Americans are confronted with images and discussion of international issues on a daily basis, leading to an increased awareness of global health challenges. The media deliver news of AIDS in Africa, disasters and earthquakes in Asia and the Atlantic, and epidemics like H1N1 influenza and SARS (severe acute respiratory syndrome) to our living rooms and inboxes daily. The ubiquity of these stories and global nature of today’s business, trade, and travel emphasize that “international” conditions are not as far away as they may at first appear. Moreover, U.S. society has expanded to include diverse cultures, values, and languages, exposing health care professionals to patients from diverse backgrounds and cultures in their own communities and highlighting the importance of understanding health in a global context.
Not surprisingly, student and clinician interest in global health experiences is blossoming as medical professionals strive to better understand the international dimensions of health. Although a desire to help those in need around the world is certainly laudable, and global health experiences have unquestionable value for the health care student and professional, the ethical implications and cultural impact of serving vulnerable populations both at home and globally warrant close examination. This issue of Virtual Mentor explores many of the ethical dilemmas that arise in the context of global health service.
A contemporary concept of global health goes beyond a narrow focus on disease diagnosis and treatment to explore the social, political, and cultural contributors to well-being, defined as more than merely the absence of physical disease. In its quest to support universal human rights, the campaign for global health embraces human diversity in all settings and encompasses an inquiry into the forces that separate privileged, empowered populations from disadvantaged, disenfranchised populations. From this perspective, discrimination, inequality, displacement, poverty, environmental dynamics, education, and health care rights all surface as factors that shape personal well-being.
Reflecting this philosophy, one important motivator for students and clinicians who pursue global health experiences is a “duty to care,” explored by Claire L. Wendland in VM’s medicine and society section. But Jane Philpott points out in her medical narrative that people who engage in global health experiences have varied motivations, not all of them admirable. And as one of this issue’s case commentaries explains, students motivated by a duty to care among other factors are commonly confronted by shocking health inequalities. Audrey M. Provenzano and Kaveh Khoshnood discuss the challenges posed in resource-limited settings and the difficulty of dealing with all the aspects of a patient’s well-being and care. Drawing from this case, this month’s clinical pearl by Carrie L. Kovarik and me outlines the WHO Clinical Staging System for HIV/AIDS, a tool that can facilitate diagnosis and care in areas with limited technological and laboratory resources.
All individuals engaged in service learning—students, mentors, and program administrators—have an ethical duty to ensure that global health programs are responsive to local needs, conducted in a way that upholds professional standards, and carried out with safeguards to prevent harm to both patients and participants. Student enthusiasm and commitment to serve must be tempered by the limitations of their clinical knowledge and relative inexperience, which leave both students and patients vulnerable. There is a common misperception that underserved and impoverished populations will benefit from any medical care, irrespective of quality or the experience level of the provider. As Mosepele Mosepele points out in his case commentary, this is but one of the numerous causes of concern in global health electives, and it emphasizes the need for effective leadership that is responsive to the host community as well as student needs and concerns. Sarah Lyon and C. Jessica Dine expand on this idea, discussing characteristics of international medical student rotations that can help ensure that students benefit educationally while also striving to meet the needs of the host community. In their op-ed piece, Kym Ahrens, F. Bruder Stapleton, and Maneesh Batra draw on their experience with the global health pathway at the University of Washington’s Pediatric Residency Program to provide principles for guiding ethical conduct of international health electives that involve resident physicians.
As many of this issue’s authors mention, developing sustainable and responsive partnerships between academic medical centers in the developed world and organizations in resource-limited settings is fundamental to building long-term partnerships that benefit both parties. Jennifer Cohn and Harvey M. Friedman describe the challenges in building these ties, sharing the lessons learned through their involvement with the University of Pennsylvania School of Medicine’s programs in Botswana. Similarly, Jane Philpott explores ways in which lessons learned from international research ethics—ensuring informed consent, evaluating the risks and benefits, avoidance of exploitation, application of a standard of care/education, and following of codes and guidelines—can be applied to international academic educational partnerships. Research ethics also come into play when physician-scientists engaged in research work in resource-limited settings face the challenge of striving to uphold the principles of beneficence and justice while reconciling their many potential roles as investigator, clinician, and educator. Hana Askelrod examines this ethical struggle in her discussion of a recent article from Clinical Infectious Diseases.
While much need exists internationally, unmet health challenges and culturally diverse experiences lie in our own backyards, and one must assess the duty to think globally but serve locally. In the health law section, Alison Johnson, Jacqueline Darrah, and Lisa Benrud discuss federal and state liability protections for physicians who volunteer and work with indigent populations—and the limitations to those protections. In response to a case that asks whether medical schools should dictate where student service takes place, Cynthia Haq and Heather Lukolyo suggest that institutions should encourage and support service learning and global health opportunities both in the local community and internationally, without dictating where the experience must take place. Lauren K. Graber, Mei Elansary, Kaveh Khoshnood, and Asghar Rastegar comment further on the obligation medical schools have to educate students about local needs, appropriate conduct, and professional standards and to prepare those planning service electives for the ethical and clinical challenges of working in resource-limited settings both in the U.S. and abroad. They argue that, while both local and international opportunities must be approached with proper preparation and care, they are crucial components of medical training and foster the values of humanitarianism, altruism, and social service.
In his discussion of Shah and Wu’s 2008 article in the Journal of Medical Ethics, Sujal Parikh elaborates on the obligation of medical schools and other institutions to promote principled and professional frameworks for students to approach service and medicine, regardless of setting.
In the history of medicine section, Phil Perry and Fred Donini-Lenhoff look at how stigma and xenophobia have complicated the treatment of infectious disease over the course of history. On an even larger scale, Josh Ruxin discusses the ways in which increasing regional and global trade impact health, from policies dictating which foods and medications countries can produce and use to market forces that drain medical professionals from areas where they are most needed.
The authors for this issue, many of whom have lived and worked overseas, bring perspectives from both domestic and international experiences—helping us to consider all sides of the issues. The new paradigm for serving resource-limited, multicultural populations both in the U.S. and abroad focuses on developing and supporting attributes such as cultural competence, understanding the community context of medicine, and humanistic self-awareness. This issue of Virtual Mentor explores the similarities and differences in “global health” in the United States (or other developed countries) and internationally (especially in resource-poor nations) in an effort to highlight the interrelationship between an individual’s well-being, health care beliefs, and behaviors and the social, cultural, political and economic contexts in which they exist.