Ethical Dilemmas in Global Health: Promoting Global Consciousness

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Dr. Stephen Winter, Director of Global Health at Norwalk Hospital, and Dr. Robert Kalyesubula, cofounder of the African Community Center for Social Sustainability, in Nakaseke, Uganda

This post is part of a series of discussions about ethical dilemmas in global health, with responses from one global health leader in the Global South and one in the Global North. Please leave us your feedback in the comments section below, and send us ethical dilemmas you would like to see discussed.

Compiled by Dr. Majid Sadigh, Trefz Family Endowed Chair in Global Health at WCHN and Director of Global Health at UVMLCOM, and edited by Mitra Sadigh, Editor of Global Health Diaries.



Many students and faculty visiting other countries often deal with culture shock. How can the stress and frustration of culture shock be mitigated? What steps have you taken as a leader in global health to address the challenges of dealing with diverse participant backgrounds and expectations?

Dr. Winter: I think it is important to identify explicit points of contact through which to interact with visiting students and faculty. Among these should include scheduled formal meetings to discuss and review experiences that have led to stress or frustration, and would ideally involve a peer from the host side for regular daily interactions and a more senior mentor relationship on a less regular basis, perhaps weekly, to help participants recognize and talk through situations that have lead to emotional or social distress. I think we have done this at the senior level, for example with Dr. Luboga in Uganda, Dr. Ndhlovu in Zimbabwe, Dr. Kimphoung in Vietnam, as well as Dr. Sadigh, Dr. Jarrett, and myself in the United States. However, I think it would also be useful to promote peer mentoring at the local level to promote cultural competency and establishment of personal relationships that bridge the two cultures. Culture shock and its effects should also be addressed in pre-departure orientation activities.

Dr. Kalyesubula: The key here is pre-departure orientation as well as proper selection of candidates for global health. Unfortunately, not everyone who wants to participate in global health is well-suited for the field. For this reason, a careful selection tool to help determine appropriate candidates is crucial. Additionally, the teams on the ground should be prepared to support global health participants, particularly through the first days of their stay, and should be in frequent dialogue with them. Regular feedback sessions should be held to discuss and explain any concerns, and communication lines should be open from both parties.

Please comment on trends you have noticed in terms of participant differences based on their country of origin. What are their respective experiences? What contributions and challenges do they bring to the program?

Dr. Winter: Although it is unfair to generalize, I think certain themes have emerged, as participants from each country bring different attributes. Our Russian participants share many cultural features with their American counterparts, as many Americans of my generation have ethnic roots in Eastern Europe and Russia. Even so, there are important nuances of interaction that can lead to misunderstanding and loss of trust. A simple phrase such as “We must get together for dinner one of these days” is a representative example. To an American, it is an idea that might lead to a firm invitation at some point. To a Russian visitor, it is a hard commitment to meet for dinner and, when not fulfilled, engenders distrust and confusion about motivation. For our colleagues from Uganda, Zimbabwe, Vietnam and the Caribbean, there are important aspects of religious belief, conservatism in dress and behavior, and family dynamics that must be understood to achieve true cultural competence.

Dr. Kalyesubula: Differences among participants largely depend on differences in character. It is not the country of origin as much as the universities and the cultures of respective institutions that differentiate participant attitudes. Most participants from the Global South tend to be more adaptive and humble while those from well-to-do universities feel more entitled and tend to think they are doing the Global South a favor by “visiting” them. They also tend to think that locals do things the “wrong” way and it is their obligation to correct all wrongs and Westernize the practices. Although they may have good intentions, these tendencies have often made the hosts from the Global South withdrawn, rendering the experience less productive on both sides. Proper induction and orientation, as well as humility, can mitigate this issue.


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