N. Jairath is a first-year medical student at the University of Michigan Medical School.

D. Fessell is a Professor of Radiology and Faculty Director of the Leadership Curriculum at the University of Michigan Medical School.

M. Heung is an Associate Professor of Internal Medicine (Nephrology) and Faculty for the Leadership Curriculum at the University of Michigan Medical School.

Word Count: 2000

Key Words: Servant Leadership, Global Health, Collaboration, Sustainability, Research, Innovation

The authors have no conflicts of interest or relevant disclosures.

Abstract

Global health is the health of populations in the global context and is defined generally as the area of study, research, and practice that places a priority on improving health and achieving equity in health for people worldwide. Dr. Joseph Kolars has focused on advancing education systems in the United States and internationally to address these disparities and has emerged as a recognized leader in the field with an extensive track record of successful collaborations. But what is it that makes these collaborations successful? This article explores the key lessons to be learned from Dr. Kolars’ career in global health partnerships and illustrates how his servant leadership style has paved the way to fostering effective, sustainable improvements in global health. By exploring Dr. Kolars’ understanding of global health, his role as a leader, his collaborative efforts, and his dedication to improving global health through research and innovation, this article will serve as a guide to those looking to become future leaders in global health.

Introduction

In 1982 in Nepal, Joe Kolars (then a fourth-year medical student) was eager to explore other systems of healthcare and training. A very sick patient entered his clinic, and he worked with local providers to do everything he could to save him. Success led to gratification if not heroism, but not everyone shared his excitement – including the patient, who would never be able to work again and thus felt useless to his community, only waiting to die. Like most students, Joe believed that life was always worth fighting for, that as trained medical professionals, we were to preserve it at all costs. At this early juncture in his medical career, Dr. Kolars was forced to broaden his perspectives on what meaningful outcomes are and how critical health (not just life) is in determining those outcomes.

This example early in the life of Dr. Kolars established a framework for what would later become his strategies in addressing current global health challenges. Global health is a complex interplay of cultures, practices, history, and social determinants of health, all of which can contribute to the variations seen in health outcomes throughout the world. Understanding that no two places are the same, and that prior experience may not carry forward into current circumstances, is an important step to being an effective servant leader in a global health setting. The willingness to learn from an environment before attempting to solve what a single individual might determine are its problems may go a long way in establishing collaborative partnerships that ensure that the goals of those being served are addressed.

Inspired by his experience, Dr. Kolars has dedicated his career to pursuing improvements in global health. Early in his career, while an internal medicine residency program director at the University of Michigan, he championed global health opportunities for trainees and increased opportunities for those abroad to study at the university. In his current role as senior associate dean for education and global initiatives at the University of Michigan Medical School (UMMS), he continues his mission to develop education systems in low resource settings that can build human resource capacity to transform health and has helped develop numerous faculty development positions worldwide. He has given lectures or conducted classes all over the globe, including China, Malaysia, Thailand, India, Peru, Germany, Pakistan, South Africa, Ghana, Uganda, Tanzania, and Vietnam.

Dr. Kolars could best be described as a servant leader who serves his communities through collaborative efforts involving local engagement and empowerment. As Dr. Kolars says, “It’s when I’m trying to enable and help others to make those things happen, achieving through others, that’s where I think I make the biggest difference.” We asked Dr. Kolars for his reflections on what he believes have been the most important insights that contribute to creating successful collaborations in his global health career, namely his identification of five key aspects to developing successful partnerships: defining global health, adopting the mindset of a learner, conducting research, encouraging innovation, and achieving sustainability.

Defining Global Health

The bedrock of how to change global health, or any large enterprise, may lie in a foundational understanding of what it is. Before steps can be taken to improve or change existing systems, the realm in which we are operating must be defined. Dr. Kolars defines global health as

This seemingly basic idea influences much of how Dr. Kolars leads within his field. He sees the entire world as a team, and being an effective leader within that team means ensuring that every member is treated equally and given a fair opportunity to excel. Although a definition of global health would benefit from explicitly stating goals for collaboration and research, Dr. Kolars implies some of this with his own definition. This is the first step toward Dr. Kolars’ collaborative approach to addressing global health challenges. Defining global health may be a subjective task; definitions of global health range from “health issues that transcend national boundaries and governments” to “collaborative trans-national research and action for promoting health for all.” Regardless of the definition chosen, a future leader in global health must understand that it can be a powerful tool to guide their future efforts in the field.

Adopting the Mindset of a Learner

Global health encompasses a vast combination of different cultures, ideas, and practices. Each situation is unique, and entering with pre-formed opinions of how to help can be fraught with pitfalls. Dr. Kolars believes that the appropriate mindset is to try to understand the situation and realities and to recognize the assumptions that might hold one back from greater understanding. This approach proves valuable in avoiding a one-sided effort in favor of one focused on collaboration. As Dr. Kolars notes,

Dr. Kolars has lived his advice. As he worked to establish a more modern health care system in rapidly developing areas of China that would also serve as learning sites for local health professionals, he also committed to living there with his family for three years to increase his understanding and effectiveness.[1] Today when embarking on a new global experience, Dr. Kolars consciously remembers to check his assumptions at the door. As servant leaders focused on building collaborative efforts, and to really make a difference in the lives of the people whom we claim to help and work with rather than for, we have to ask, “what’s your sense of good and bad, right or wrong” rather than inserting our own value systems into other ways of life. This lesson is an extremely valuable step to collaboration and ensuring the goals of all parties involved are being met.

Research: Sharing Knowledge to Enact Change

A leader looking to make change has to deeply understand the problems being faced as well as be able to share insights regarding those problems; pursuing rigorous scientific investigation is one approach that encompasses each of these aspects of enacting change. Dr. Kolars has worked to expand knowledge of issues facing underserved populations, such as shortages of primary health providers and lack of access to easily obtainable westernized medical practices, in efforts to identify potential solutions. Unlike more traditional forms of medical research, such as basic or translational sciences, global health research is multidisciplinary and interdisciplinary by design.[2] It is multidisciplinary in the sense that no one field can solve the great global health challenges of our time, and interdisciplinary in that solutions can be reached through collaborations that integrate ideas from different academic and clinical traditions. Despite its departures from the structures of traditional scientific research, global health research is an effective avenue that Dr. Kolars has chosen to use to share his knowledge and insights with others to amplify the efforts of the global health community.

For example, in a recent study, Dr. Kolars helped identify the lack of healthcare providers in rural China. With his colleagues, he explored barriers to entry in healthcare and reasons for this disparity. They conducted a correlational study that identified students from rural backgrounds as significantly more likely to practice in rural settings after graduation from medical school. Therefore, a solution to the lack of healthcare providers in rural China might be that top schools recruit more students from rural backgrounds.[3] To accomplish this, it became necessary to work with departments of public and social health, as well as with local community members, to better understand the problem and work toward devising a solution.

A leader focused on collaboration also recognizes that his successes are not only his own. Dr. Kolars has been working with the Peking University Health Science Center as a collaborating partner at the University of Michigan and has seen immense success. In 2009, each institution donated $7 million for joint research projects in areas of mutual interest, and within 6 years, 52 joint faculty proposals were submitted, and 25 were funded. The projects involved more than 100,000 patients in the United States and China and generated 13 peer-reviewed publications. In 2015, each institution agreed to commit another $7 million to the collaboration. Recognizing that there was not much research in the field on how to replicate this success, Dr. Kolars wrote an article demonstrating how a partner was selected, the process of reaching an agreement upon mutual research interests, and outcomes from the partnership.[4] He also authored a similar article for teaching collaborations in Sub-Saharan Africa, in which he provided an approach to strengthening collaborative relationships between three medical schools in the United States and four in Sub-Saharan Africa, with an explicit focus on achieving partnerships that enable institutions to improve care.[5]

A leader is also devoted to his mission and ensuring its continuation in the long-term. For this reason, Dr. Kolars has worked tirelessly to train future leaders by introducing global health initiatives and curriculum changes to UMMS and has conducted a number of studies concerning how it can continue to be improved.[6][7][8][9][10] But as Dr. Kolars has demonstrated on multiple occasions, he sees global health as a global effort that requires international participation, and his motivation in publishing this work is in the hope that it will be picked up by other institutions that can eventually demonstrate similar successes. If we choose to synthesize the previous lessons learned, it would follow that global health should serve to alleviate disparity in as far-reaching a manner as possible, and by identifying problems and sharing solutions through a collaborative research mindset, future leaders in global health can make progress toward this goal.

Innovation as a Path Forward

Research, although insightful, is even more potent when coupled with a drive for innovation. In a talk given at the Mayo Clinic in 2013 called “Overshooting the Moon,” Dr. Kolars compares our efforts in global health to the moonshot, a lofty dream that many people did not believe in but was advanced to push the boundaries of what we believed was possible: “It’s tough to analyze what might have happened had we not gone to the moon. What we would have lost based on the incredible amount of spinoff technologies that resulted from the effort. It’s not about being in Ghana to save Ghana. It’s about doing this to save ourselves.”

Dr. Kolars notes that universities and their academic medical centers are often thought of as “ivory towers,” prioritizing discovery and innovation. Although ivory can bring beauty to its surroundings, it also can also lack relevance or impact. Dr. Kolars believes that work in global health can and should benefit the communities they are meant to serve. For an example, Dr. Kolars points to the significant problem of postpartum bleeding deaths in Ghana. In collaboration with Ghanaian partners, the UMMS team worked around the relative scarcity of resources to create an innovative, low-cost device that simulated how a uterus should be closed up to stop bleeding, significantly reducing complications in this community. The device would light up in spots where pressure should be applied, like an easy-to-play game. However, the team did not even know whom to train until reaching Ghana. In fact, people were not even going to doctors, so they centered the device design around training traditional community birth attendants who would assist with the delivery.

The UMMS team collaborating in Ghana brought the idea of this cheap and easy-to-use training device back to their own institution to influence education through insights gained in a different environment. This is a very important lesson: often, the most innovative solutions come from places where resources are the most limited. It forces us to think in creative ways, and by exploring innovation in these situations, the world as a whole can benefit. Besides simply seeing this as a great example, note that although innovative ideas were utilized to creatively design a simple, yet effective device at a low cost, it would have been useless in solving any issues without community outreach to identify those who would be most likely to use the device. Innovation and creativity, coupled with the previous lessons learned from Dr. Kolars’ career, provide a path forward in addressing global health challenges.

Collaboration and Sustainability: A Two-Way Street to Achieving Our Goals

Collaboration is defined as the action of working with someone to produce or create something. In the context of global health, this creation should be able to be maintained long after one of those parties leaves or, in other words, to achieve sustainability. As demonstrated in the previous examples, Dr. Kolars believes that collaboration, and developing an understanding of how each institution involved should benefit from a collaborative partnership, is the single most important factor in determining that partnership’s success. Importantly, this is a two-way street, and one institution should not take advantage of another. For example, US academic health centers benefit largely from international trainees who seek further clinical or research training in the United States. Unfortunately these learners typically are not trained or encouraged to use their skills to benefit their home countries. Dr. Kolars provides an example of how he attempted to demonstrate that this problem can be overcome:

There are no short-term solutions to the complex issues faced in global health. So someone looking to make a real change in global health must become involved in the society or community they are working with, be willing to have their assumptions disrupted, and seek to collaborate. Only then can sustainable, lasting change be implemented. Servant leaders like Dr. Kolars understand and advocate for this collaborative approach to global health.

Conclusion

From the case of Dr. Kolars, we can surmise that there are five major keys to successful collaboration in global health endeavors. The first is to understand the niche in which one has chosen to work by defining that space, and the second is to understand the people one wishes to serve in order to work in parallel with their goals. Research, the third key, serves the dual purpose of fostering an understanding of the populations one wishes to work with as well as dissecting global health efforts to analyze and disseminate the characteristics that make them successful. Fourth, innovation is the driver for progress, serving as the bridge for connection across borders and as a means to improving practice, potentially creating even more far-reaching changes than those applied to the specific community in which they originated. Finally, working toward sustainability ensures lasting collaboration and benefit for all parties involved. Employing these tools to maximize collaboration in a global health setting is paramount to creating successful and sustainable partnerships.

Improving global health is a complex journey and one that takes well-coordinated and dedicated efforts. Successful endeavors are not common, yet Dr. Joseph Kolars has managed to show a consistent track record of success in his own undertakings and has influenced countless others. By identifying and analyzing ’the collaborative approach to solving challenges demonstrated by Dr. Kolars, we hope for this manuscript to influence the actions of aspiring future leaders in global health.

Acknowledgments

The authors wish to thank Dr. Joseph Kolars for his willingness to be interviewed for this piece and for his thoughtful review of the manuscript.

Funding Support: None.

Other Disclosures: None.

Ethical Approval: Not applicable.

Disclaimer: None.

Previous Presentations: None.

References

1. Kolars JC. Should U.S. academic health centers play a leadership role in global health initiatives? Observations from three years in China. Acad Med. 2000;75(4):337–345.

2. Merson MH, Black R, Mills AJ. Global Health. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2011.https://www.ncbi.nlm.nih.gov/pubmed/25072570

3. Hou J, Xu M, Kolars JC, et al. Career preferences of graduating medical students in China: a nationwide cross-sectional study. BMC Med Educ. 2016;16:136. doi:10.1186/s12909-016-0658-5

4. Kolars JC, Fang W, Zheng K, et al. Collaboration platforms in China for translational and clinical research: the partnership between Peking University Health Science Center and the University of Michigan Medical School. Acad Med. 2017;92(3):370–373. doi:10.1097/ACM.000000000000120

5. Kolars JC, Cahill K, Donkor P, et al. Perspective: partnering for medical education in Sub-Saharan Africa: seeking the evidence for effective collaborations. Acad Med. 2012;87(2):216–220. doi:10.1097/ACM.0b013e31823ede39

6. Gruppen LD, Mangrulkar RS, Kolars JC. The promise of competency-based education in the health professions for improving global health. Hum Resour Health. 2012;10:43. doi:10.1186/1478-4491-10-43

7. Ton TG, Gladding SP, Zunt JR, et al. The development and implementation of a competency-based curriculum for training in global health research. Am J Trop Med Hyg. 2015;92(1):163–171. doi:10.4269/ajtmh.14-0398

8. Mullan PB, Williams J, Malani PN, et al. Promoting medical students’ reflection on competencies to advance a global health equities curriculum. BMC Med Educ. 2014;14:91. doi:10.1186/1472-6920-14-91

9. Williams BC, Mullan PB, Haig AJ, et al. Developing a professional pathway in health equity to facilitate curricular transformation at the University of Michigan Medical School. Acad Med. 2014;89(8):1153–1156. doi:10.1097/ACM.0000000000000286

10. Abedini NC, Gruppen LD, Kolars JC, Kumagai AK. Understanding the effects of short-term international service-learning trips on medical students. Acad Med. 2012;87(6):820–828. doi: 10.1097/ACM.0b013e31825396d8

11. Olapade-Olaopa EO, Baird S, Kiguli-Malwadde E, Kolars JC. Growing partnerships: leveraging the power of collaboration through the Medical Education Partnership Initiative. Acad Med. 2014;89(8 Suppl):S19–S23.