President of the Carnegie Corporation of New York was here and they're interested in capacity building in low income countries. Maybe you should call him. So I called it, I did it to Cabo Lucas, who was a Nigerian who was President of the Carnegie Corporation. And I said, would you be interested in funding a residency training program in Ghana? And he said, wow, I've been waiting for this phone call. We went to New York, we wrote a grant and we had suddenly within about a month, we had $7 million to set up a residency training program in Ghana. The requirement from Lucas was that we engage the local Gadaans in the decision making, that the two medical schools in Ghana, that the department chairs and the clinical faculty would be engaged in it, that the American College of OBGYN, that the Royal College of OBGYN would be involved and that the Ghana Ministry of Health would be involved. And so between 1987 and 1989, we had a series of meetings in London to decide what this residency training program would look like. And in 1989, the program rolled out in Ghana. So it was the Carnegie Corporation to New York, the Royal College, the American College and the Ghana Management Committee. So the management of this program from day one was managed by Ghanaians. They were the ones that set up the curriculum, they were the ones that picked what they were onto the curriculum to be like. They actually came to the United States, they went to London, there were some things they liked in the US, there were some things they liked in the UK, there were some things that they liked about their own program, so they made a country-specific program and they picked the best of all the models. Let me give you an example. In Ghana in 1989, the medical school faculty were proud based on the number of medical students that they failed in their exams. Those of you who trained in the UK system know that British professors like to boast on how many students they failed. In the United States, we have an opposite paradigm and that is if the students failed and we feel it as professors, we've failed. And so when the Ghanaians saw that, they were like, well, we like the American system where you actually tell the students what you need to know and then test them on their competencies that you've given them, which is the antithesis of the British system. The British system, well, in 1989 in Ghana, the final exam for OBGYN might be gestational diabetes and you've got to write as many pages as you could on gestational diabetes and then somebody would grade your paper and you either pass or fail. There was kind of no real competencies. And so Ghana said, well, we like this kind of letting people know what the curriculum is and then testing them on the curriculum. And so the Ghanaians picked what they thought was best from the US and the British models and they set up a five-year curriculum with the goal of certification by the West African College of Surgeons, which was an extant multi-country body in West Africa. There was both Anglophone and Fraxophone that gave written examinations and oral examinations and certified people for advanced competencies. And the fellowship in the West African College of Surgeons was the final qualification. And again, as I said, time was ripe for OBGYN because it was recognized that maternal mortality was an issue, fishelists were an issue, kind of women's health issues were at the nexus of what people were talking about in terms of global health in 1989 and the program was started. So, this is the success story from Ghana. The funding from the Carnegie Corporation lasted from 1989 to 1992, as I said, we got about in total, with extensions, about $7 million. When the program stopped, when the funding for a Carnegie Corporation stopped, by then, in 2003, you can see that already 20 OBGYNs had been trained in the program. And the Ministry of Health was so enthusiastic about this because they now had 20 people who were practicing in Ghana that had trained in Ghana that the Ministry of Health continued the funding. So, postgraduate education OBGYN in Ghana today at four teaching hospitals is entirely funded by the Ministry of Health. They fund the salaries for the residents in training just like we do here in the United States. In 2014, when we did the last survey, 142 people had been trained in Ghana, 140 of them are still practicing in the country. So, this long history of brain drain had been reversed by in-country training. Last year, I was just, one of my faculty members who's been working over there just came back, last year, the Ghana College of Physicians and Surgeons certified 40 people as OBGYNs. So, you can see what happens with these kind of training programs is there's kind of a slow startup and then they're very, very successful. The OBGYN departments are very successful. The best medical students want to do OBGYN because they want to grow up and be like the people who've populated the programs. So, as of the summer of 2015, 142 specialists completed the program. 140 of them remained in the country. One of them came to the United States and one of them was dead. We're going to take credit for the one person who was the Minister of Health. One of our former residents is currently the Minister of Health of Ghana. They've published over 100 peer-reviewed journals, articles, and three major textbooks. One of the first things that we said is there need to be country specific, region specific textbooks so that we can teach the medical students and the residents and the fellows using textbooks that are locally relevant and we can tell them what's gonna be on the test. It's the textbook and if you study the text then you're gonna pass the text. And what happened very, very quickly, the pass rate for the West African College of Surgeons examinations before this program ran about 40%. So it had about a 60% fail rate. Last year, the fail rate for Nigerians was 60%. The fail rate for Ghanaians was zero. The pass rate was 100%. And that's because the West African College of Surgeons is using these textbooks as the basis for its examinations. So it's very important to have professors. I mean, what we did was train the professors who then wrote the textbooks. There are now four OBGYN departments in the country, all four department chairs, one Dean and the Dean of the School of Public Health are all former students. So we've been very successful in setting this up. The fellowship programs after you start training residents, people wanna have fellowship training programs and several years ago with funding from again, from the Buffett Foundation. We set up a family planning fellowship training program. They funded it for two years and the Ministry of Health took over. The first G1 oncologist just finished his training and joined the faculty at one of the medical schools. The first year of gynecologist just finished his training and last year the MF Maternal Field Medicine started training. So you can see that the same kind of progress that happens in the United States there happened fairly quickly. Now, this is the cover of one of the textbooks. One of the first things we did, we wanted the family planning fellows actually to write a textbook on family planning and reproductive health and family planning. And this was a textbook written by Ghanaian family planning fellows that's now used for medical students, residents, nursing students, midwifery students, public health students and community health workers. So everybody in the country has a single book written by experts, by specialists, sub-specialists that define kind of the reproductive health curriculum for the country and the competencies for the country. This is the second edition of comprehensive aesthetics and the topics and these books are all entirely written by Ghanaian authors. There's not a single non-Ghanaian author of any of these books and actually what's interesting is those four authors are the four department chairs who I all, well three of them I knew when they were residents and one of them I knew since he was a medical student. And so this long-term sustainability of this program I think has been one of the hallmarks. Now, for me personally, when I came back to the States in 1986, since I told you I was a division chief, I had an academic career, I didn't have tenure. Doing global health was a big risk. I decided I wanted to do it but I decided that I had to carve out a niche. And then I decided for me I only had time and I only had bandwidth to do one country. So my personal narrative is that since 1986 I've only been working in Ghana. I've been there 60 times. I know virtually everybody that we've trained they're on my rapid dial. And we still are exchanging medical students, we're still exchanging residents. And as I talk to young people who are interested in doing global health I encourage them to think about identifying one country and sticking with it. Because one of the critiques is that if you do multiple countries, if you have multiple bandwidth it's just more than you can kind of cope with. And it's very attractive to kind of be opportunistic and wherever the funding is you move to that country. And not kind of saying I'm gonna work with Ghana during the good years and the bad years and I'm gonna be back. Now that is a lesson actually that's a fairly strong lesson for domestic engagement and low income communities as well. I mean I certainly can't speak for the University of Chicago but I can say that Hopkins has is notorious for getting grants, moving into the East Baltimore community saying we're from Hopkins we're here to help you. Setting up a clinic in the basement of a church and then two years later when the funding goes away the clinic goes away. And I think that kind of engagement in low income communities has been a hallmark of the way many of us in the West have engaged our own local low income communities. And this idea of long term sustainable community partnerships is something that I think is to be regarded highly and one of the lessons I learned from doing work in a low income country. So again we traded critical mass with very very high retention. We just published an article in the American Journal of Public Health that demonstrated the long term public health trickle down because what happens training specialists is that they train medical students, they train general medical officers, they train midwives, they train nurses, they train public health workers. So the downstream benefit of training specialists is actually demonstrable and we were able to show. In the first couple years everybody stays at the university because that's where you wanna stay but once you've trained 140 people they start moving all across the country. And we had students that went over one summer with their GPS and they mapped where the OBGYNs were and there really was a scattergram across the country. It's very important to do leadership training and pipeline is important because we've trained people that have gone to community hospitals and private hospitals and regional hospitals and they've had multiple public health projects. So my personal journey is and one that I talked to our students about is kind of this but for story. But for the fact that one of my colleagues got sick and said hey would you like to go to Ghana. But for the fact that I picked up the phone and called the American College of OBGYN and said hey, is there a possibility that there might be funding and but for the fact that the Carnegie Corporation had been there the week before none of this would have happened. And so I encourage students to be opportunistic and to take advantage of these doors when they suddenly appear in front of them, in front of you. And for me obviously doing this global work has been transformational. So what did we learn from the Ghana program in postgraduate training? We learned that in country training was very appropriate that Ghana which has been economically stable and politically stable that kind of political and economic stability is important. I think Haiti has been politically and economically unstable and it's very difficult to do this work in countries where you have to worry about your learners and your students are in that country. I mean one of the biggest risks for me and for the University of Chicago is to send your students to a place and have something happen to those students because that would be the end of the program and finally, people from Ghana said gee, if there's a quality program in country and there's economic future for me and for my families then I love my country and I'd like to do the work here. So there's a certain degree of nationalism that's important. Long-term partnerships, local decision making, bilateral exchanges, transparency, these will come up and be themes as we go through here. So and again, as I said earlier, one has to think both strategically and opportunistically but what you learn experientially may apply to other partnerships, both global and domestic. So this is the story of the Ethiopian partnership. One of my former residents, former fellows, former division chiefs who was Ethiopian decided that she wanted to replicate the Ghana project in Ethiopia and she was able to do in Ethiopia in three years what it took us almost 12 years to do in Ghana because we knew what to do and what not to do. She got funding from the CDC. She got a $3 million grant to set up a reproductive health women's health in Ethiopia. She coordinated with many of the internal partners and she set up a new OBGYN residency training program that just graduated first group of residents. She set up a surgical training program and emergency medicine training program and a pediatric program, a transplant program. And this is the new women's hospital that's being built over there at St. Paul's Millennium Medical Center which is our partner in Ethiopia. So the minister of health came to me and said I want you to do the same thing in Ethiopia that you did in Ghana and I said I don't have the bandwidth. I only do Ghana but my colleague is willing to do that. And so tonight I went to do that work. This is, she set up this hospital clinic. This is the Gandhi Memorial Hospital, the largest delivery hospital in Otis where they have a family planning clinic. The staff by our family planning fellows and you notice the maze in blue. It turns out Mishu means compassion in Ethiopian. So the Mishu clinic is a compassionate care clinic and Mishu obviously means you Mish and maze in blue and all that kind of stuff. As a graduate of the University of Michigan I've become a corn ball for maze in blue. This is the specialty clinic in Bahar Deer. Bahar Deer is in the middle of nowhere in northeastern, northwestern Ethiopia where they have this family planning clinic as one of the new medical schools. And all of this was based on the charter principles that I talked about before. So this is the Ghanaian flag. And in 2009, we had a process where we spent a week together at Elmina Castle which is one of the slave castles on the coast of Ghana. And it was a partnership between the Ghana Health Service which is basically all the physicians that are employed by the government. The Kwame Nkrumi University of Science and Technology, the University of Ghana, the University of Ghana Ministry of Health and the University of Michigan. And we spent a week talking about what does a collaborative relationship look like? And this is gonna be my introduction to kind of thinking ethically past a kind of a core four quadrant view because I think a lot of the principles that came out of what became the Elmina Declaration of Partnership looked like. The charters talked about recognizing that human resources and capacity building was important, that human resources development was important, that there are barriers to care. And you can see right here at the bottom where the principles that were enunciated as being key to a collaboration. And this document was signed in Ann Arbor by about 30 people. We actually, as we set about doing the document for the first two days of our meeting at Elmina, we pulled the Declaration of Independence, we pulled the Magna Carta, we pulled the UN Declaration of Human Rights, we pulled the American Constitution. We looked at all of those documents and we said, okay, how can we develop a charter for collaboration that uses these kind of human rights principles? And you can see down here, these were the principles that were considered key by that group, trust, mutual respect, open communication, accountability, transparency. And by transparency, they're talking about financial transparency, accountability, leadership and sustainability. And I think these are the new keywords that we need to think about in terms of developing true global partnerships and accountable global engagement to do the kind of work that we're talking about. If academic institutions wanna do this work, this is how they have to behave. This is the ethos, this is the moral and ethical space that they need to have to live in. And this is basically talking about engaging communities and giving them respect. For those people who do public health, this is kind of like community-based participatory research. This is not us going in and saying, this is what we think your program should look like. This is us going in and saying, okay, what do you think your program should look like? How can we help you develop the programs that you would like and then how can we help you operationalize them? And we've been doing this domestically and I guess what I'm calling for today is kind of a globalization of this type of community-based participatory engagement. As we do global health, we need to engage our global partners both in the thinking about education, in the thinking about clinical services and obviously the thinking about research. But again, community-based participatory research was kind of the first public health activity. Research really comes after clinical practice. I mean, as a department chairman, I always think that research and education are important. You've got your department chairman back there. I always tell people that in the morning I wake up and I shave and I say research and education the mirror three times and then I go to work and I spend the rest of my day worrying about clinical practice. The most important thing that we need to do as academics is make sure that the clinical environment for our students and our learners and our research is high quality. It's unethical and immoral for us and I think incredibly cynical to train medical students to train residents in a clinical environment that's not the best we can make it. And I think this program is built on the recognition by Dr. Siegel and others that in order to do ethical training and ethical education and ethical research, you first of all have to have a high quality clinical environment where patient safety, unsurpassed clinical care, excellent patient care, patient safety are the first things that have to happen. And this I think is true in low income countries as well. We really can't go over there and do research until we've helped them develop a clinical environment that's high quality. So here's where I wanna kind of tie it all together and say that there's increasingly a demand for institutions and universities to engage in global health activities and that I think what I've given you today is my journey towards what I think is an academic approach to global health engagement. If universities really want to provide global health opportunities for its learners, it's undergraduate learners, it's graduate learners, it's postgraduate learners, it's faculty and even alums. We have a lot of alums that call me and say, hey, I wanna go do global health. Can I do some missionary work? And I'm like, well, that's not exactly what we do. We do academic engagement and if you'd like to teach and do research and you'd be surprised how many people will be doing that. And there's huge demand. Our medical students are demanding these global experiences. Our residents are demanding these global experiences. They, we have a, those places who can offer medical students, residents, fellows, faculty members, global experience has to have a competitive advantage in recruitment because of these global opportunities, especially for millennials who have kind of a broad global view. Why the academy? Well, the two great institutions of Western civilization are the church and the universities. NGOs are not on that list. And I truly believe that if one instills in the academic environment, these type of educational research and clinical programs that one can develop sustainable programs like the one that we've developed in Ghana that's entirely based on academic partnerships. The OBGN residency training program that we have at Michigan in Ghana has now been reproduced in emergency medicine, in pediatrics, in anesthesia, in midwifery, and increasingly kind of other departments that have gone over and helped them. Emergency medicine didn't exist in Ghana until our emergency medicine, they were building, actually this is a good story. They were building a new emergency and accident room at Kouamina Krumi University in Kumasi and they took me through it and I said, well, who's gonna staff it? And they said, well, medicine's gonna be on this half of the room and surgery's gonna be on this half of the room. And this was like seven years ago and I said, well, that's not the model anymore. Emergency medicine in the United States has done away with medicine owning half the emergency room and surgery owning half the other. And they said, well, what would you wanna do? And I said, well, why don't you start an emergency medicine residency training program? And they did that. So, let me suggest that the university can be a nexus for global partnerships because we share academic values with these academic institutions and once established, these academic institutions have roots and they have the capacity to really continue in the future in ways that clinics and NGOs and missionary trips and all the other kinds of things that I talked about earlier don't. Who are the learners? Undergraduate students, graduate students, professional students in medical school, postdoctoral students, medical specialists, medical sub-specialists and lifelong learners are all potentials for engagement in the academic exercise. And I know your program here at Chicago has taken advantage of this. Having said that, universities who engage in this type of global health work I think have responsive developed programs that are both ethical and sustainable. That saying, oh, we'd like something where our students can go for the summertime and not really engaging in something that adds value to the partners in the other country. Don't realize that you have an ethical and moral responsibility if you start something over there to finish it over there is the university's kind of abrogating their responsibilities. And it's easy for administrators, for presidents and provosts to say, oh, let's start a program at X and let's send our students over there. And low-income countries, if you send money and students, they would love to take them, especially the money. But whether or not that's building any long-term capacity or whether that money's being funneled into a few elites who take advantage of it and use it to their own benefit is really one that's problematic. So the University of Michigan, all the way to the level of the president and the provost are very engaged in these types of platforms. So the University of Michigan has now a platform in Ghana, a platform in Ethiopia, a platform in Sao Paulo, a platform in Keto, a platform in India. And by platforms I mean sustainable capacity and administrative infrastructure on the ground with buildings and people and people who can help your students when their visa gets stolen and their passport gets stolen and their visa card gets stolen and all the kinds of things that happen when you've got a large number of students there. So what students would expect? I think we're living in a world where the students are actually gonna have to demand of academic institutions that they be ethical and that they'd be moral. I mean, finishing up a book called Engaged Academic Global Health where I make the case that in addition to universities having the responsibilities, that students have the responsibility to overlook their universities to make sure they're being ethical and responsible. And I think as we learn in the 60s and are learning today, students are pretty good at holding their academic institutions accountable for doing this kind of work in a reasonable way. So students should expect an established program. I get phone calls all around the time from people in other institutions where a student has gone to somebody and they say, well, I wanna go do something and they say, well, call Dr. Johnson at the University of Michigan and he'll fix it up for you. Well, you know, I'm busy enough taking care of the University of Michigan Medical Students. If University of X wants to start a program, then they can't use me as the one-off. They really need to be thinking about having an established program where they can develop a long-term partnership and where they can add value to someplace else that they can be a long-term partner to. It has to be safe for the students. You can't send students to a war zone and there has to be some kind of supervision. The students, I mean, we don't allow our students to function unsupervised here and so they have to have a supervision there and they have to have evaluations there. There are seven faculty members at the two medical schools in Ghana who have adjunct appointments in my department who supervise our students when they're in Ghana. So what's in it for them? They have adjunct appointments. What it's in it for our students, they're being supervised by an adjunct faculty member from the University of Michigan who I know, who I've trained, who I know is giving them good supervision. There has to be a curriculum. It's not just go over and choose your own adventure. There has to be kind of expectations and the students have to have a pre-test and a post-test and they have to do a reflexive piece. There has to be evaluation feedback. There can potentially be academic credit and there has to be a viable academic pathway for the people who do this as their careers. This is another one of my critiques. There's several global health fellowships in the United States and I won't name any names but Duke has one and they have a two-year fellowship and they take OBGYNs and they do two-year fellowship and when they're done, they're told to call Tim Johnson and he will help them find a job. So if you can have a fellowship, then you have to be responsible and make sure there's a career pathway for those fellows to be able to find an academic niche and continue to do the work. Students need to demand that it be ethical and bilateral, that for every student from here that goes there, that there be students that have an equal opportunity, that it be sustained, that it be honest and that they basically follow the charter principles which I'm suggesting in many ways or a good way to think ethically about kind of expanding social justice to think about how do we engage our Western concepts of social justice as we do international global health. Major lessons. So for me, the major lesson is you always get more out of it than you put into it. The lessons that I've learned that are applicable both to my clinical practice and to kind of how I think about doing research and clinical medicine and clinical teaching in the United States has been vastly more than what I put into it. People, whenever I go to Ghana, are like, oh, we're so grateful and it's like, no, no, I'm grateful for having had the opportunity for being on this journey and learning so much from you over all these years about it's often easier to see how to fix a problem in a country that has no infrastructure and is just beginning to do things than it is to do here. And many of the experiments that we've done in Ghana are experiments that we were able to do here. What universities need to do in the next millennium to deal with Gen Xers? And this is a big challenge. Gen Xers and millennials are a particular challenge for those of us who are baby boomers. We need to learn to act on student and learn her feedback, to be responsive to students and suggestions and to change using lessons learned from partners and students. The old paradigm of the faculty being patriarchal and not listening to the learners and the students is gone and especially when you have so many students in low income countries, they come back with really great ideas and we're able to change very, very quickly based on the student experiences there. We need to change the curriculum, we need to change the programs and we need to change institutional practices and structures. I mean, it's very interesting that lessons that one learns from global health become very applicable to the way we do business and kind of our academic structures and practices here. And we need to develop our student learners as engaged partners and leaders. They're gonna be the leaders of the future. Why not let them begin leading as students? I'm gonna pass over this and just simply say I think more and more I think that the traditional three legged stool is becoming a fourth legged, needs a fourth leg and that fourth leg that we've never been explicit about talking about is about leadership and advocacy and activism. That we need in addition to a clinical arm and a research arm and a teaching arm to think about how are we engaging our students to be activists, advocates and leaders? And that's simply certainly something that this center has done here. So, increasingly now I think about global health strategically, opportunistically and ethically. And how do we demand of our academic institutions that if they wanna have these types of global health programs, whether they're of the medical school or the level of the entire university, that we do it in a way that reflects our institutional values. And that a lot of what we learned is applicable and our president went to the university, went to visit Ghana and came back and had all kinds of ideas just talking to the university presidents over there. So, let me just say that this way of thinking about academic global health, I mean global health and the concept of the academy is a different model than the traditional topography. That we need to start thinking about the fact that we as academic institutions, whether we're centers or departments or schools or universities can develop an ethically appropriate model of global engagement that's really quite disruptive and that's radically transformative, especially for low income countries, but also for us that's sustainable and that sustains a progressive change in countries both low and high income that are about academic partnerships. And that's ethically grounded, basically it's an ethically grounded laboratory with leadership development at its core, which is kind of what you're talking about here, right? We're talking about centers that are ethically grounded and that are training future leaders. Increasingly we need to think about academic global health as a human right. In the United States for too long we've not thought about health as a human right and obviously that's language that I adhere to. And the SGDs, the sustainable development goals of the UN are appropriate for that. Again, we need to think about these things both strategically, opportunistically and ethically. So these are the University of Michigan partners I mentioned most of them today. Let me just finish by two quotes that I like. For me, going to one country and staying there and going back there and going back there and going back there has been important. Those who stay will be champions is a famous quote from Bo Schembeckler, all of you are from the University of Chicago. So I know you know nothing about football and don't recognize that Bo Schembeckler was the coach of the Michigan football team who told freshmen that if you stay at the University of Michigan you will be champions and this is a famous Michigan quote. It's over the football stadium and it's over everything. So those who stay will be champions. And then the Abraham Lincoln quote, the best way to predict the future is to create it. I think we've been doing that in academic medicine for a long time but I think when we do think about global health that we need to think about creating a future that is consciously ethical in terms of its description. So I'm gonna stop right there and I'm happy to answer any questions. What kind of technology educational are you using? Okay. The medicine? So what kind of technology are we using? So right now we're using telemedicine. We do telepathology, we're doing teleptomer boards. So we have a breast cancer tumor board and a GYN oncology tumor board that happened every two weeks with both of the medical schools in Ghana and those are the major things. We've pushed a lot of kind of technology over there in addition prior to our going over there. So they have access to library material, internet material, the students and the learners are using almost everything off the internet. I mean it's, everybody's using up to date and everybody's using apocrates and they're more per capita cell phones in Ghana than they're in the United States. And so what's happening is that we're pushing over mass amounts of information and how to teach the next generation of physicians in Ghana to use that kind of electronic equipment to be able to practice in the new environment is something that we're just thinking about and starting to develop kind of pedagogical scholars in Ghana that look at how do we use new technologies. But telemedicine, especially for some of the super subspecialties, is something that's been very powerful. You don't have to have a pathologist in every country to be able to do high quality GYN oncology for example and cytology. We have once a month we do a kind of a cytology tumor board where they look at colposcopy and colposcopic correlations. The same thing's going on in surgery, same thing's going on in breast oncology but it's expanding out to other areas. Thanks for the question. Hi, I love to talk. I wanted to ask a question about the medical voyeurism which I think is an interesting concept and really does play a role in I think some of the global health that happens. And I'm wondering what you guys do to try and minimize that aspect of things and how you ensure that your program isn't based on medical voyeurism going both ways. Yeah, so the question is how do we, so both groups of students have a pre-visit tutorial that they go through. So they're written materials and online materials that both students from Ghana coming to the States and our students going to Ghana have to go through to talk about what to expect, what are the cultural competencies, what are the expectations for the rotation, what do we expect them to do. So the medical students from Ghana that come to us know we want them to see some normal deliveries. We want them to see how doctor-patient interactions happen, we want them to learn about the electronic medical record. And we want them to see laparoscopic surgery, CT scans and robotic surgery. So some of it's seeing the technology that they wouldn't see but some of it's seeing things that they don't see. So in Ghana, medical care is still very paternalistic. The patients come in and they're told what to do. And the idea of kind of doctor-patient interactions and patient education and patients' shared decision making is totally, totally foreign to the medical students. And it's one of the things that they like the most. They commonly say, when I go back, I'm actually gonna talk to my patients. Well, you know, that's a pretty cool thing to teach a large number of students and they've gone back and taught it to other medical students. And so those are the kind of the goals for the rotation. For our students going over there, they have some basic epidemiology, they have some basic public health, they learn about some STDs that they're not gonna see, and then they go over and they practice on the wards. You know, it's an interesting environment when they go over. So in Ghana, on Monday, you're on, in the OR, on Tuesdays, you're in clinic, on Wednesdays, you're in the ER, and on Thursdays, you're off. And then on Fridays, you're back and you rotate every, you know, they don't have services like we do here. They have Team A, Team B, Team D, and Team D, and they rotate in terms of their responsibilities. And so we're gonna see those kinds of things, things shift. But our educational priorities for the medical students coming both ways are different for the residents going both ways, are different for the fellows going both ways. And we've got learning objectives and measurable outcomes for all learners at all different kinds of levels. We've also got a booklet on, you know, what to do and what kind of clothes to take and how to take your malaria prophylaxis and, you know, what to do if there's an emergency and so on and so forth. So there's a lot of kind of cultural competency learning. For our students to go over there and realize that most of the patients they talk to don't speak English and that even the doctors in Ghana can't understand what their patients are saying because there are 45 different dialects. And you have to get somebody who translates and that translator may be somebody who can't translate at all or it may be somebody in the family who's not translating appropriately. Is also really, really interesting. So there are lots of transcultural lessons, transnational lessons and kind of linguistic lessons that are learned about the process. So it's an incredible learning experience for the students but you have to be very intentional as you look at them in terms of are they developmentally ready for what's going on? And again, the only people that we let have clinical experiences are third and fourth year medical students and above. Below that, you know, undergraduate students, medical students in the M1, M2 year, they get to do research, they get to see patient charts but they don't get to be on the wards and they don't get to see blood and guts and those kinds of stuff. Tim, thank you so much for an outstanding presentation and for showing and demonstrating to us how to have a global state of mind because I think the way Michigan does it is the only way to do global health through capacity building. You didn't say it specifically but I would like you to contrast the approach that University of Michigan has taken to some of the NGO and some of the, you know, people can be, if I can even be specific, the Paul Farmer type approach. Can you contrast that for us? So our approach is a very academic university grounded approach using traditional academic structures and vehicles and paradigms and rules to do the work that we do which is very different than the Paul Farmer method. Paul has been very engaged to a large number of years in Haiti but in using partners in health and NGOs to kind of build the work that he does partly because he came from Harvard where they don't have any structure either, right? I mean, I'm being facetious but I mean, they don't have the kind of vertically and horizontally integrated health system that you have in Chicago and that we have in Michigan. I mean, he can't go to a hospital and say you wanna do something because they don't own any hospitals. So I mean, I think that what he developed was what he could develop given what he had but our model I think is fundamentally different and actually as I've spoken to Paul he's gotten much more interested in human resource capacity building in residency building. His new program in Rwanda is focused on resident education and those kinds of things and it's kind of the old teaching man, give a man a fish in the lead for a day, teach a man a fish in the lead for a lifetime. These aren't, these are biblical lessons but again, as I said, I think that academic institutions are a good place to ground this work because if there's a coup, if there's a government turnover if there's economic instability an NGO is gonna be swept aside but a university and the structure of university is gonna remain, it may not be as robust but the phoenix that arises from the ashes is gonna rise much more quickly and in a much more recognizable fashion than whatever rises from an NGO after an economic disaster or political disaster. So I really think that sustainable capacity building is, I think academic institutions are a good way to think about sustainable capacity building. Now having said that they need to do it in an ethical way and in a way and it's always about money, right? What's gonna sustain it in the long term? What's happened at Ghana though is that now Ghana is able to provide us resources. I mean, they have all these professors, they're getting money from the Fogarty Foundation. They're coming over to the States and bringing money with them to do the work that we're doing and so after a couple of years if you've trained 150, 200 academics they actually have a certain gravitas that both academic gravitas, intellectual gravitas as well as financial gravitas that brings something real to the table. Please. I'd like to congratulate you on establishing a great program, training 142 clinicians and also, leading them to be involved academically and publish more than 100 papers. I guess one question I had that's sort of comparing to surgery. I know that there's a Lancet Commission on Global Surgery that's talked about some of the markers that you wanna look for in every country in terms of are they meeting goals and one of the statistics you mentioned was when you went in 1986, about 90 out of 100,000 women were dying in Ghana versus about 10 here and I was wondering if you could comment on how you've been involved in. Yeah, so great question. So the most recent data from Ghana suggested the maternal mortality is 300 per 100,000. So it's a third of what it was. Now that's not just because of this program. There've been lots of other things that have happened as part of the Safe Motherhood Initiative but I think training subspecialists who've trained other people. I mean what the key thing, Caesarean section, so if you read the, there's a really good chapter on obstetric surgery in that DCP book that you're talking about. I know it's particularly well written because I wrote it. But we talked about kind of years of life saved and dallas associated with both Caesarean section and operative vaginal delivery and Caesarean section has got one of the highest economic benefits in terms of years of life saved and disability associated life years reduced of any intervention because of, these are young women and if you can prevent them from dying in childbirth by doing Caesarean section which is a life saving operation. One of the things that we did in Ghana is we trained all physicians to do Caesarean sections. So it's not just OBGYNs but general medical officers at little district hospitals in rural Ghana have been trained to do Caesarean sections and that becomes a life saving skill. And so kind of pushing down and kind of job sharing. For a long time they were talking about job shifting but now we're talking about job sharing but not just OBGYNs but general medical officers and maybe even some places in the Zambia for example midwives doing C sections is something that can happen but only in a structure where you've got kind of senior specialists who understand kind of what, you know doing quality assurance and making sure that people are trained and retrained and so on and so forth. So yes, what you're talking about number one, there's a significant public health downstream and horizontal effect and you can, I mean I think these kinds of initiatives in terms of thinking about countries especially Ghana which is about to move from low income to middle income status in those transitions you can really see some of the benefits of this type of health interventions. And as I mentioned, emergency medicine was another great thing that happened. As they developed, so when emergency medicine started over there the first thing they did is they said oh, we have to train nurses to be trauma nurses because plain old med surgeon nurses can't run a trauma unit or an emergency department and so there was nursing training, then they trained residents and then they discovered that they didn't have a national ambulance system and so they set up a series of kind of communication systems so that people could communicate and the mortality from motor vehicle accidents in Ghana in the last 10 years has dropped by 50% and that's because in the old days you laid on the road forever. Now they have a system where they can identify, they can do on the field identification of patients that would benefit from transportation and are transporting patients to emergency centers within 24, within a short periods of time, within one to two or three hours where they can get appropriate care but the entire discussion around the importance of surgical interventions I think has become clear recently and Charlie Mock and the group that did the disease control prevention books that just came out from the WHO I think have made a significant contribution to thinking about what are the minimal things that we want in terms of surgical interventions to be able to repair typhoid perforations and bowel perforations and caesarean section it turns out of all the surgical interventions caesarean sections was far and away the most cost beneficial from a economic point of view in terms of years of life saved and disability years avoided. Thanks for the question. Go ahead, do you have a question? He asked before. Okay. Yeah, yeah. So I mean it goes past OBGYN it goes past kind of women's reproductive health but it's a way of thinking about the fact that women are central and if you can kind of repair some of these women's health issues in countries where women's issues are increasingly important that there's spinoff in other areas and people recognize oh by the way we need ER docs and oh by the way we need general surgeons and oh by the way we need neonatologists I mean if we're gonna reduce perinatal mortality and reduce early stillbirths then we need some neonatologists to deal with some of those issues as well. Great. Thank you so much. Yeah. That's my question.