The human population has
a history of regional and national advances in science, industry
and enlightened thought, taking us from the building of simple tools
to an understanding of the beginnings and the nature of the universe,
which we inhabit. Being a relatively early form of life, in a relatively
newly formed universe, human thought may even be the most advanced
level there is, in this point of space-time.
Obviously our thirst for knowledge has been linked
to our advances as a global population, with technology, art, philosophy,
science and medicine contributing to our greater understanding,
and the ability to have some degree of authority over our own lives.
Much of this knowledge has extended to the reach
of most humans - and the internet, in modern times, has allowed
for greater access to repositories of information and education,
both good and bad, though this paper focuses on the positive aspects
of equity of access to education.
There are areas of education however, with a huge
financial premium on them and much of this is for the right reasons.
Those practicing in various scientific, educational and medical
fields, need to be properly schooled to ensure that when they put
that education into practice, it is achieving the often complex
aims of the education.
Unfortunately the price of access to some of this
knowledge means that potential scholars in many countries cannot
afford it and in the case of medical education this is possibly
the most problematic and restricted, while being a basic right for
all humans - that is, access to proper medical care.
This leaves some countries with few or no trained
doctors and even in the wealthiest countries there are shortages.
It also means that those in low-income nations who are able to access
medical education because of money or luck, use their degrees as
a ticket to a better life in a developed country, looking for their
skills. On an individual basis you cannot blame people looking for
a more advantageous life for themselves and their families but generally
it just perpetuates the drain of resources from poor countries to
wealthy countries, where the shortages in trained medical personnel
Now is the time is to look at inequities of access
to medical education particularly, in an age when Information and
Communications Technology (ICT) does provide for strategies for
innovative and strategic means of better and cheaper distribution
of, and access to, vital knowledge not just in the interests of
individual access for the student, but universal access to the means
of making it a better world for all.
Knowledge leads to enlightenment of thought, creativity,
compassion and empathy and possibly world peace via better public
and academic education.
Attempts have been made, in recent times, to look
at the global problem of inequities in medical education and practice.
The dearth of high quality educational resources
in some regions is self evident, with many global doctors practising
in fields in which they have no formal training whatsoever. These
doctors however are filling vital roles and doing the best they
can under the 'local' circumstances.
Good global education needs to fit the requirements
of a greatly diverse consumer, with diverse values, diverse levels
of prior training, and be accurate in all situations.
These problems are magnified when dealing in medical
education, particularly primary care, and when dealing with a multinational
approach and a multinational endpoint.
The Applied Sciences of Oncology Distance Education project2
The International Atomic Energy Agency (IAEA)
and the Regional Cooperative Agreement for Research, Development,
and Training Related to Nuclear Science and Technology (RCA) financed
a Distance Learning Course on the Applied Sciences of Oncology,
to be delivered on multimedia CD ROM. This training course is an
outcome of an IAEA Technical Cooperation Project implemented under
the (RCA). RCA is an intergovernmental agreement among seventeen
Member States of the IAEA in the Asia and the Pacific Region.
Following the identification of the shortage of
well qualified radiation oncologists in the region, the Member States
of the RCA decided to address this problem through the development
of distance learning material. The National Project Coordinators
also assisted in the pilot testing of the training material. Three
RCA Member States, three AFRA (Regional Cooperative Agreement for
the Africa Region) Member States and two ARCAL (Regional Cooperative
Agreement for the Latin America Region) participated in the pilot
testing of the distance learning material.
The requirement was to 'educate without teaching',
for fear that an untrained doctor may follow the instruction by
rote, for example, in every case of breast cancer, when it is the
lymph nodes that are involved, that indicate appropriate treatment.
Any prior level of medical knowledge was also not to be assumed,
so the project also involved complementing or reviewing 'basic training'.
Essentially the task was to combine science with
socio-economics and to look in depth at the many issues involved.
While initially developed as a training aid, it was deemed in 2005
a successful TC by the IAEA and accepted as global curriculum to
train 900 oncologists in developing nations every 5 years.
The major challenge in the ASO project was the
learning environment. In the case of the ASO project the environment
was multimedia CD as it required complex scoring and tracking, access
to web based services from the CD itself - video, pfd, and animations
plugged in, date stamp recorded on course certificate/report as
each module was completed.
If using an English language platform there are
both technical and language issues to be overcome. Even an apostrophe
can turn into a foreign character on a non-English language PC,
but the most important aspect is the level of language used. Unambiguous,
clear and simple language is best but certainly hard to achieve
when dealing in quantum physics for example.
Obvious issues are the recommending of certain
facilities, equipment, medicines and so on that may not exist in
the country in which the doctor is practicing.
There was also no ethnic or cultural viewpoint,
no geographical location, no national approaches, and level of language
at ESL (English as Second Language,). In many cases it was actually
very difficult for the authors to mentally remove themselves from
a national viewpoint to an international viewpoint.
To localise content you need to look at both ends
of the process. In the case of global medicine the source of the
medical education is as important as the endpoint (the global doctor,
registrar or medical student). Medical education is usually written
for the audience it is going to teach, within a process and with
certain facilities, which match the conditions within which the
resultant medical graduate will practice.
The second aspect is the learning environment
on the CD based courseware itself. Intuitive navigation for the
student was the goal, and several visual techniques were employed.
All units in the same subject areas were colour coded for familiarity,
where possible easily recognized symbols were used e.g. forward
and back arrows for screen navigation and so on.
Once patterns were struck they were repeated again
for familiarity - this applied to question styles and graphic styles,
Pilot countries involved were Egypt, Morocco,
Malaysia, Pakistan, the Philippines, Argentina and Uruguay, and
also included students from Costa Rica, studying in Argentina.
The success of the project has seen it achieve
curriculum status and ongoing maintenance is intended, to ensure
that the course remains current as oncological practice changes.
It is hoped to translate the modules into Spanish, French and possibly
Chinese, Russian and Korean, after 2007.
It is estimated that a fully functional and regularly
updated course in English, plus these major languages, could support
the training of up to 900 radiation oncologists every five years.
Access to global medical education involves three
basic issues, and the first is the content and the focus of that
education. It is the experience of the authors that medical education
currently tends to stop at borders and that education within national
boundaries can have a focus that depends on the wealth of that country.
In wealthy counties there is much education and focus on diseases
of wealth, for example cardiovascular disease, diabetes type 2,
but little focus or need for the same on malnutrition, malaria,
typhoid, cholera and other even preventable disease.
This can disadvantage both ends of the spectrum.
The global community misses out on the contribution
to real education needs and also the wealthy community, through
the medicalisation of what is often lifestyle or cultural or media
induced trends. With emphasis and money spent on cure and amelioration,
there is less emphasis on self-help, prevention and discipline.
The second aspects are affordability and accessibility.
With few quality education facilities within a country, or with
poor access due to war, famine, national catastrophe or other ignorance,
the potential scholar has to finance their own solution. This is
not as big a problem to the wealthy in the community, but the wealthy
have greater access to all forms of education and therefore greater
choice. If we focus on those who have the commitment and the ability
but not the money, that is, the vast majority of international medical
students, then both accessibility and affordability are the major
problems, but in the solving of this conundrum, it provides a great
solution to the inequities of the healthcare of the global population.
And it is good economics and good epidemiology, as pockets of illness
and disease have an even greater ability these days to affect the
global population, such as our experience with SARS, avian flu and
Issues of affordability
Even giving that the individual developing nations'
medical student could afford the course at an overseas institution
(not withstanding the high degree of variability of quality in institutions
even within countries) there is also travel, accommodation, cost
of bureaucracy, cost of personal support and issues of loneliness,
isolation, cultural differences and other compounding factors.
And affordability must always have a national
perspective. If a doctor practising in a developing country, earns
the equivalent of $US 200 year, most sources of outside education
are immediately placed out of reach.
The reverse of the national exchange rate however,
can be put to good use. Spending 'outside' money within a developing
country however sees costs greatly reduced, and a solution taking
advantage of existing infrastructure, is even better.
Our World CME project was born out of these very
circumstances. The situation was compounded by the countries that
greatly needed this repository of medical education and training,
were those who could not afford it, at all, in some cases.
Usually this is where it ends. The market place,
in this case universities, have finite costs they must cover and
if the student does not have the means, then the quest ends there.
Information and communications technology however,
has given us the means of distributing and authoring global public
and professional education. Even in developing countries most educated
people would have email and access to a PC. Using these as mass
distribution tools, in a strategic and focused way eliminates huge
costs and makes education dissemination viable.
So do developed nations leave quality medical
education on the shelf which is needed by half the world, simply
because they cannot afford it? We were faced with this dilemma and
World CME (www.WorldCME.com)
was our solution.
The two issues were money and distribution, in
other words, 'sustainability'. The solution was to put it on the
Internet for countries to 'help themselves' but needs of accreditation
and standards and quality assurance - to allow national medical
standards to develop - were the next priority, and so the full World
CME service was developed, and utilising different ICT solutions
for different nations.
History of World CME
We have taken a three tiered approach to pricing of education based
on National Income Status (World Bank pdp 2005)1, with low income
nations receiving education free as long as we can cover distribution
costs. Putting it on the internet has allowed us to distribute it
at no end cost to the user and given the relative socioeconomic
status of our students (doctors and medical students) this has been
a viable approach. Other strategies have been using CD where internet
is not prevalent, and medical centres can usually provide a PC.
Rights to issue on paper are given where ICT is not readily available.
Re-writing and revising content
As the internationalisation of medical education has not yet occurred
we have had to devise it ourselves and it looks at much the same
issues as with the ASO project.
But mostly education has to be both understood
and relevant to the local situation. This may mean instead of prescribing
iron tablets to an impoverished anaemic pregnant woman who cannot
afford them, the recommendation is the growing and eating of green
leafy vegetables; and it may mean using the ancient medical arts
of history taking and physical examination, when expensive tests
are not available,
World CME is now used in 6 developing nations
and is just as much the brain child of those participating countries
who have made the leap of faith to do something positive about the
national situation. Indeed the leap of faith has not seen World
CME as a poor substitute, rather as an enhanced interactive format
as a positive advantage and a means to leap ahead nationally by
using the advantages of ICT and interactive education.
Other global or regional approaches can include
face to face teaching, via focused medical education delivered regionally
in conference style formats, such as with MEAMA the Middle East
Academy of Medicine for Aging4.
The number of older people is growing and they
frequently have health-related problems with a mixture of physical,
mental, social and behavioural aspects. In the past, these problems
were seen only in a few older people and the families were able
to take care of their parents or old relatives. However, societies
are changing as a result of the demographic and cultural developments
and they face the increasing possibilities of modern medicine. The
MEAMA was founded in 2002. The first course was held 2003/2005 to
stimulate the development of health care services for older people
in the Middle- East area. The course has been built up with 4 sessions,
each of 4 days, that will cover important topics of the health-related
problems in older people. The second course will follow the same
format and will start in April 2008.
The organisers of the MEAMA conduct this course
with support of the European Academy for Medicine of Ageing, the
European Union of Geriatric Medicine, the Geriatric Medicine Section
of the European Union of Medical Specialists and the International
Association of Gerontology. MEAMA is the first organisation in the
Eastern Mediterranean Region dealing with education of the health
care professional in the art of elderly care.
Following on the acceptance and use of these approaches
to strategic international medical education, has been the development
of a multimedia medical university (MMU) built on the same principles
and due for launch in 2008.
Its distance learning formats using ICT, will
allow it to cater to the postgraduate medical needs of doctors and
medical students worldwide.
The education will also offer enhanced formats,
for example, interactive video of surgery procedures and a range
of clinical topics in interactive formats. The global multimedia
aspects also allows MMU to select the best academics/teachers globally,
to provide and write the medical courseware.
The aim is to provide the highest standards in
the delivery and content of medical education, to meet the real
needs of international health and to make such affordable to all
doctors in all nations, in an attempt to provide both genuine equity
of access to education and genuine equity in the delivery of national
1. World Bank Report 2005