“Taxes,” “Antes,” and “Bonuses”

To the Editor: Drs. Palazuelos and Dhillon1 summarize a popular mind-set around phvysicians’ involvement in global health experiences abroad: that everyone who wants to ought to be able to do global health work abroad. Unfortunately, simple logic suggests it is not feasible to provide meaningful work abroad to the two-thirds of U.S. medical students who express interest.2 Yet, this ideal drives an ever-growing number of trainees and young physicians to invest in master of public health degrees and research/study-abroad electives, and promotes efforts by specialties not traditionally involved in population-level health work abroad (e.g., surgery) to label their work “global health” in competing with more traditional fields (e.g., public health or primary care) for attention and resources. Others argue that global health should be a recognized physician specialty, with accredited training programs and defined career positions within a particular practice profile. This would address the striking parallels with “start-up” culture as described by Drs. Palazuelos and Dhillon, where few of many entrepreneurs “make it” against seemingly insurmountable barriers, often at great personal sacrifice and/or thanks to circumstantial advantage. Those who fail are left to reprioritize after having invested time, passion, and money. Directing some practitioners towards a formal training and career pipeline might provide greater stability and direction. Indeed, what Drs. Palazuelos and Dhillon describe as “wild cards” are various life priorities, for which the choice of career is no different, and often in competition with other seemingly immovable priorities, such as massive debt, or a domestically focused spouse/partner. At present, pursuing an expatriate career leads to inevitable sacrifices without guarantee of success, which makes the global health “tax” described by the authors more realistically an “ante.” The authors conclude that without support, many will ultimately exit the field of global health. While unfortunate, this is reasonably expected as individuals reprioritize, which means at minimum any support should include improved career mentorship and guidance. The establishment of formal training programs leading to defined employment might also help rationalize the existing “start-up” environment. Formally trained specialists would resemble the differences between public health physicians and physicians interested in public health; the former are vocationally trained, the latter are clinicians with side projects. Should global health work continue to solely exist “on the side,” then much like early clinician–researchers chasing their first grant, interested practitioners will ante up hoping to “make it” into an expatriate career—perhaps against their better judgment. Lawrence C. Loh, MD, MPH Adjunct professor, Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada, and director of programs, The 53rd Week Ltd., Brooklyn, New York; [email protected]

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