From the Editor
Sep 2019

Ethical Issues in Global Health Education and “Immersion” Experiences

Gillian Naro
AMA J Ethics. 2019;21(9):E711-714. doi: 10.1001/amajethics.2019.711.


Global health programs provoke a great deal of institutional interest among health professions students. More than 25% of surveyed students report having participated in a global health experience during medical school.1 Students drawn to these experiences often incorporate inclusive practices in their future work, which enhances their cultural sensitivity and clinical skills.2,3,4 Initially, learners tend to take part in these experiences to understand challenges of global health care and gain exposure to advanced or rare pathologies while developing and ultimately practicing clinical skills in serving many with limited access to health care.5 These trips can help students and patients, but some students return questioning the quality of the care they helped administer and the sustainability of the programs in which they participated. Mismanaged trips can lead to student distress, resource depletion, and inadequate care. Academic institutions and international nonprofit organizations should consider the value of these trips to communities they seek to serve as they continue to promote students’ learning.

This theme issue of the AMA Journal of Ethics aims to reflect on the ethics of global health immersion experiences. In particular, it addresses ethical questions about standards of care and the impact these trips have on local communities, including patients’ access to care and technology and whether and when some care is better than no care.

Several contributors consider who is best served by these trips. Jennifer Jacobs and I respond to a case of a student who doubts the value of the care her program provides to local patients and has conflicting emotions about her participation. We argue that global health experiences should prioritize a community’s needs, especially for building capacity of the local health system. Claudia Gambrah-Sampaney, Jesse E. Passman, Andrielle Yost, and Glen N. Gaulton examine how global health initiatives can be restructured to meet students’ and participating institutions’ needs. Hannah R. Sullivan also shares her personal experience fostering cultural and academic exchange as an administrative maternal health program volunteer in Kenya.

When we zoom out from students’, clinicians’, and patients’ experiences to consider roles and goals of institutions that design these trips, standards of global aid distribution should be considered. Taryn Clark, Julia Terle, and Robert H. Gilman discuss how a Johns Hopkins University-directed program implements low-cost, high-impact training in Peru and Bolivia to help these countries meet Millennium Sustainable Development Goals. Ben Bowman and Brian Callender examine the World Medical Association’s updated Physician’s Pledge, paying special attention to health professions students’ obligations to proactively support domestic and international human rights and civil liberties.

International partnerships among host institutions and US-based academic institutions can inject health service delivery and research resources into local communities. However, gaps between expectations and reality can emerge when some host countries find that costs of hosting students exceed estimates.6 Kristin K. Sznajder, Michael C. Chen, and Dana Naughton consider how to respond to one-sided partnerships. Elizabeth Hutchinson, Vanessa Kerry, and Sadath Sayeed discuss a bidirectional partnership between the nonprofit Seed Global Health and the WWAMI-University of Malawi/College of Medicine to illustrate prioritization of fundamental ethical principles in the pursuit of global health aims. Kelsey Walsh discusses physicians’ participation in the American Medical Association’s Volunteer Physicians for Vietnam Program (1966-1973).

Patients who depend on free clinics for access to primary care, domestically and internationally, are particularly vulnerable when clinics are primarily staffed and operated by inexperienced students not yet certified to offer standard of care. Sural Shah examines the overlap between global and domestic community health in low-resource settings and argues that ethics training can help prepare students for ethical questions arising from suboptimal care, limited resource availability, and systemic inequality. Fatimah Hafeez Choudhary visually represents some students’ doubt about how to express respect for patients’ humanity. Harold W. Baillie and John F. McGeehan consider how to balance stakeholders’ interests in providing care to patients who are poor; they argue that to provide just care, students should be trained to deliver care in teams. And Rolvix Patterson and Richard Rohrer provide a framework for evaluating technologies and devices in underresourced settings in responding to a case in which a global health program’s use of mammography might undermine local capacity to provide follow-up care.

As long as people across the globe need health care and either can’t afford it or can’t access it, ethics and justice questions raised in this issue will persist. Even the best, most well-planned and well-intentioned programs can fail in the face of policy, corruption, or crumbling infrastructure. Many assume that some care is better than no care, but this idea deserves ethical investigation. Rachel Koch, John G. Meara, and Anji E. Wall respond to a case of a boy in a low-income region who receives free cleft palate surgical interventions offered by a team of international surgeons on a global health trip. The authors argue that surgical mission teams should use norms for medical mission work as benchmarks to determine whether a particular intervention meets ethical standards.

As health professions trainees prepare for global health trips, good program oversight is critical. Shailendra Prasad, Fatima Alwan, Jess Evert, Tricia Todd, and Fred Lenhoff argue that, to preserve the social contract health professions have with society (at home or abroad), schools, sponsoring organizations, and governing boards should ensure that global health experiences satisfy social expectations about caregivers’ competence and accountability. Robert Hash and Barbara Barzansky examine the Liaison Committee on Medical Education’s accreditation standards regarding risk assessment, supervision, and education in global health settings. Finally, William B. Ventres proposes 6 themes—identity, ideology, ignorance, imagination, intention, and investment—to guide students’ cultivation of self-awareness.

International health care will continue to be important in health professions education. Scholars and experts contributing to this issue model ways to grapple with ethical questions raised by these programs.


  1. Association of American Medical Colleges. Medical school graduation questionnaire: 2018 all schools summary report. Published July 2018. Accessed June 19, 2019.

  2. Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global health in medical education: a call for more training and opportunities. Acad Med. 2007;82(3):226-230.
  3. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The international health program: the fifteen-year experience with Yale University’s Internal Medicine Residency Program. Am J Trop Med Hyg. 1999;61(6):1019-1023.
  4. Johnson O, Bailey SL, Willott C, et al; Global Health Learning Outcomes Working Group. Global health learning outcomes for medical students in the UK. Lancet. 2012;379(9831):2033-2035.

  5. Panosian C, Coates TJ. The new medical “missionaries”—grooming the next generation of global health workers. N Engl J Med. 2006;354(17):1771-1773.
  6. Ijsselmuiden CB, Kass NE, Sewankambo KN, Lavery JV. Evolving values in ethics and global health research. Glob Public Health. 2010;5(2):154-163.


AMA J Ethics. 2019;21(9):E711-714.




I would like to thank the authors for their time and dedication in providing stimulating contributions on a topic so important to me and close to my heart. I also want to thank my mentor, Dr David Craft, for his guidance and support. Finally, I thank my parents Nick and Erin Naro and my friends, particularly Marie Libassi-Behr, for their constant encouragement and love.

Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose. 

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.