The Other Side of the Looking Glass
The blood will not stop flowing.
Marked with many of the sequelae of late-stage AIDS, my 19-year-old HIV-positive patient has just delivered a stillborn infant. Secluded at Kalafong Hospital in rural South Africa, there are only two physicians in the labor ward, and my patient is bleeding profusely. Even though it is still in the early morning hours, my colleagues are busy. The registrar (equivalent to a resident) is in the OR with an emergent case, and the intern is delivering a breech infant. Only a medical student at the time, I call for help, but am told to start treatment.
I am on my own.
I do everything I can think of: I check for clots, lacerations, and retained products of conception – the bleeding continues. I place an additional 16-gauge IV, and hang another liter of intravenous fluids – still she hemorrhages. The uterus feels atonic so I begin uterine massage and give a standard dose of oxytocin – no effect. Nothing is working; all I can do is hope someone more experienced than I will soon come to our rescue.
While true, this scenario is an extreme example. It exposes many of the ethical and pedagogical concerns often raised about medical trainees undertaking global health electives (GHEs). Much of the current literature raises critical concerns with the GHEs,1,2,3 but these electives can still be exceedingly important for medical training, and if organized well can benefit both host and trainee. Despite a progressive increase in the number of medical students and residents participating in GHEs (30.2% of all 2013 medical student graduates),4 until recently there has been a paucity of comprehensive global health education programs surrounding these electives, especially in the realm of medical ethics.
There is significant concern that medical students and trainees participating in GHEs are in positions to deliver care beyond their qualifications or without adequate guidance, potentially leading to malpractice and serious medical error.1 However, the shortage of health professionals in places such as sub-Saharan Africa leads to 3% of the world's healthcare workforce bearing 24% of the global disease burden.5 This leads to the omnipresent ethical dilemma of potentially practicing beyond one's medical abilities. Critics of GHEs argue that participants frequently have the perception that people who live in poverty will benefit from any medical care, irrespective of the provider's experience level.6 There are further concerns of exploiting already resource-limited settings and reinforcing the paternalistic views that were inherent in colonialist relationships between the global “North” and “South.”7
While these are legitimate concerns, the literature surrounding ethical dilemmas during the global health elective is really still in its infancy.8 Much of the evidence appears anecdotal and revolves around egregious examples like students performing surgery and then bragging about it.7,9 In the clinical vignette that opened this article, help did eventually arrive, and the patient was rushed to the operating room, where she had a partial hysterectomy. Some may argue that based on extenuating circumstances I was in a “forced to act” situation, while others might cite there was potential for me to cause more harm than good. However, in South Africa ethical dilemmas arise on a daily basis and are often not adequately addressed by Western education.
Consider these cases:
A prolonged government strike leads to severe staffing and resource shortage. There are no disposable gloves and many procedures are performed barehanded. One day during rounds in the labor ward, the chair of the department asks you to draw blood from an HIV-positive woman in labor as the team is presenting the patient in her room. The only remaining gloves in the hospital are a few pairs of sterile gloves reserved for emergency Cesarean deliveries.
You are a first-year medical student in a rural South African HIV/AIDS clinic: It is your first day and there are 12 lumbar punctures that need to be completed after rounds. You are tasked with performing a lumbar puncture on a dying patient in an open-air TB ward. You have never done one and have only seen it performed once previously. A senior medical student is supervising.
An HIV-positive mother whose baby you delivered is in your research study, and returns for a follow-up visit with her child. She has walked 10 miles bare-footed to come to the clinic. At three months of age the child is still the size of a one-month-old infant. He is emaciated and limp like a rag doll. You notice that the mother is feeding him a black solution from a bottle. Upon further questioning the mother states she is not able to breastfeed and cannot afford formula, so she has only been feeding her child black tea.
Interacting with vulnerable populations who are marginalized or oppressed and who subsist in extreme poverty often drives individuals to pursue global health work.10 No matter the location around the globe, this work is often fraught with ethical dilemmas that can be exceedingly difficult to manage for an inexperienced Western provider. One often prominent difficulty is how to manage local expectations, since there is a fine line between practicing beyond one's abilities and having a “cop-out” mentality and not performing anything one has not been trained to do.11
While a seemingly trivial episode, Case one raises many global health issues such as resource allocation, cultural competency, and personal safety. Do you draw the blood barehanded? Do you leave the room and get a pair of sterile gloves? Should you refuse to perform the procedure altogether? Each decision has potential pitfalls associated with it. There are high rates of HIV-exposure and nearly half the staff is currently on post-exposure prophylaxis. Sterile gloves are a limited resource generally reserved for emergencies, and refusing to perform the procedure risks alienating the local medical team that is so graciously hosting you.
It is often assumed that ethics training in developed world settings is applicable to health situations globally. However, there are fundamental differences in both the clinical and research arenas that necessitate an alternative paradigm of analysis in the developing world. There is concern that even well-intended efforts might result in inappropriate informed consent or unacceptable risk-benefit ratio, thereby putting in jeopardy the fundamental medical principles of autonomy, beneficence, non-maleficence, and justice.1 However, the four-classic principles of health have their origins in Western philosophies and do not represent the summation of global moral language.10 What constitutes “justice” is different in different societies, as is the standard of care. While we often seek a universal standard of care and an irreducible set of ethics, these are both highly bound by culture and local medical practices.
With respect to Case two, in the South African medical system students perform most of the procedures. At this particular clinic there is a single intern who is supervising the entire facility. There are no senior residents, fellows, or attending physicians. Do you perform the LP with the given supervision, or do you ask for more senior supervision? Or do you refuse to perform the procedure altogether? Interestingly, in South Africa the “see one, do one, teach one” methodology for procedures is nearly universal. That is the standard of care. By acquiescing to the LP, are you being a team player, or are you being complicit in patient exploitation? If you refuse to perform the LP, could you potentially be imposing Western views that were conceived in a different time and place? There are no easy answers to these questions. Each situation is unique and must be analyzed carefully.
Nevertheless, it is important to separate these concepts from the notion of ethical relativism, or the changing of ethical values or priorities simply due to the situation.10 We should uphold our basic ethical framework, but at the same time understand that it may be applied differently when viewed through a different cultural context. Case three raises complex issues such as global health disparity, learned helplessness, research ethics, and respect for enrolled participants. Do you try to admit the child to the hospital even though the family will not be able to pay the bill? Do you buy the child formula? Do you avoid intervening since the child is a subject in your study? How do you choose whom to help and whom not to help?
These scenarios are difficult to navigate by any metric, and exceedingly difficult to manage for the novice GHE trainee. Preparation is the key for success. This begins with a sustained global health curriculum for medical trainees and should be supplemented by country-specific pre-departure training prior to a GHE.12 As of 2005, only 30% of North American medical schools provided some kind of pre-departure education or counseling for students pursuing a GHE.13 This has slowly improved, and we are seeing the advent of more sustained global health programs, and even a formal textbook for global health training in graduate medical education.14
This training should include principles of global health ethics that follow best practice guidelines,15 and expose trainees to practical clinical scenarios they may encounter while working abroad.16 Pinto and Upshur introduce trainees to the concepts of “introspection, humility, and solidarity,” with a focus on the challenges that arise when working with individuals from different cultures who possess different concepts of health.10 With “introspection” we examine our motives, become aware of our own privilege, and understand the basis for this privilege. In the midst of a prolonged strike (case one), I realized that using a valuable resource such as sterile gloves was an untenable option. I acknowledged the situation and considered refusing to perform the procedure, however I made the calculated decision (I felt proficient with this particular procedure) to draw the blood barehanded with help from the nurse. Introspection further allows us to develop a worldview that identifies multiple forms of oppression and systemic social inequality.17
“Humility” refers to trainees recognizing their limitations, being open to education from all sources, and is a general attitude that helps erode the neo-colonial underpinnings that often permeate relationships between the North and South. In case two, I quickly realized I did not have the appropriate level of training to perform the procedure. I expressed my reservations to the intern who appreciated my honesty and took time to explain the procedure in depth, and encouraged me to attempt the lumbar puncture under supervision. I ultimately performed the procedure successfully, but the dilemma raised my awareness regarding standard of care and consent issues among vulnerable populations.
“Solidarity” emphasizes the concept of a “global commons” and is based on the belief that the health of all people is connected, and interdependent. Even though the patient in case three was a subject in my study, I considered it a potential gross violation of research ethics to not intervene. After reviewing the situation with my local adviser, we decided to purchase formula for the patient and exclude him from our study. We recommended admission for the child but the family refused, citing financial concerns. Solidarity is a powerful value to bring to global health work and without it, “we ignore distant indignities, violations of human rights, inequities, and deprivation of freedom.”18 Even though we intervened, I still look back with some misgivings that perhaps we could have done more to change the outcome for this child.
With adequate preparation and a basic framework of global health ethics, trainees can enter the realm of global health and aim to have a positive impact. From an institutional standpoint there must be organized leadership that is accountable for the GHE process, focusing on long-term sustainability and development of mutually beneficial collaborations between both visiting and host sites. We must also select trainees who are adaptable, motivated to address global health issues, sensitive to local priorities, who are willing to listen and learn, and who will be good representatives of their home institution and country.15 Global health electives often have a profound effect on participants. One study found that 70% of students participating in GHEs subsequently entered primary care residencies or intended to work in resource-limited settings.19 These experiences lead to enhanced clinical and communication skills, humanism, cultural competency, and understanding alternative concepts of health and disease.
Global health electives are critical for trainees in fostering a deeper understanding of the global collective and how one's own health is uniquely connected to the rest of the world.20 Claude Bissell, a Canadian author and educator, understands the untapped potential of our trainees when he remarks that they “risk more than others think is safe, care more than others think is wise, dream more than others think is practical, and expect more than others think is possible.”
- Bhat SB. Ethical coherency when medical students work abroad. Lancet 2008;372:1133-34.
- Dowell J, Merrylees N. Electives: isn't it time for a change? Medical Education 2009;43:121-126.
- Roberts M. Duffle Bag Medicine. JAMA. 2006;295(13):1491-92.
- Association of American Medical Colleges. 2013 GQ Medical School Graduation Questionnaire: all schools summary report. Washington, DC. Association of American Medical Colleges; 2013.
- WHO. The Global Shortage of Health Workers and its Impact. 2007. http://www.who.int/mediacentre/factsheets/fs302/en/index.html. (Accessed 1 May 2013).
- Shah S, Wu T. The medical student global health experience: professionalism and ethical implications. Journal of Medical Ethics. 2008;34:375-78.
- Hanson L, Harms S, Plamondon K. Undergraduate International Medical Electives: Some Ethical and Pedagogical Considerations. Journal of Studies in International Education. 2010;15(2):171-185.
- Mosepele M, Lyon S, Dine CJ. Mutually Beneficial Global Health Electives. Virtual Mentor””American Medical Association Journal of Ethics. 2010;12:3.
- Niemantsverdriet S, Majoor GD, Van Der Vleuten CPM, et al. ”˜I found myself to be a down to earth Dutch girl': a qualitative study into learning outcomes from international traineeships. Medical Education. 2004;38:749-57.
- Pinto AD, Upshur REG. Global Health Ethics for Students. Dev World Bioeth. 2009;9(1):1-10.
- Elit L, Hunt M, Redwood-Campbell L, et al. Ethical issues encountered by medical students during international health electives. Medical Education. 2011;45:704-11.
- Sarfaty S and Arnold LK. Preparing for International Medical Service. Emerg Med Clin N Am. 2005;23:149-75.
- Miranda JJ, Yudkin JS, Willmot C. International health electives: Four years of experience. Travel Med Infect Dis. 2005;3(3):133-141.
- Chase JA, Evert J.(Eds.) Global Health Training in Graduate Medical Education: A Guidebook, 2nd Edition. San Francisco: Global Health Education Consortium, 2011.
- Crump JA, Sugarman J. Ethics and Best Practice Guidelines for Training Experiences in Global Health. Am J Trop Med Hyg. 2010;83(6):1178-82.
- Decamp M, Rodriguez J, Hecht S, Barry M, et al. An Ethics Curriculum for short-term global health trainees. Global Health. 2013;9(5):1-10.
- Razack N. Anti-discriminatory Practice: Pedagogical Struggles and Challenges. Br J Soc Work. 1999;29:231-50.
- Benatar SR, Daar AS, Singer PA. Global Health Challenges: The Need for an Expanded Discourse on Bioethics. PLoS Medicine. 2005;2:e143.
- Thompson MJ, Huntington MK, Hunt DD, et al. Educational Effects of International Health Electives on U.S. and Canadian Medical Students and Residents: A Literature Review. Academic Medicine. 2003;78(3):342-7.
- Drain PK, Primack A, Hunt DD, et al. Global Health in Medical Education: A Call for More Training and Opportunities. Academic Medicine. 2007; 82(3):226-230.