Since January 2020 billions of people across the world have been “locked down” and
hundreds of thousands have died because of the COVID-19 global pandemic. The pandemic
is creating enormous adverse economic and social consequences throughout the world,
with direct and indirect impacts on global health activities - particularly through
the participation of health care workers, clinicians, investigators, technologists,
and students in research training and educational programs in low- and middle-income
countries (LMICs).
A primary approach of global health training programs has been to bring trainees to
grantee institutions in developed countries to participate in in-person coursework,
attend skills-based workshops, and/or work directly with researchers and mentors.
Another important component has been travel by mentors in the grantee institutions
to partner institutions in LMICs to facilitate workshops, lectures, and in-person
clinical investigation and laboratory trainings. Training has also consisted of participation
in formal courses and degrees, with trainees completing either full-degree or certificate
programs at universities, and/or working directly with their mentor. However, the
near-complete shutdown of international travel prevents faculty, mentees, and mentors
from taking part in these indispensable exchanges.
CURRENT AND FUTURE CHALLENGES
One of the largest institutions funding this type of education and training is the
United States (US) National Institutes of Health (NIH) Fogarty International Center
(FIC), dedicated to supporting and facilitating partnerships between health research
institutions in the US and LMICs around the globe, and training scientists to address
global health needs [1]. FIC has funded 153 global health training programs, including
118 programs that were active as of April 2020 [2]. FIC D43 training programs are
funded through peer-reviewed grants and designed to be collaborative, long-term, and
flexible to meet the research priorities of both the US and foreign institutions [2].
The training goals of a D43 program include short-, medium- and long-term goals. Short-term
training goals are designed to be accomplished in less than three months and are usually
composed of faculty-led workshops or training sessions focused on specific areas of
research methods or laboratory skills [3]. Medium-term training goals are designed
to be accomplished over three to six months and include components such as working
directly with a faculty mentor on a research project and taking non-degree courses
to support specific research topics [3]. Long-term training goals are designed to
be accomplished over a period of six months or more and can include formal graduate
education such as master’s, doctoral, and post-doctoral degree programs related to
the training areas needed and public health concerns within trainees’ home countries
[3].
Table 1
provides information on strengths and weaknesses reflecting the impact that the COVID-19
pandemic may have on activities of global training programs based on our own experiences
learned from our NIH FIC D43 training program in Nigeria and other global health educational
programs. Short-term training activities previously had in-country, on-site components
requiring travel by US faculty and mentors, which resulted in significant team-building
and socio-cultural adoption. Due to COVID-19, travel is postponed or cancelled, replaced
by shorter and more frequent virtual communications and lectures. This paradigm shift
has resulted in lower program expenditures, more frequent contact between trainers
and trainees, and allowed for the recruitment of a wider range of faculty for educational
activities than would normally be feasible. Conversely, online interactions represent
a loss of opportunity to expose mentees to other cultures and a diversity of ideas
only available through international travel, including learning about different approaches
to work and study methods, making new friends, starting networks potentially outside
their original trainee study groups, and building global citizenship.
Table 1
Challenges and opportunities of global health training program due to COVID 19 pandemic*
Pre-COVID-19
During COVID-19
Planned Activities
Weaknesses
Strengths
Adapted Activities
Weaknesses
Strengths
Short-term training programs (0-3 months-duration): conferences/symposia, workshops,
faculty enrichment; 1-3 participants in the US, 1-30 in-country
On-site workshop training
Requirement of travel
Direct in-person contact
Replaced by video presentations and discussions led by US faculty
Lack person-to-person interactions
Expenses reduced
Costly
Able to spread out for more contact over longer time
Limited frequencies
Cross-institution team building
Lack of experience in US institute
Can source lectures from more faculty without cost barrier of travel
Social-cultural adoption
On-site annual meeting
Requirement of travel
Direct In-person contact
Replaced by video meetings
Lack person-to-person interactions
Expenses reduced
Costly
Limited frequencies
Lack of experience in conferences and meetings
Social-cultural adoption
Cross-institution team building
More US and LMIC faculty are able to join without cost barrier of travel
Faculty Enrichment
Requirement of travel
Cements cross-institution collaboration
Postponed
Rely on email and other online communications
None
Costly
Medium term: specialized training (3-6 months)
Specialized training
Requirement of travel
Able to focus on specific research skills for competencyD
50% of trainees postponed
Loss of direct contact with faculty
Expenses reduced
Trainees joined virtual lectures for increased contact with US faculty
Costly
irect In-person contact
50% of trainees were able to participate in online nondegree training
More trainees able to join virtual sessions
Long Term: Graduate degree and non-degree training (>6 months)
Masters (Non home in-person)
Social-cultural adoption
Advanced research training in variety of skills
Trainees that already started continued
Loss of direct contact with faculty
Expenses reduced for those transitions online
Trainees joined virtual lectures for
increased contact with US faculty
Must set up LMIC in-country research from US
Trainees expected to start were transitioned to online per university
Loss of interaction with other students
Masters (US online)
Less direct contact with US faculty
Advanced research training in variety of skills
Trainees continued as university adjusted
None
Trainees joined virtual lectures for increased contact with US faculty
Access to NU online resource
PhD (US in-person)
Must set up LMIC in-country research from US
Social-cultural learning
Trainees that already started continued
Loss of direct contact with faculty
Expenses reduced for those transitions online
Advanced research training in variety of skills
Access to NU resources
Trainees expected to start were transitioned to online per university
Loss of interaction with other students
Trainees joined virtual lectures for increased contact with US faculty
LIMC – low- and middle-income countries
*Based on Northwestern University Fogarty International Center (FIC) funded D43 global
health training programs (full list of training grants can be found at https://www.globalhealth.northwestern.edu/centers/communicable-diseases/index.html
and https://www.globalhealth.northwestern.edu/centers/oncology/index.html).
Photo: From the authors’ own collection, used with permission.
Medium-term training activities were often accomplished through a mix of in-person
training in the US and LMICs. Trainees take part in specialized training with US-based
faculty, with either party traveling, followed by in-country research. These medium-term
training activities have similar weaknesses and strengths to the short-term training
activities in response to the COVID-19 pandemic. For longer-term training activities,
the COVID-19 pandemic is not projected to substantially impact in-country research
and graduate training beyond the loss of travel for US and in-country partners and
the delay in trainings that are absolutely needed in person. Many global health research
training programs were already shifting online and can continue uninterrupted; traditional
US-based graduate training is quickly catching up, with most already offering some
online curriculum materials to trainees who are unable to travel to the US. While
the COVID-19 pandemic may have a lasting impact on global health training and education,
at the same time, these challenges can provide new opportunities.
OPPORTUNITIES IN A POST-COVID WORLD
The COVID-19 pandemic has forced global health research education and training program
leaders and educators to consider and explore opportunities available through distance
learning. Below, we give some examples from our programs that could hint at future
transformations.
Virtual education lectures
Our own experience using a technological solution to replace traditional, in-person
lectures has been well-received. A pilot presentation was set up for a US-based faculty
member to give an introductory lecture on one of our project core competencies, cancer
epidemiology. The lecture information and instructions to access and use the web-based
video teleconferencing system were shared with two Nigerian sub-sites. In real time,
attendees listened to the lecture, viewed the slides, and interacted with and provided
feedback to the lecturer, facilitated by including defined opportunities for questions
and discussion. To fully participate in the discussions, attendees had to ensure they
had a secure internet connection. Conferencing etiquette skills such as muting of
participants to preserve audio quality, use of hand-raising functions, and control
of video view initially stifled open discussion but were rapidly adopted. Attendees
expressed their enthusiasm for being able to attend in real time and having the opportunity
to interact with the instructor. The lecture series has continued successfully as
monthly sessions. Using remote lectures allowed mentors to connect with trainees at
partner sites and accommodate more trainees, and enables lectures from more professors.
Telemedicine approaches
Traditionally, pathology training has been conducted under a microscope in a trainee’s
home institution. Under COVID-19 travel restrictions, we have been using digital or
telepathology technologies to provide training sessions to our pathologist trainees.
Pathological slides are translated into digital or virtual images using an image scanner
and shared by mentors and mentees from a desktop/laptop computer without restrictions
to geographic location with no loss of information. The image can be stored in a cloud
and accessed and reviewed any time by both mentors and mentees, at the same time,
with no additional laboratory equipment. Similar approaches can be used in other medical
training programs, such as digital radiology and other telemedicine.
Molecular laboratory training and education
The training of molecular laboratory scientists has largely been conducted in local
laboratories, or by bringing trainees to the host institution(s). Since the COVID-19
outbreak, we have used virtual and digital technologies to train molecular laboratory
trainees at our partner universities in Nigeria in both theoretical and practical
perspectives with excellent feedback and promising results. These virtual approaches
enable us to streamline the complicated tasks common to molecular laboratories such
as development and implementation of protocols and quality control (QC) procedures,
sample collection and processing, inventory and tracking, data entry, and load balancing.
Such virtual cross-talk allows mentors and mentees to connect via video, and allows
the mentees to see each protocol step in detail regardless of geographic proximity.
Training health care providers
Before the COVID-19 pandemic, Northwestern University and the University of Lagos
in Nigeria had been planning a user-centered palliative care training program for
health care professionals without formal training in Nigeria. We initially planned
a 2-day on-site workshop leveraging the previously implemented content from the EPEC
(Education in Palliative and End-of- Life Care) program[4] which trains physicians,
nurses, and other health care professionals in fundamental palliative care skills
in communication, ethical decision-making, psychosocial considerations, and symptom
management. Because of the COVID-19 pandemic, we have redesigned the curriculum and
workshops. Lecture, video, role plays, and small group discussions will be held virtually.
To enhance the interactions between trainees and mentors, we use breakout room features
for small group discussion and chat functions to support interactive question and
answer periods. Other online apps or interactive software for polling, whiteboard,
and extension technology functions are also adopted to enhance the interactions.
As shown by these examples, the COVID-19 pandemic has transformed global health training
and educational programs. While virtual approaches can be effective at lower cost,
they may also have deleterious effects on trainees’ mentorship and professional development
as a result of weakened or lost in-person interactions, team building, socio-cultural
adoption and understanding, and interpersonal relationships [5]. Given the altered
formats and timelines of training as demonstrated in
Table 1
and the possibility of long-term adoption of these changes, future programs may attract
different types of learners with different and varied motivations, expectations, and
outcomes [6]. The development of new “hybrid” models using proven virtual components
but with built-in, in-person activities better suited to discussion, idea generation,
and team and relationship building may provide the best approaches for global health
training and education in the post COVID-19 era.