Choosing impact over location: the myth of the “global health gamble”

by Lawrence C. Loh

“It sounds like you’re doing lots of great work!” my student mentee said, smiling. “Lots of great work with lots of impact!”

Her enthusiasm contagious, I paused and reflected. She had asked a simple question: what was I working on in my role as part of the management team of a local public health department? In turn, I had shared our current mandate and the many projects I was leading to support that while mentioning that raising two beautiful daughters was another one of the other fulfilling parts of my day-to-day.

But in hearing the word “impact”, I was brought back to some old dreams of my youth: the idea that I wanted to make an impact globally rather than here at home. Like many global health aficionados, I’d always imagined myself someday working for one of the big guns: WHO. UN. MSF. Something that would let me connect with people across this wonderful world while “making a difference.”

In that moment, then, the student became the teacher; I saw that she’d already figured out what I had taken my early career to realize: in the long run, the impact of your work matters far more than where you do it.

My own path from dreamer to pragmatist

My early career was filled with a lot of advice about how to launch myself into a global health and development career – and angst when things didn’t seem to be heading towards the traditional stereotype of “making a difference” during a freewheeling, jet-setting, nomadic life. Serving as an Official in the International Federation of Medical Students’ Associations (IFMSA) had given me a taste of global health policy, and my subsequent ambition was to build a career that gave me that broad reach with purpose, tackling contemporary challenges internationally.

This in turn led me to burn multiple candles at multiple ends. I completed a Master of Public Health degree at Johns Hopkins, which provided me with the skills, time, and connections to start a non-profit in the Dominican Republic. I also carefully structured my senior residency placements to give me exposure at the federal level in Canada and at international agencies in Geneva, New York, and Washington D.C.

Out of work in these settings came research, presentations, and publications, which in turn gave me access to a never-ending stream of conferences, workshops, and talks all over the world. I worked hard, traveled extensively, and built a portfolio, entirely committed to networking, delivering, and somehow, somewhere, either building or landing the gig. This all happened largely on my own dime and own time, while I also balanced a nascent domestic career in public health with clinical practice, teaching as a junior faculty, and nurturing a home life with a wife I loved dearly.

While I was good at my domestic endeavours and also enjoyed clinical practice to some extent, the early career aspects of both just didn’t initially captivate me the way the glitzy international “hopey-changey” stuff did. I also couldn’t convince my pragmatic, no-nonsense wife to join me in taking the global health plunge. “But everyone tells me that to build a meaningful career in global health and development, you have to have extensive experience abroad!” I pleaded more than once. No dice, however: she suggested that I heed my medical school debt and the opportunities I had found myself in domestically and work to make the most of what I’d built domestically.

Thus, redirected from the notion of doing near-pro bono for some years to develop my “cred abroad”, my domestic career and family life instead flourished over moves between three cities in Canada and increasing positions of responsibility at all three levels of government in two provinces at five different agencies. Two daughters later, hindsight suggests that tying our lives at home was the right move.

So what is the “global health gamble”?

The “global health gamble” is fairly simple – broadly speaking, not everyone who wants to work abroad will get the opportunity to do so on a full-time basis, or even at all. While many might dream of being involved in high-level global health discussions, entry into an internationally-focused career is not merit based and realities necessarily limit the probability that someone with ambition will succeed.

Besides limited positions, funding, and resourcing for organizational budgets on the position supply side, interested professionals face their own limitations—be it immovable family members, insurmountable debt, skills limitations (e.g. being monolingual), the wrong educational pedigree, or otherwise. Sometimes it’s even a case of just not knowing the right people—and lacking the means to break into that network.

Whatever the barrier, plenty of dreamers try – for a substantial period of time and at considerable expense – to make it into the arena; much like trying out for the big leagues, young folks are taking graduate degrees, doing unpaid internship after unpaid internship, prioritizing the professional over the personal, in the hopes that it will pay out some day. Still, others are fortunate to not have financial and personal barriers and may travel far and wide while living start-up life or try to get a head start by attending and networking within various conference circuits.

As with any gamble, the sacrifices sometimes pay off, but more typically, many young professionals return to the realities of domestic careers. While they return with memories and experience, they also perhaps come back a little more disillusioned and poorer.

The lessons I’ve learned

While I sometimes find myself longing for that international career that hasn’t transpired (yet – I’ll get to that), my experiences have given me a new perspective on what I call “the global health gamble”. Specifically, I have learned about the primacy of impactful work. Coupled with keeping in touch with friends who did take the global career plunge, I’ve been fortunate to learn a few lessons along the way.

Lesson 1: Where you work matters to a threshold

There is no silver bullet in pursuing a global health career, and it’s important to remember that work abroad can be valuable – but to a point. A different mentee of mine once asked me if she should pursue an internship with a small child health organization in southeast Asia versus a project manager position with a mid-sized consulting firm here in Toronto.

I steered her very quickly to the latter, for several reasons:

  • Firstly, the skills she would derive from the latter would stand her in better stead for the next opportunity, domestic or international, than anything she could learn from the former;
  • Secondly, the opportunity to develop solid financial footing rather than sinking additional funding into a “learning opportunity” would help to remove a barrier to global work in the future; and
  • Thirdly, the potential credibility upside favoured the project manager role—being able to say she had rolled out an indicator framework, which she’d never done before, versus doing intern work that would likely be no different from her time as a graduate student (e.g. completing a literature review or cursory analysis.)

The ultimate litmus test was my suggestion that she imagine: if she were to decline each position, would she be offered them again later? Naturally, the internship seemed a lock for a mulligan, but it wasn’t clear whether the project manager role would be up for grabs again. In this case, it didn’t matter that the internship was overseas; what mattered was the impact and upside each role presented.

Lesson 2: Would people notice if you weren’t there?

Naturally gregarious and scholarly, conferences appeal to me because of the opportunity to network, learn from others, present my own work, and of course, travel. Those registration fees, airplanes, and hotels (if you’re not fortunate to have a couch to crash on, as I have been grateful for) do add up in the long run though, and one quickly needs to wonder: is this worth it? This, in turn, gives rise to another measure of impact: where you fit and whether people would notice if you weren’t at that meeting.

Early on, I was just content to show up, because it was neat to be in the same room listening to those global health rockstars, maybe even ask them a question after the session, and try to engage them on e-mail or social media afterwards. I’m sure you all have that one person on your social media who always post about their worldwide travels and all the exciting “connects” they’re exploring.

For me, children really put things in perspective, and I’m not interested in just showing up anymore. Transitioning now into my mid-career, there are clear threads of professional activity that have formed and if a conference or meeting doesn’t fit, I’m content with giving it a miss. I’m also content with the idea that my work can go without me (e.g. if a collaborator presents – particularly if it’s helpful to their own development, like passing it on to a student on my team!)
The corollary to that philosophy is that for the meetings I do end up showing up to, it’s because I have some sort of knowledge or expertise to share that’s meaningful – and as a natural extension, means that I’m not on the hook for my own attendance. The nature of a gamble means that your early involvement should lead to broader opportunities and attending that meeting should build up your portfolio and vice-versa. A good rule of thumb: if you’re not retired but are showing up at a meeting to simply hang out for the third or fourth time, then it might be time to revisit your strategy and purpose in attending.

Lesson 3: Impact takes time

The idea of things taking time applies in a few different regards, particularly those who might choose a domestic career with the hopes of translating work into global health down the line.

It takes time to get involved in the portfolios that matter. Sometimes, this is just a matter of incremental responsibility; other times, it’s just a matter of being in the right place at the right time. I served as interim head of my health department during the opening discussions around the legalization of cannabis in Canada. This led me to sit on a provincial taskforce as a public health representative on the subject, allowing me to work with my colleagues to provide input into the various policy discussions and analyses that have taken place. Adding this work to my portfolio has, in turn, led to my staff and I being invited to present on the subject at three different conferences in the coming months, which reflects the ultimate career upside: Canada’s legalization of marijuana has global implications, which will almost certainly lead to future opportunities at home and abroad.

Other times, it takes time to see the impact of what you’re working on. When I started at my current job, I was given the task of chairing a provincial committee that aimed to align the procurement and implementation of Electronic Medical Records across Ontario’s health units. Being not technologically inclined (I always used to jokingly call it “electrifying” our medical records – I have since learned that it is in fact “digitizing”) I didn’t initially see the value inherent in the portfolio.

Several years later, however, I have been fortunate to lead a talented team to coordinate work across multiple organizations, overseeing critical discussions to secure resources and engage vendors in trying to figure out a way forward. I have developed a broad understanding and a diverse range of skills on digital standards and requirements gathering, privacy, procurement, building business cases, negotiations, and leading organizational change. All that is left is to deliver, or to fail and learn, and in either case, the impact is tangible. Where I work in the future is immaterial: those skills and knowledge are transferable, and this project a roadmap to guide me in future work at home or abroad.

Lesson 4: No path is challenge free

What could possibly be wrong with a high-flying international career, where one travels 50-70% of the time? I often imagine that’s where the counterfactual me might’ve ended up. And while it’s true that the path I’ve chosen has made it challenging to get the requisite experience working abroad, it has provided me with benefits that I didn’t fully appreciate until recently. A loving family, with plenty of time spent raising my two little girls, meaningful friendships, a job that I continue to learn from which has provided me with growth and opportunity, homeownership and financial stability, and the chance to still work on global health issues on the side—all this has come from my decision to prioritize a domestic path over the international one in my early career.

I sometimes tell my friends who did make the international dream their life about how I sometimes envy their photos from far-flung places around the world, their minds and perspectives open to diverse thoughts and ideas at high-level meetings, their career opportunities in the global health arena being built up. They often remind me of the challenges though—impossible deadlines, time spent away from loved ones, relationships that fail for want over distance, chronic fatigue, safety concerns, and a feeling of displacement away from home, and yes, frustrations with whether their work actually has meaning or not. Some also describe health challenges: with alcohol, with getting enough exercise or sleep, with feeling chronically displaced. I’m thus always reminded that the rosiness of the stereotypical path doesn’t itself translate to solely happiness, but also brings its own challenges.

What next?

To be clear: this is not an indictment of the freewheeling lifestyle that some are fortunate to enjoy as they pursue their career dreams in global health – or perhaps even work for one of the big guns I mentioned earlier. For those who can make the sacrifices and overcome the challenges, be it due to privilege or sheer grit—I encourage those folks to enjoy it and reap the benefits!

However, for many others, this article is about identifying and pursuing what makes sense for your context and situation, recognizing that there are many paths to your ultimate goals. The standard “global health gamble” is not a guarantee, but like any other game, too often people buy in and struggle to figure out when to cut their losses and walk away.

Thinking on impact is thus the best way to rethink one’s goals. I have previously suggested in some mentorship talks that Koplan’s definition of global health gets it wrong; that global health work typically involves work abroad. It does, to some extent – but really reinforces the stereotype that you have to work abroad to work abroad.

Just think: if you have the chance to lead an innovative project that supports greater health equity here in Canada – do it! If your work involves combatting the opioid epidemic with data – you know that success in that field will be held up as this era’s equivalent of battling HIV. There are so many domestic efforts that have global implications that will almost certainly act as leverage for rewarding work abroad in the future, should one choose to position those experiences as such.

Hence, while many things can set up for a global career—that work experience abroad, that extra language, that internship—one’s overall goal should be to build a career that has an impact. If that is done abroad early on, then all the better, though know that this has its own challenges. And for those who are starting out domestically by choice or necessity, know that time, commitment, and determination on the things that matter will also lead to global opportunities in the future.


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