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.
A wide range of ethical dilemmas is integral to global health experiences. Please comment on the following two scenarios:
Upon entering a global health elective program, students are sometimes uneasy about their role in an underserved setting. They may feel that rather than contributing to the global health setting, their presence expends valuable time and resources that medical staff could otherwise use to care for patients. How would you respond to students who feel uneasy about their role in a global health program?
Dr. Kalyesubula: I would explain to students that they should view the global health elective as an investment for the future and, as such, should not expect to provide any immediate contribution to the communities to which they are assigned. Rather, students should use the experience as a stepping-stone from which they can return once they are more qualified to provide patient care. Furthermore, the experience can help them exhibit strong leadership that considers global health principles when it is demanded of them in the future.
Dr. Winter: I would frame this in terms of students’ ongoing training and preparation for future involvement in global health, and the ways in which this experience prepares them for the time when they can give back in terms of capacity building in similar settings in the future. In other words, students are accumulating debt that they should expect to pay back at some future time. By analogy, this situation is similar to what happens on the wards in U.S. hospitals in which residents and faculty take themselves away from patient care to teach students in the expectation that they will do the same for others when they become more senior. The bedside, not the library, is where doctors learn- and other doctors must be our teachers.
Personal safety issues often arise in the context of large cities in both the Global North and Global South, some of which may be relevant to particular international rotations. For example, using boda boda transportation in Kampala comes with a risk of head trauma, as does walking in the wrong neighborhood at night in New York or Harare. Is it enough to warn students of the situations they should avoid, or should we be more proscriptive and possibly punitive rotation for example) if they do not comply?
Dr. Kalyesubula: It is better to be strict in this respect because students always want to experiment. It is better to be safe than sorry. One bad event can easily terminate an otherwise very promising collaboration.
Dr. Winter: I would recommend that issues involving high-risk behavior be discussed in the pre-departure orientations, and that their importance be emphasized in the program materials. I would also recommend that participants be required to sign a document acknowledging the risk of specific behaviors and promising that they will not participate. Beyond that, I would not be punitive at the level of rotation termination.