An increasing number of US graduate medical learners and pediatricians seek training, clinical practice, and scholarly involvement in global health (GH),1  often motivated by their desires to mitigate pediatric health inequities around the world. GH is described as a discipline that applies the resources, knowledge, and experience of diverse societies to address the world’s health equity challenges.2  One such challenge in the global pediatric community is mortality caused by vaccine-preventable illnesses. Most pediatric deaths occur in low- and middle-income countries (LMICs), in which vaccine-preventable deaths remain a substantial contributor to inequities.3  Many LMICs are formerly colonized societies that were once forcibly socially, economically, and politically controlled, mainly by European powers, and are often described as less developed and less capable of change.4  Unbeknownst to many, formerly colonized and enslaved people have contributed to advances in medicine and the GH field.5  In her book, Medical Apartheid, Harriet A. Washington writes about Onesimus, an enslaved African, who in 1721, taught variolation to his slave owner.5  Variolation is a transformative process by which exposure to viral material causes a mild local infection, resulting in lifelong protective immunity. Onesimus freely shared the knowledge he learned from his native tribe that ultimately saved populations in the New World from the dreaded smallpox epidemic. And yet, variolation was only disseminated and accepted in the New World through the word of Boylston, an American colonial physician, who secured himself the unearned credit of Onesimus’ technique.

Medical contributions like Onesimus’ are not universally taught in US-based pediatric global health education (GHE) because GH did not originate from these untold stories,6  nor did it center on protagonists like Onesimus. Instead, GH, and thereby GHE, evolved from colonial and tropical medicine, which were disciplines used by colonial powers to exert social, political, and economic control over colonized people and promote the erasure and abandonment of knowledge they produced.4,7  In modern days, GH perpetuates white supremacy through ongoing economic and geopolitical injustices, such as unequal access to vaccines between high-income countries and LMICs during the coronavirus disease 2019 (COVID-19) pandemic and the climate crisis, which disproportionately affects LMICs.4,7,8  Teaching untold stories centered on protagonists like Onesimus that describe medical accomplishments developed by oppressed societies would advantageously diversify medical learners’ worldviews and build shared cultural humility to better understand the realities of the sociopolitical drivers of health in the communities in which they will work.6 9  The current pedagogical shortcomings of GHE risk leaving US-based pediatricians unaware and unprepared to optimally address current pediatric health inequities.6 9  To transform US-based pediatric GHE into a discipline that aligns the pediatrician’s mindset with the global mission to improve the health of children regardless of nationality, culture, language, religion, or socioeconomic status,10  we must reconcile 4 aspects of our pedagogy. First, we must identify curricular gaps that will redress the colonial roots of GH. Second, we must instill a transformative learning framework that promotes cognitive shifts through the critical reflection and confrontation of assumptions into GHE. Third, we must foster equitable and just partnerships. Finally, we must diversify GHE leadership. Although we focus on pediatric GHE, we recognize that these issues transcend pediatrics, and solutions could apply to other medical specialties.

The basis of GHE in the United States arose from the legacies of colonialism.4  This is problematic and likely why the pedagogy has not been able to fully uphold the discipline’s ideals.4,7 9  Maintaining the status quo withholds the recognition and dissemination of powerful knowledge that, if reconciled, could serve to address health and systemic inequities.7,8  Thus, we must be intentional about transforming GHE. We, therefore, call on GHE programs to recenter and restructure their curricula around justice and to include diverse voices and teachings of formerly colonized communities. Our team identified critical gaps in US-based GHE after reviewing the literature,4,7,9  conducting a needs assessment,11  and seeking diverse expert leader and partner consensus (Fig 1).

FIGURE 1

Critical gaps in global health education. Through literature review, needs assessment, and expert consensus, we identified 8 domains required to redress colonial roots in global health.

FIGURE 1

Critical gaps in global health education. Through literature review, needs assessment, and expert consensus, we identified 8 domains required to redress colonial roots in global health.

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To successfully inoculate a novel anticolonial and antiracist curriculum into GHE, developing a framework that thoughtfully engages and challenges learners with the content is needed.

A learner-centered approach, such as Mezirow’s theory of transformative learning,12  adjusts thinking through critical reflection while making meaning of new information. The framework encompasses activities that promote self-examination, learner interaction, simulation, and exploration through reflection prompts.12  Trained educators guide learners to assess their perspectives, recognize assumptions or biases, engage in new information, solidify alternative approaches, and build confidence in future actions.

Exposing GH learners to concepts that question the basis of GHE “will challenge students’ preconceived ideas, often by confronting them with disorienting dilemmas.”7,12  A dilemma could be a cognitive recognition to unlearn and relearn knowledge, such as shifting the historical credit for coining variolation from a white colonial physician to an enslaved African or a dramatic experiential dilemma, like role play, requiring learners to apply culturally-informed skills to a resource-constrained clinical simulation. Much like variolation, this transformation starts with learners being willing to accept some discomfort to gain proficiency and self-confidence in their future GH actions. We call on GH educators to instill a transformative learning framework so that a stronger version of GH can exist, one that is more immune to racism, colonialism, and other forms of discrimination.

GH partnerships between US academic institutions and LMIC partners are wrought with pervasive power imbalances. One such imbalance was exposed when US medical personnel and learners were quickly pulled from GH sites at the onset of the COVID-19 pandemic, leaving many LMIC partners with human resource shortages.13,14  Yet, scientists in LMICs made impactful scientific contributions during the COVID-19 pandemic, such as the early identification of the Omicron variant in South Africa and the dissemination of simple innovations to prevent disease transmission first used in Sierra Leone during the 2014 Ebola epidemic.15  Lessons learned from these communities’ resilience and resourcefulness should not be forgotten as GHE begins its transformation.

The pandemic highlighted the need to rethink partnership models and ensure equitable practices, including decision-making, flow of learners, research agendas, and awards.13,16  Rethinking partnerships also means that US GH leaders should embrace their role as allies. We call on GH allies to dismantle power imbalances by leveraging their privilege and influence in consideration of LMIC partners who have long been marginalized, exploited, and underrecognized.

Recent publications examining the diversity of GH leaders reveal a stark underrepresentation of historically marginalized groups (non-exhaustively including women, people living with disabilities, Black people, Latinx people, Indigenous people, and nationals of formerly colonized countries).4,17  Similarly, representation in GHE is lacking. In 2021, nearly one-third of survey participants in US pediatric, emergency, and family medicine GHE programs reported not having educators who identify as underrepresented in medicine or as international medical graduates.11  This lack of diversity has unsettling implications: GH learners are often taught through the lens of historically privileged groups, and international medical graduate and underrepresented in medicine GH learners lack access to mentors who may share their lived experiences.

Beyond increasing diversity, GH educators need to foster inclusive environments that skillfully elevate the voices of GH learners with intersectional identities and diverse experiences. We, therefore, call on GHE programs to be more intentional about diversifying leadership by focusing on recruitment, retention, and advancement and offering facilitator training to promote learner inclusion.

To address the 4 unreconciled aspects of GHE as described above, an antiracist, anticolonial curriculum is needed. Through joint efforts of global educational scholars and support from organizations, including the American Academy of Pediatrics, a new open-access modular curriculum, Global Health Education for Equity, Antiracism, and Decolonization (GHEARD), was developed.18  The modules address the gaps identified in this paper using carefully curated and peer-reviewed activities designed to engage learners through a transformative learning framework. A versatile implementation guide with robust facilitator training exists to support GHE programs in various stages of readiness. Studying the impact on learners and the implementation of the GHEARD curriculum nationally will be paramount to assessing the transformation of GHE over time. As with variolation, intentional exposure to new material can mount the necessary response to transform individuals, cultivate collective action, and ultimately secure a more equitable shared understanding of GH.

Thank you to the GHEARD Author Group for their inspiration for this perspectives article, including Drs Bethany Hodge and Sheridan Langford for introducing us to the educational theory behind transformative learning.

Drs Fanny, Tam, Rule, Barnes, and Haq conceptualized the perspectives paper, drafted the initial manuscript, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

COVID-19

coronavirus disease 2019

GH

global health

GHE

global health education

GHEARD

Global Health Education for Equity, Antiracism, and Decolonization

LMIC

low- and middle-income countries

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