According the World Health Organization (WHO), diarrheal diseases, human immunodeficiency virus (HIV and its gastrointestinal complications), tuberculosis (TB and its gastrointestinal complications) are among the ten leading causes of death in low-income countries,Footnote 1 an observation emphasizing the importance of systematically increasing the number of gastroenterologists entering the field of global health. There are numerous entry points for gastroenterology (GI) specialists wishing to engage in global health work including international non-governmental organizations such as Doctors Without BordersFootnote 2 (commonly known as Médicins Sans Frontières or MSF), global health fellowships, and other programs. Yet, in order to enter global health practice, there is a crucial need for targeted education and training. In this issue of Digestive Diseases and Sciences, Jirapinyo and colleagues provide a timely and important study about the potential for global health training among GI fellows, highlighting the need for as well as the nature of global health training among GI specialists [1]. Our reflection on this important study begins with the premise that the field of global health requires not just additional technical diagnostic and treatment capacities, but a deep engagement with issues of history, culture, political economy, and ethics. In other words, technical skills must be complemented by a normative commitment to uphold the dignity and recognize the capacity of persons around the globe, and engage in mutually beneficial relationships [2–4]. In the absence of appropriate training and preparation, a doctor may potentially do more harm than good.

Jirapinyo et al. [1] provide novel insights into the current state of and potential for global health curricula development for GI fellows. They surveyed GI program directors and fellows regarding their experience in global health training in the USA, gathering data from 36 % of the gastroenterology training programs recognized by the Accreditation Council for Graduate Medical Education (ACGME). The authors reported that only 2 % of programs sampled offered a dedicated global health training track during fellowship and 17 % offered global health-related activities, with very few faculty members involved in these programs. Furthermore, the least commonly taught content were related to important material such as policy, ethics, and the preparation for work or volunteering experiences in developing countries.

Since medicine is practiced in varying social, political, and cultural environments, it is important for curricula to integrate individual competencies such as humility and introspection [5] while also fostering a deep understanding of how history, politics, and economic factors, among other social dynamics, can influence issues of global health access, equity, and justice [6, 7]. In other words, GI fellows must be given the opportunity to develop their capacity to exchange knowledge and skills and facilitate partnerships and collaborations across diverse cultural practices and norms in order to contribute to the sustainability and effectiveness of their actions within the global environment.

In the study, seventy-five percent of respondents expressed the desire to volunteer overseas, a common desire among health professionals interested in global health. Such experience can provide tangible exposure to the provision of care in different contexts. As we note above, in order to prepare fellows to volunteer overseas, it is important to situate the training in the wider sociopolitical context. Responding to the diverse medical needs of populations around the world requires cross-cutting competencies related to healthcare systems, social and political determinants of health, and cultural awareness and training in low-resource and cross-cultural settings [8]. It is widely recognized that the ultimate goal of global health initiatives is to contribute to the training of local practitioners specializing in the care of underserved populations, or the building of the capacity of professionals already working in developing countries or underserved areas of the USA through the development of robust local health systems. In the interest of promoting sustainability, it is necessary to reinforce the capacities of local practitioners, enhancing their ability to provide services to their communities and improving the quality of their skills that will continue after the foreign professionals have left. For example, Macfarlane and colleagues highlight the important function of North American and European academic institutions in working to “…strengthen developing country institutions … to prepare all our future leaders to protect the world’s populations against future health threats” (p. 392) [9].

The article also identifies important barriers to establishing global health curricula, including funding (94 %), scheduling (88 %), lack of standardized learning objectives (78 %), and insufficient data with regard to the impact of global health curriculum on fellows’ education (75 %). The ACGME can mitigate some of these barriers for example by working with members and program leaders to establish standardized objectives. Since there are extensive data suggesting that GI issues persist in many resource-limited settings, this evidence itself may provide a sufficient rationale to enhance the attention paid to these issues in the US global health GI curricula. The difficult question for training program leaders is how best to address existing needs in a way that fosters sustainable capacity building for all involved and that prepares future doctors for the challenges of providing services within developing or underserviced contexts.

Although there likely was a response bias as participants with an interest in global health were more likely to participate in the study, the study underlines an evident desire from participants for furthering global health curricula. This desire sharply contrasts the lack of such curricula in current US medical training. Eighty percent of respondents thought that: “Global health education would strengthen fellows’ medical knowledge, clinical diagnostic skills, understanding of cost-effective care, cultural competency, and awareness of the social aspects of health.” Approximately half of the fellows thought that the ACGME should include global health education for those intending to work or volunteer abroad after fellowship. The study points to a clear desire among respondents to engage with global health in a more systematic manner during their training. Eighty-eight percent of respondents stated that they would commit to a global health elective during GI fellowship if it were offered.

The trainees’ overwhelming desire to engage more deeply with global health in their training can help overcome any institutional barriers to curriculum development. This desire emerges in a global context from which the embedded interconnectedness of so much of our political, economic, and social landscape is being clearly observed and articulated. The explosion of social media has provided easily accessed first-hand accounts of global health events such as the Ebola outbreak, with global health events intensifying contact between nations, ethnic, and cultural groups through forced and voluntary mobility of populations across borders. It is in this context that it is heartening to see findings that point to the desire among GI fellows for more exposure to health issues of global import.

The researchers conclude that “…the adequacy of their current training to serve populations from developing countries or underserved areas within the US appears to be inadequate, that global health opportunities and mentorship should be available for GI fellows and that GI leadership should begin the work necessary to make standardized, high-quality global health curriculum available to all fellows.” We concur with the authors’ conclusions and hope that the findings reported in their work can support the creation of more opportunities for GI fellows interested in global health work. It is also hoped that these findings prompt a continuing and meaningful discussion of curricular development with attention to normative considerations that can complement discussions about the development of technical competencies. We also hope that given the nascent expressions of interest in developing national curricular standards, that discussions build upon the experiences of doctors and program leaders who have worked and who currently work in developing countries or underserviced areas in the USA and are informed by partners in host countries in order to develop curricula driven by the goals of sustainability, impact, and reciprocity.