The promise of global health has been that it can inspire and coordinate efforts that will improve an equitable access to health for all. In contrast to colonial medicine, tropical medicine and international medicine, the new and better approach promised by global health has been to confront the systems that allowed for great disparities in health outcomes across the globe, initially most prominently in access to treatment for HIV, but increasingly in access to what has been termed universal health care (1). Nevertheless, these processes inherited centuries of historic injustices and ongoing economic extraction between different groups. These differences have sometimes been envisioned as a Global North and a Global South, with the colonial legacy perpetuated even within countries, such as in the rural–urban divide, or within groups, such as the divides of gender, ability, race, class, ethnicity, LGBTQ+ status, etc. (2) Any group hoping to work thoughtfully with another group that has a different worldview, and that may have been historically marginalized, should understand both the history leading up to that moment and the current position that this history has put each group (3).

This was our understanding when founding Compañeros En Salud (CES), the Mexico branch of the United States non-governmental organization Partners In Health (PIH), currently operating in Chiapas, one of Mexico’s most impoverished and marginalized states. Formally launched in 2011 as a healthcare strengthening organization for rural primary care in partnership with the Mexican government, it drew upon decades of local experience, relationships in the area, and partnerships with institutions far away from Southern Mexico. Most importantly, this included fundraising in the United States and collaborations with universities, either through formal partnerships or more informal coordination, such as Harvard Medical School, the Tec de Monterrey, Universidad Nacional Autonoma de Mexico, la Facultad de Enfermeria y Obstetricia, Notre Dame, and others. This all afforded CES access to increased funding not available to most other groups in the region, and a pool of talented staff that traditionally had not chosen to work in the area. With this foundation of improved inputs, CES was able to more fully implement core components of a functioning health system, what PIH has formulated as “the 5 Ss” (Staff, Stuff, Spaces, Systems, Social Supports) (4).

In addition to offering an improved clinical space for Mexicans, CES has also found a way to include trainees from the United States, and to a lesser extent Europe, looking to incorporate global health rotations into their training. Also known as the short-term experience in global health (STEGH), these rotations grew rapidly in popularity in the first decade of the 21st century, reaching a peak in 2010 when 30.8% of all graduating medical students in the United States reported such experiences (5). Their experiences with STEGHs, however, had been mixed, with many describing challenges arising from medical students being asked to perform outside of their level of training and being traumatized in the process (6), or local hosts feeling that the medical visitors were ill prepared to contribute meaningfully in a context they did not yet understand (7). CES created a system that above all else aimed to respond to the call to “design new instructional and institutional strategies” that can provide transformative educational experiences to health professionals (8). The goal was to design an educational program with clearly delineated roles and responsibilities so that that the experience could be equally as impactful for both Mexican and United States-trainees, and patients. What follows is a detailed account of our experience in building and running the educational aspects of this program, recognizing that what we present is framed by our unique vantage points and biases as co-founders and program leadership.

Chiapas, is the southernmost state of Mexico. It is blessed with abundant natural wealth, but it also contains some of the most impoverished and marginalized communities in the country. This is not by accident; Chiapas has long been positioned as an agricultural and mining region within Mexico, where industrialization and development have fallen far behind compared to the rest of the country (9). More so, the communities where CES started operations are about 8 hours away from the closest urban centers. Getting there involves traveling for hours on unpaved roads, on the back of pickup trucks that run perhaps once a day, or through unsafe mountain roads where deadly accidents are still all too common (10).

The design of the Mexican Health System intended to cover the entire population through a vast network of primary health centers, present in most communities in the country, with referral capacity to higher level hospitals. According to WHO data, Mexico has a physician density of 24.1 per 10,000 people, compared to 35.5 in the United States (11). However, in neither country doctors are equally distributed. The 6 million people living in Chiapas have access to only two tertiary care level hospitals, and most services are concentrated in the four biggest cities. In hundreds of small communities across the state, care is provided through the smaller health centers, although the most remote places struggle to find permanent medical staff and are sometimes barely functional as a result.

The Mexican ministry of health (MoH) offers contracts available for doctors to work in some of these communities, and promises a higher salary as an incentive, however, it is very rare that doctors decide to work in such communities. A similar phenomenon occurs in rural areas all over the world, including developed countries like the United States (12). In 1935, the Mexican government attempted to address this issue by instituting a year of mandatory social service, where newly graduated doctors are obligated to work for the MoH in order to obtain their medical license (13). The majority of these newly graduated doctors, called pasantes, are still placed to this day in rural areas to cover for hired doctor shortages. For most of this program’s history across Mexico, the pasantes were the sole providers for one or more communities, usually while having limited access to tools and supervision (14). CES operated by engaging with physicians about to start their social service year and enticing them to work in these communities by offering a package of economic and academic incentives (15). These young physicians were scheduled to graduate from the program each year, but CES has been able to attract new hires to replace graduates and therefore guarantees continuity of care. Many graduates have even opted to stay longer to work with CES in a leadership position or as a clinical supervisor. In general, pasantes have limited clinical experience, and although the Mexican health system allows them to oversee their health centers, CES realized early on that they would benefit from support and mentorship from more experienced clinicians. The majority of this clinical supervision is provided continuously by the cadre of clinical supervisors, the majority of whom are recent Mexican graduates of the CES pasante program. To augment this foundation of in-house supervision and mentorship, CES also implemented a program for hosting foreign clinicians who could come to participate in a purely teaching capacity.

Since the first class of pasantes joined the program in 2013 up to the writing of this paper there have been a total of nearly 100 pasantes working in 9–10 primary care clinics, and later participating in a local referral hospital and a maternal waiting home, though staffing for those clinical entities involves even more clinicians. During this time, around 150 foreign medical volunteers have rotated through the clinics. This is within the context of CES hosting over 300 total volunteers, many for longer placements such as recent college graduates and gap year medical students who worked from 6 to 12+ months as research assistants, program coordinators, or office volunteers. See Table 1. The CES program is experienced by participants as a squarely Mexican run clinical program that is enriched by a large cast of rotating foreign visitors whose work is interwoven with daily operations.

Most countries in the world require that clinicians have a domestic license to practice medicine, and Mexico is no exception. Global health projects from the Global North have often been rightfully criticized for sending unlicensed or partially trained staff to treat patients in the Global South (16). Even for fully licensed clinicians, the question remains of whether practitioners for the Global North should be allowed to practice freely in the Global South for only short visits, as the opposite would never be possible (17).

As soon as CES started clinical operations in 2012, it began attracting physicians from the United States who wanted to do global health rotations during their residency. They visit usually for 1 month and are paired with the Mexican doctors at their community clinics. The United States residents act as bedside clinical educators and coaches, working in the spirit of what PIH calls “accompaniment.” This is a philosophical stance, but also a rubric for programmatic design (18). At CES, the Mexican doctors remain responsible for the patients’ care and have the final say about the diagnosis and treatment. Legally, United States residents are acting as visiting students, in the same way that foreign students rotate in the United States, acting always under the supervision of local professionals and therefore contribute without violating any Mexican regulations.

For global health programs in Europe and the United States, it is important to find field placements that fulfill the student’s learning and exposure expectations. The United States residents in CES are mentored by the CES medical director, who serves as a bridge between the practice of medicine in the United States and in rural Mexico. This position has historically been held by both US and Mexican physicians, showing how success in this role is determined not by nationality alone but by the ability to be an inclusive mentor. See Box 1 for further information on how CES structures the visit in order to set clear expectations and facilitate a beneficial experience for the pasante, the United States visitors, and patients. Additionally, even though many of the visiting residents have had only limited experience in resource constrained settings, they are instructed during their orientation on the relative lack of diagnostic and treatment resources in the rural CES clinics. Accommodating to this reality can be a struggle for some, so the CES cadre of clinical supervisors will often pay extra attention to supporting those clinicians when they visit them in the community; through ongoing on-site reflection and discussion, many of these foreign clinicians are able to learn how to provide high-quality clinical care in rural Mexico through the tutelage of their more experienced Mexican colleagues.

For care delivery organizations in the global south, it is important to benefit from visitor’s expertise; many patients in CES-supported communities who presented with more complex diagnoses, for example for neurologic or cardiologic conditions, could get access in their local clinic to a team of clinicians thinking about how best to address their health concerns. Otherwise, traveling to see a specialist in the few referral hospitals could be quite expensive, difficult logistically, and may not even result in a favorable outcome. Through this partnership, thousands of patients were able to have access to better care and follow up, without leaving their communities and without losing continuity with their local doctor, which can result in both clinical and economic benefits for the patients. Notwithstanding, any patient who seeks help from CES and ultimately needs specialist care is still accompanied to receive that care, usually in the urban medical centers, through CES’s “Right to Healthcare” program (19).

Table 2 shows select quotes gathered from exit surveys submitted by visiting doctors. These were collected during exit interviews that included opportunities for both verbal and written feedback. Concerns and criticisms were usually discussed and addressed verbally, so written submissions nearly always captured generally positive responses. These do not represent a complete analysis, but rather are included to give a sense of how this program performed at its best. The responses suggest that with proper preparation and mentorship, visiting residents can balance both learning and service without causing harm to patients or engaging in unregulated practice. Exit interview responses from Mexican pasantes were not routinely recorded but in verbal interviews with CES leadership they nearly universally expressed enjoying the company of a fellow physician in their clinics and their communities, having a companion at a time that could otherwise be a terrifying assignment. Both parties regularly expressed feeling that they were supporting and teaching each other. A more complete and rigorous analysis that includes the opinions of all staff, participants and graduates of the program should be conducted. The Brigham and Women’s Hospital IRB reviewed inclusion of the quotes and determined that as presented are not human subjects research (REDcap ID #679).

CES was launched from a mixture of early experiences in the area (36), new energy sparked by the rise of global health as a discipline (37), and the need to meet increasing student demand for meaningful experiences in the field (38). Invigorated by the moral clarity that health is a human right, we as co-founders and leadership of CES recognized that by marshaling the necessary resources, we could build a health care delivery and educational system that would be locally transformative and internationally relevant. Now with over a decade in operation, CES continues to grow. This has included expansion into a maternal waiting home to provide more person-centered birthing care, revitalization of one of the referral hospitals, and during the COVID-19 pandemic, a renewed focus on provider safety and access to intensive care (39, 40). The CES experience suggests that privilege can be leveraged to redistribute capacity and human resources, and build systems that extend improved care to communities that need to be supported on a priority basis. If well designed and managed, this enterprise can be used as a beacon experience for training the next generation of professionals who hope to do similar work. The convening force of such a program can also generate a common and shared space that builds a multi-national community of change agents who can continually turn to each other for advice and inspiration.

It is important, however, for any organization to reflect at regular intervals, such as after the collective trauma that was the COVID-19 pandemic, to reconsider why and how the work is being pursued. The most recent 2023 AAMC graduation survey discovered that United States-based medical students now self-report a level of participation in global health experiences that is nearing a low rate not seen in nearly three decades; after a height at 30.8% in 2010, the rate dropped slightly in 2019 to 24.2%, but then continued dropping to 14.2% in 2022, and finally reached a new low of 11.3% in 2023 (41). The reasons for this are likely many, but we suspect that many United States and European students have recognized that they can pursue their professional interests in equity by working domestically, especially considering the important and active struggles that arose from the murder of George Floyd, the repeal of reproductive rights in the United States, and the rise of far-right extremism that increasingly pushes anti-immigrant rhetoric and policy, etc. Many others are concerned about the environmental impact of international flight to participate in only a short-term experience (42). There is also an ongoing conversation on how to best embed anti-racism and anti-colonialism praxis in global health (43).

The CES experience shows how a clinical and educational program can be built to structure equitable interactions between people who may be dissimilar in terms of nationality, region, race, class, gender, ability, and other axes of difference. The tactical design principles described here can serve others hoping to launch similar programs. A lot of attention has been paid to the potential unintended consequences of work in global health (44). There still remain, however, many threats to human health globally that are the result of actions by actors who have all the intention to gain profit regardless of the effects on people or planet. The CES experience suggests that global health does not need to abandon finding ways to work together. Instead, global health efforts can be structured to unite like-minded individuals in multi-national teams to work in common cause as we confront the biggest threats to our common future, but always by centering the perspectives of those in the Global South who stand to be most affected by these threats.

This report was written by the co-founders and current leadership of CES to be a descriptive tour of what we see as the key lessons from our experience. We are aware, however, that these descriptions are tainted by our personal investments in the program. While there are many benefits to how we have chosen to work, there are alternative models for pursuing social change, and we invite the discussion comparing and contrasting different approaches.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethical approval was not required for the study involving human participants in accordance with the local legislation and institutional requirements. As the Mass General Brigham IRB determined that the content and activities presented in the manuscript do not constitute human subject research, written informed consent for participation was not required in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the photographed individuals for the publication of identifying images.

DP and HF wrote the original draft. VM provided conceptual and editorial support in writing the manuscript. All authors contributed to the article and approved the submitted version.