Ninety percent of the world’s children live in low- and middle-income countries, where barriers to health contribute to significant child morbidity and mortality. The American Academy of Pediatrics is dedicated to the health and well-being of all children. To fulfill this promise, this policy statement defines the role of the pediatrician in global health and provides a specific set of recommendations directed to all pediatricians, emphasizing the importance of global health as an integral function of the profession of pediatrics.
Although its definition may vary, we define global health as a discipline that prioritizes equity in health care and stresses the commonality of health issues that require collective, interdisciplinary action both within and across national borders.1 The American Academy of Pediatrics (AAP) declares that pediatricians are “dedicated to the health of all children." To fulfill this promise, pediatricians can work domestically and collaboratively across international borders to improve the health of children throughout the world, regardless of the nationality, culture, language, religion, or socioeconomic status of those children.
Under this broad definition of global health, it is clear that AAP members may engage in global health both within the United States—for example, by caring for children from different cultures—as well as outside US borders. Disparities in health and its determinants are often striking across ethnic and cultural groups, both in the United States and abroad, and warrant a global health framework. For example, pediatricians in the United States routinely care for immigrants, refugees, non–English speakers, and international adoptees who often have specialized health needs similar to those of children in other countries.2 In addition, a record number of US citizens (87.7 million), many of whom are children, traveled abroad in 2017,3 resulting in exposure to health conditions and communicable diseases prevalent in foreign countries. Finally, emerging global pathogens, such as Ebola and Zika viruses, have arrived in the United States. Thus, global health is local health and comprises both domestic and cross-border issues.
Ninety percent of the world’s children live in low- and middle-income countries (LMICs), where barriers to health, including poor control of infectious diseases, insufficient chronic disease prevention, malnutrition, health care worker shortages, armed conflict, injuries and surgical diseases, mental health, and environmental health issues, contribute to significantly increased child morbidity and mortality.4,–6 Although the number of childhood deaths in LMICs has been cut by more than half in the last 2 decades, approximately 5.4 million deaths among children younger than 5 years still occur each year.7 Furthermore, the burden of risk for poor developmental outcomes remains extremely high; in fact, approximately 250 million or 43% of children younger than 5 years in LMICs are at risk for not attaining their developmental potential because of extreme poverty or poor nutrition.8 To underscore shared commitment and to establish a universal global agenda, leaders from 193 countries created the Sustainable Development Goals (SDGs), an ambitious set of 17 goals meant to be achieved by 2030.9 The SDGs provide a global framework for eliminating poverty and improving health and well-being. Meeting the SDGs will require an emphasis on the health and well-being of all children and their right to both survive and thrive in an equitable and sustainable world.9,10
Role of the Pediatrician in Global Health
Global health is an increasingly valued dimension of medical education, and more than 25% of pediatric residency programs in the United States now offer formal global health tracks.11 The American Board of Pediatrics, AAP, and their academic partners, represented by the Federation of Pediatric Organizations, have called for global health training for all pediatricians,12,–14 and as a result, standardized curricula for residency training in global child health have been published and implemented.15,–17 This policy statement, by contrast, focuses on practicing pediatricians—all pediatricians, not just those who may pursue a global health career or more extended global health experiences. The intent of this statement is to describe the collective role of pediatricians in the evolving field of global health. Recommendations may also be relevant to other health professionals working with children.
Pediatricians may engage in global health activities in multiple domains, including but not limited to direct patient care, teaching and training, research, and advocacy. Examples of patient care include US pediatricians who provide medical homes for children from other countries, as well as pediatricians who travel internationally to provide clinical care for children in LMICs. Pediatrician educators trained in global health may teach young physicians in the United States to be globally minded and clinically prepared to care for children from diverse socioeconomic and cultural backgrounds. Pediatricians with the requisite background may also train physicians and health care workers in LMICs.6 Participation in global health research is an opportunity for pediatricians from all countries; it can be a means to address emerging challenges in medicine, including low-cost technologies, social determinants of health, and implementation science.18 Finally, examples of global health advocacy include efforts to deepen or sustain investment in global childhood vaccines, research, pharmaceuticals, and supporting policies that aim to fulfill achievement of the SDGs.19,20
Engagement in global health is not without challenges or risks, so efforts to address ethics, safety, medical liability, and legal and fiscal considerations are essential, along with adequate preparation and supervision.11 Regardless of the domain in which pediatricians may engage in global health and regardless of personal interest, global health has clearly become integral to the profession of pediatrics. Implementation of the following recommendations has the potential to advance global health and the profession of pediatrics.
Pediatric continuing medical education (CME) providers and departments of pediatrics are encouraged to make training in global health available to pediatricians and trainees. Topics include the global burden of disease; immigrant and refugee health; patient communication through interpreters; social determinants of health; cultural humility; global child health disparities; disaster management; travel and tropical medicine; population health, including strategies for prevention and treatment of common diseases; and ethical considerations, including the ethics of short-term international medical missions and international research. Although some topics are regularly included in courses offered by CME providers, gaps exist, and topics are frequently addressed without a global health framework.
As part of their CME training, pediatricians are encouraged to recognize the enormous differences that exist throughout the world in access to and quality of health care for children and to examine how different models of care variably affect health outcomes for children.
Before volunteering for short-term trips or accepting long-term positions abroad, pediatricians should become knowledgeable of best practices (eg, pre-travel preparation, coordination with local partners, language study, cultural sensitivity, and attention to ethics).17
As described in the AAP Blueprint for Children,21 pediatricians are encouraged to advocate for government policies that support global child health, including promotion of the growth and development of every child to his or her full potential; access to education; equitable distribution of immunizations and life-saving medicines; prevention of child abuse and neglect; tobacco control; health equity and disaster preparedness; access to essential surgery, safe anesthesia, and perioperative care; and protection of children from violence. The United Nations’ Convention on the Rights of the Child can serve as an effective advocacy tool.20
Pediatricians working in global health should work collaboratively with international partners to achieve shared goals, whether broad (eg, fulfillment of SDGs) or context specific.
Pediatricians working in global health are encouraged to incorporate the use of telemedicine as a viable option for enhancing knowledge transfer and increasing access to patient care.22
Pediatricians are encouraged not only to use skills learned at home to benefit children abroad but also to use knowledge and innovation gained abroad, such as the use of cost-effective diagnostic and treatment strategies, to improve medical and surgical care for children domestically (reciprocal innovation).
AAP chapters are encouraged to play a role in coordinating and offering global health training and service opportunities within their regions.
Pediatric organizations are encouraged to consider a global health perspective in their missions and activities, including addressing global health disparities and supporting young pediatricians and trainees in becoming globally minded.
Pediatric societies and organizations around the world are invited to collaborate with the AAP to promote long-term partnerships that support global health training, advocacy, and leadership.
Dr Suchdev served as the lead author for the manuscript, organized the writing team, drafted the initial manuscript, and finalized the manuscript; Dr Howard contributed to writing the manuscript and reviewed and revised subsequent versions of the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
FUNDING: No external funding.
American Academy of Pediatrics, Section on International Child Health: http://www2.aap.org/sections/ich/
Association of Pediatric Program Directors, Global Health Pediatric Education Group: http://appdgh.wordpress.com/
Global Pediatric Education Consortium: http://www.globalpediatrics.org/
Consortium of Universities for Global Health educational modules: http://www.cugh.org/resources/educational-modules
Johns Hopkins Berman Institute of Bioethics, Ethical Challenges in Short-term Global Health Training: http://ethicsandglobalhealth.org
Boston University, The Practitioner’s Guide to Global Health Course: http://www.edx.org/course/the-practitioners-guide-to-global-health
American Academy of Pediatrics, Immigrant Child Health Toolkit: https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-Community-Pediatrics/Pages/Immigrant-Child-Health-Toolkit.aspx
World Health Organization: http://www.who.int/en/
Global Initiative for Children’s Surgery: http://www.globalchildrenssurgery.org/
Parminder S. Suchdev, MD, MPH, FAAP
Cynthia R. Howard, MD, MPHTM, FAAP
Section on International Child Health Executive Committee, 2017–2018
Parminder S. Suchdev, MD, MPH, FAAP, Chairperson
Kevin J. Chan, MD, MPH, FAAP
Cynthia R. Howard, MD, MPH, FAAP
Patrick McGann, MD, FAAP
Nicole E. St Clair, MD, FAAP
Katherine Yun, MD, MHS, FAAP
Linda D. Arnold, MD, FAAP, Immediate Past Chairperson
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.