GH Ethics - Archived 20090901

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Contact: azad.mashari@utoronto.ca. Mailing list: http://www.straightjacketstudio.com/mailman/listinfo/ghethics.

Contents

Abstract

Of the roughly 6000 languages spoken in the world in the middle of the 20th century, fully half are either already extinct or are no longer being taught to children. It is predicted that by the end of this century only 10% will be left [1] Every two weeks someone who is the last speaker of a language and the last carrier of its culture dies. This accelerating loss of diversity does not simply make for a less colourful world; it narrows the range of humanity's adaptive possibilities precisely at a time when our most politically and technologically dominant cultural paradigms are proving to be increasingly unsustainable. As anthropologist Wade Davis writes, we are "living through a time when virtually half of humanity's intellectual, social and spiritual legacy is being allowed to slip away... It is not change and technology that threatens... it is power... these peoples are not failed attempts at being modern, quaint and colourful, destined to fade away by natural law... these are dynamic living peoples being driven out of existence by identifiable forces..."

As individuals striving to understand and improve the health of the world around us we often find ourselves participants in processes arising from world-unifying visions and insidiously infected with that kind of power. In the name of 'help' or 'development,' other ways of life are devalued against our own fully 'developed' civilization and we wonder whether we are destroying the very things we are trying to preserve.

As the presenters, we have found that the traditional methods of 'helping' are not ideal and are often based on a world view with implicit assumptions that we hesitate to affirm. These assumptions shape our advocacy, our research and our field work. Most importantly they shape our interaction and our perspective of those we strive to help in subtle and potentially destructive ways.

What are our motivations to engage in global health? What constitutes Health for a given people and place? How do we evaluate the impact of our activities on it? Why do we ask the research questions we do? Who do the answers and publications benefit? What is our relationship to the host population? How do they see us? Can we overcome the immense distances created by culture, material wealth and political power? Are we supporting or encouraging the aspirations of other peoples towards our own environmentally destructive and unsustainable life styles and institutions? What does it mean to be "culturally sensitive"? "Polite respect for the amusing but dispensable quaintness of other cultures"?

In this workshop we want to create a space for discussion and sharing of experiences, questions and arguments on these themes.


Approach

Our focus here is on ways of seeing. We want to dig beneath our own frames and views of the world to better understand the meaning of our actions for ourselves and for others who are affected by them.

To expose the limits and shortcomings of our ways of seeing, we focus on situations and questions that make us uncomfortable. We see this discomfort as a sign that our habitual mode of looking at problem is not able to properly make sense of these situations or questions. We hope that by valuing and pursuing this kind of discomfort, instead of avoiding it, we can break out of our narrow perspective. We see discomfort as a harbinger of insight.

We do not offer answers because we don't have any. Our goal is to refine our questions through conversation and debate as a means of developing an approach to future encounters with real-life problems. There may be no difference between finding the best way to ask a question and finding the answer. We want to hear your thoughts on these questions, their content, their framing and bias.

We want to pursue this process in order to refine our approach to future practical problems. This is not intended to be just an intellectual exercise. If this process leads to ethical paralysis then it has been a failure.

We want the workshop to be interactive in something other than the following sense: adj. being manipulated into coming up with the speaker's opinion in such a way that you believe it to be your own.

~ ~ ~ ~ ~

We have come to believe that many traditional methods of helping are potentially unethical & destructive. We believe that some of this is due to intentions arising from honest self-interest (i.e. the perpetrators admit to themselves that what they do is not intended to benefit anyone else). We are however more concerned about what seems to be the more common scenario, where the perpetrators actually believe that they are doing good while inflicting harm.

We have found ourselves in this situation in the past.

We wish to understand why so as to avoid doing so in the future.

We have found that the negative impacts of our actions are often grossly underestimated. A more honest & accurate sense of the overall balance is needed.


On Hope

Avoiding honest analysis of what is destructive, dark, unpleasant is not hope, it is the worst form of cynicism.

Just as courage cannot exist without fear, hope is meaningless without a deep awareness of the forces that oppose it.

Hopefulness is not a state of bliss that is found. It is a state of productive struggle that we choose to create, a commitment we make to face the threats to what we value.


Going There

Much of the discussion of ethics around global health appropriately focuses on very concrete situations that we might find ourselves in when we are actually "there" where ever "there" might happen to be. To be so concrete and focused such discussion must take a lot of background choices and assumptions for granted. Here, we want to question those choices and assumptions. We want to question the world views, the ways of seeing that are always in the background of this kind of work.

In that sense this is going to be more abstract but it is still meant to be very practical. In order to keep our kites tethered to the ground, and have some hope of landing lightly at the end of it we are going to focus on our "field" experiences and stories and the thinking, reading, questioning, joy, guilt etc. that has followed from them. We hope that in this way we can maintain our balance on the line between wilful blindness and ethical paralysis.

Our experiences are inevitably limited, and our stories are, inevitably, through our own eyes. So all conclusions and answers are also ours and we do not intend to convince of you of them or even offer them up for debate. The stories lead to the questions and it is the questions which are our main offering to you and it is your thoughts and feedback on the content and method of the questions that we ask for in return. So, if any part of this comes across as a polemic or a thesis or worst of all an answer, please kindly rephrase it in your minds as a question, because that is how it is really intended.

By questioning our experiences we want to expose the limits and shortcomings of our own ways of seeing. We took a tack analogous to science: we decided to look at situations that really get under our skin, made us uncomfortable, scared us, or just didn't make sense. Discomfort is often caused by the failure of our habitual perspectives to make sense of the situation, and so it exposes the gaps, attitudes and questions that we might otherwise have not been aware of. A quick and simple example.

  • In Phnom Penh, to get from my house to the main street you had to go through a narrow lane. It was often necessary to take turns passing through in opposite directions. I had never really paid attention to this process. One day, I was in a good mood, and I encountered a middle-aged Cambodian man walking towards me. I stepped back and let him through. I suddenly had a wave of euphoria wash over me as I congratulated myself on being so kind and enlightened as to allow even a Cambodian man to go ahead of me. And then I realized what had just happened. That moment did more to sensitize me to all the power dynamics and racism that I was swimming in. I had read and thought lots about racism. But I really didn't have any insight into the racism implicit in a lot of my attitudes until that moment.

What I am learning is how to see past my disgust or guilt and being able to channel the energy of that stomach knot into actually transcending beyond those attitudes in a visceral, embodied way so that they are reflected not just in my explicit beliefs but also in my choices and actions. For example I have learned that stories are a really good way to approach this discomfort and process it constructively while staying joyful and energized.

This process is not pleasant. It has taken us a long time to bring ourselves to ask some of these questions and take them seriously at gut level. And I, for one, am aware of other questions forming that I still cannot face directly because they are too threatening. We want to refine our questions through conversation and debate as a means of developing an approach to future encounters with real-life problems. We want to hear your thoughts on these questions, their content, their framing and bias.

Background

Demographics exercise for all participants. For each questions move along your row to the point which best represents you in the spectrum between the extremes (right to left of the room).

  • How much education have you received in global health (formal or informal)? (none ... tons)
  • How clear is the term "global health ethics"? (as mud ... as a mountain stream)
  • Have you worked or volunteered abroad in "global health"? (never ... very often)
  • Have you worked or volunteered domestically in "global health"? (never ... very often)
  • In your work (here and abroad), how often have you encountered issues of "global health ethics"? (never ... very often)
  • In general, how comfortable are you that you understand the impact of your work? ("Not a shred of doubt in my mind" ... "I have no idea")
  • What do you think is the overall impact of your work on the world? ("I am building paradise on earth" ... "I work for Lucifer")


Case Studies

Canadian medical student project in Tanzania (KA)

Scenario:

  • 8 multidisciplinary health professional students travelling for 7 weeks to a site in East Africa, with plans to provide free screening physical exams to both persons living with HIV and related disease, as well as orphans and vulnerable children.


Initial impression:

  • An annual project, each year raising money and supplies for travel and local contributions, with continuity between student teams.
  • Faculty oversight from an infectious disease specialist.
  • A local (in-country) physician involved and paid by the student team to provide care to the same screened individuals between each summer student visit.
  • Students spend six months learning the local language before departure.
  • The physical exams are conducted in the local language, with referrals for additional care made to the local physician.
  • Scholarships provided for screened children to attend primary school.


Further concerns based on information that came to light during the project:

  • At the screenings, it becomes clear that the children and PLWHA told (by local physician and nurses) they were being screened by physicians, not students.
  • PLWHA receiving screenings found to have multiple care providers and adequate healthcare already; came to screenings mostly to receive travel stipend.
  • Students did not adequately prepare for HIV screenings; had never knowingly met an individual living with HIV. Unable to recognize local clinical problems. No supervision.
  • No translators available due to confidentiality concerns; nurses end up translating for students and neglecting care for other hospital inpatients, as well as neglecting teaching local nursing students.
  • Almost all individuals referred on to local physician, as we were unable to rule in or rule out disease.
  • Extreme disagreement on the team regarding the benefits and risks of our involvement; team considers shutting down the project.


18 months later:

  • I met the Dean of the local medical school. He describes the ethical and practical problems surrounding too many visiting medical students.
  • In 2007, 120 local medical students; 120 visiting medical students.
  • Likely due to hospitable culture and sociopolicial/financial agreements with sending institutions, visiting medical students are given absolute learning priority.
  • Local healthcare infrastructure failing in part due to inability to teach local medical students.
  • Receiving institution feels hard pressed to decline additional visiting medical elective students.


Currently:

  • A new team preparing to leave.
  • The information package begins: "In our Medical Outreach programs, students go to third world countries to help."


Questions

  • What are all my reasons for pursuing this global health elective?
  • Am I accepting of my less altruistic motivations?
  • Is there a cost to satisfying these motivations and if so, who will pay that price?
  • Do I feel a need to intervene in the lives of others to make them "better"?
  • If so, where did it come from? What are the assumptions behind it?
  • How do I know if this intervention is wanted?
  • How would I tolerate being on the receiving end of such intervention, from somebody from a very different culture, with whom I can not communicate adequately?
  • Are my gut instincts sufficient in assessing my impact on a community I visit?
  • If there is an inherent risk of community harm through my presence, is the proven benefit to my own education worth the risk of that harm? Should this be my decision alone?
  • How do power imbalances impede my ability to understand how welcome or useful I am?
  • To what extent will I ever know the full impact of my involvement in a vulnerable community?

The more we disregard the context of our work and presence the easier it is to convince ourselves that we are making a difference when we are not. Is this true?


University of Toronto in Cambodia 2003-2007 (AM)

Preamble: "Going There"

  • We still believe it's important to be exposed to other surroundings and cultures vastly different form our own, definitely for our education. Whether we can be effective in making a positive change in such surrounding is debatable.
  • How we conduct ourselves, the personal comforts we seek, the technology and symbols of wealth that we take with us, our attitudes & self knowledge, all influence how we see ourselves, how we are perceived and what kinds of impact we have.

I went to Cambodia through a U of T Centre for International Health project. The Centre had signed an agreement with the Cambodian government 5 years ago to implement a primary care system in one of the poorest regions.

Students were to go for summer projects gathering epidemiological, needs assessment and program evaluation data. Several of these student reports touched on the very high maternal mortality rate in the area, which had remained unchanged despite the programs implemented by the centre and the building of local health centres set-up and operated by the government. My goal was to figure out why the available services were not being used despite the apparently high need.

When I got there I solved "the mystery" in one day: The services I had been led to believe were "under-utilized" did not in fact exist, and had never really existed in the form reported on. And the person who had suggested I go there, one of my role models during medical school, knew that.

  • No patient care services had been provided by the centre in the five years aside from a few sporadic "outreach camps"
  • Other services & organizations had been diverted from area because of the perception that it was being served by CIH
  • The small local hospital & health centres still had no electricity, no clean water, no ability to manage complications of labour.
  • The cost of labour and delivery amounted to over 2 weeks of income for the average farmer living on ~25-50 cents per person, per day, with no increased safety and significant transport problems between most villages and the health centres.
  • None of the reports were translated into the Khmer or French. Most had no Ethics approval.
  • Most were by students with little experience, minimal faculty supervision; Most of the data is essentially unusable.
  • ~7 of the reports present high quality & novel data. No recommendations have been implemented.
  • Other organizations associated with group have dissociated themselves.
  • Local officials were threatening to dismiss the organization.

Impacts

  • Deep distrust of outsiders; The general (and evidence-based) attitude that most foreigners came, asked lots of questions, filled surveys, sat on the beach, ate seafood, left, and were never seen again.
  • Development of a reaction system in the community ... selecting for some of the most unscrupulous (and relatively well-off) individuals in the community to set-up operations to counter-exploit foreigners within their range of activities. Some of these gains occasionally benefit the community.

Notes


I abandoned this project and started looking at other opportunities and began to get a broader picture of the aid scene in Cambodia and I became interested in looking at the side-effects of these processes and whether there was any systematic cost-benefit analysis out there.

  • In Cambodia the presence of such a large number of foreign aid workers has caused significant inflation, in particular effecting land and food prices (as much as 10-fold increase in land prices in 3-years). Various other factors contributed to this inflation as well, but the consumption rate and purchasing power of aid workers made many things inaccessible to the local population.
  • Landlessness is a particularly striking example. It is the predominant determinant of poverty and hence health for subsistence farmers.
  • Slums evacuated in Phnom Penh to make apartments which will be mostly occupied by aid workers.
  • After 15 years of being one of the top 2 per-capita aid recipients in the world most people in the country still do not have access to clean water and sanitation. Child mortality, according to the WB's own data has actually gone up since the civil war ended.

This is where my questioning started.

We each have a responsibility to ask these questions of our experience. We need to consider the impacts of our action as broadly as possible. We'll have different experiences but these questions will still apply.


Questions

Why was I here? What did I think I was doing?

  • Well there were a lot of reasons I could list but in the end they came down to two: First I wanted to Help, to do good, because I felt responsible, or altruistic, or guilty about my privilege or whatever else. The second I was curious, I wanted to learn, I wanted an adventure, values that my culture prizes. I'll start with curiosity.


Some thoughts on Curiosity

  • As you are well aware Curiosity Killed the Cat. Until recently I had always interpreted that curiosity as being the Cat's curiosity. The cat was curios, went in to the street and so on... But then I realized that far more often things die not because they are curious but because someone or something else is curious about them. Someone else's curiosity about the cat may have killed it. We live in a culture that assigns a very high moral value to curiosity and desire for learning. It has been essential to the material achievements of our civilization. Despite the realization the curiosity can be dangerous and destructive (hence Research Ethics Boards) deep in our psyches we still seem to see the love of learning as something pure, beyond all evil. I am certainly guilty of this, even now.


Some thoughts on Help: How do I picture "helping"?

  • I am doing something, I need help, I call you over, tell you what I need, if you can and you want to then you grant my request.
  • Or I see someone on the ground, I ask if they need help, they say yes, then...
  • Or they are unresponsive in which case I assume that they do not have the capacity to accept/refuse and I make the decision by myself.

Most of the "help" situations I found myself in fit uncomfortably into the above schemes

  • People asked me for money, I was repeated told not to start giving money
  • I was not asked for any of the "help" that I actually did provide
  • Most of the individual recipients, and communities were alert and oriented x 3 and fully capable of asking for help. But I had no way of really having a meaningful conversation with them about their needs either by myself or through my cultural intermediaries.


What was I "helping" them to do or get? I was "helping" them to "develop" to be more like me ... YIKES What does "Development" mean? "Developing country"?

  • Seeing our way of life, our way of defining health and illness, as the ultimate objective and all alternatives not as different but as inferior.
  • We live in a time of massive loss of cultural diversity. Some 90% of languages that were spoken in the 1960's will be lost by the end of this century.


What is the impact? The only book I have found to date that is actually written by someone who was on the receiving end of this help in Cambodia is Towards Restoring Life in Cambodian Villages by Meas Nee

"And so it was that I could be so easily degraded by foreign aid workers. They came with humanitarian assistance and would sometimes give me the responsibility I wanted - the chance to work for our people. This was like putting an oxygen mask over my mouth and nose. I needed this to live. But they could so quickly criticize and blame me for no reason that I could understand. It was as if they kept their hand over the tube coming from the oxygen cylinder and could squeeze that tube whenever they wished." (page 28-29)


Where am I getting my feedback from?

  • People here telling me I am a saint
  • Positive ego feedback when I give a presentation like this
  • People I worked with, some with more experience (but with careers and lives dependant on this)
  • Talking to the "Locals" I worked with ... But
    • racism of this notion of "locals"
    • how "local" where they?
    • What interests did they really represent?
  • Did I have any way to know whether the people I was "helping" really wanted or benefited from this kind of help?
  • I became more and more aware of the Distance that separated my world and that of the people I was supposed to be helping, and how it was so easy to think that I knew what they wanted when I really had no idea. So back to Meas Nee
"[The] message that we were less than human was repeated over and over. I recall that from time to time Site 2 [the Refugee Camp housing 180 000 refugees] was shelled and all foreigners working there were taken out to safety. We were left inside. We would often say that the foreigners were like the angels who could fly from danger; greater than ordinary human beings. We on the other hand were less than human, more like the spirits in hell." (p30)


Then a friend sent me a lecture by Ivan Illich titled To Hell with Good Intentions. Given that Illich was a Catholic priest, I took those words rather seriously.

"If you insist on working with the poor, if this is your vocation, then at least work among the poor who can tell you to go to hell. It is incredibly unfair for you to impose yourselves on a village where you are so linguistically deaf and dumb that you don't even understand what you are doing, or what people think of you. And it is profoundly damaging to yourselves when you define something that you want to do as "good," a "sacrifice" and "help."


Why wasn't I working in homeless health or aboriginal health?

  • because I had a better visceral sense in the distance between my own experience and that of a homeless person here, or someone living in a remote aboriginal reservation. In those cases I could see the vastness of the distance I would have to traverse to be relevant, to be taken seriously. Here I had somehow been lead to believe that "Just being there" and "meaning well" and "caring" and "bearing witness" would mean so much to "these people"
  • Sure it changed my life, and I learned lots, but at whose expense? What right did I have to make that decision unilaterally (I had the power but did I have the right given that the cost was borne by others?)
  • After coming back for a while I thought that I should have spent more time living in a village, and less time in the city with so many other foreigners. I still think that would have been great for education, but I realized only while working on this presentation, that I never asked myself what right I had to just show up in a village and essentially impose myself as a guest on a community that had never invited me and couldn't really tell me to get lost because I was too linguistically and culturally ignorant to understand them. I would have just seen their smiles and interpreted that as approval.

What rights do I grant myself? Should I voluntarily give up doing some of the things I have the power (and even social encouragement) to do?

  • When I am "working there" I am not just working there. I am also being there. I live there, I interact with other people, rich and poor, I interact with animals, the plants, the land, the imported products. Even if I don't think about it, like breathing, it still happens. And the people who see me, who I interact with, will perceive me in terms of their own perspective, will assign meaning and be effected by that meaning of my actions, even if to me the action was entirely "without intent." I had no idea that this little bundle of medicine on my belt would be a constant reminder for you that your life was worth less than mine.

The Questions

Motivations, here & there

  1. What motivates us to help?
    • Is altruism an appropriate foundation upon which we should stand in our endeavors to increase health equity and social justice in resource-poor environments?
    • Are guilt or anger or ego or "moral indignation" appropriate sources of motivation?
    • Aside from the significance of the issues and principles themselves, is there something about our personalities and the ways we deal with our own personal challenges that makes us want to pursue such causes?
  2. What is our relationship to the individuals & populations we are trying to help? How do they see us?
    • If we are driven to ‘help’ a particular community, do we need to actually be a part of that community? And is that possible?
    • Can we overcome the immense distances created by culture, gender, age, material wealth & political power?
    • Are we just tourists on a break? Would that be a bad thing? Am I allowed to have fun in this place? Can I go to the beach? Should I take my laptop? ipod?
    • In medical electives, how do we ensure that we are not a drain on the system? Are we impeding the training of local medical students and health professionals? Are we addressing local needs?
  3. What are costs and benefits of "just being there" or "bearing witness" (for ourselves, for those we are witnessing, for the planet, for those we bring our stories to)?
  4. Should we consider international relief over development?
  5. Where is the evidence in global health development work? Who are our teachers and role models?
  6. Should we use our power as physicians to advocate for global health at home? And if not, why are we not interested in this?
    • Are you involved locally in refugee and community development issues?
    • If not here, then why internationally?


History of Global Health

History: "International/Global Health" is a historical offshoot of colonialism. Many elements from that world view still persist today in the language and assumptions behind many "global health" interventions. We no longer take seriously the hierarchy of the medieval Great chain of being and its more racist future adaptations, but our own notions and definitions of development, progress, poverty etc. carry their own implicit judgments about which way of life is more or less sophisticated; which beliefs and practices are more or less evolved; which should be encouraged and cultivated and which should be allowed to die or actively destroyed.

The answers implicit in our actions often betray the catastrophic assumption that our own civilization and way of life is the pinnacle of human achievement and that other peoples should be, and want to be, more like us; and that they deserve our help in achieving that goal.


Global health research

Research in low and middle income countries (LMIC) is undertaken by a variety of actors for a variety of reasons. While reflecting on your personal reasons for engaging in global health research, you may have asked yourself similar questions to those listed here. Today, there is growing recognition that health research has made positive, sustainable contributions to development processes in many countries (Nuyens 2005). Nonetheless, conducting research in LMIC raises particular ethical questions. This section aims to encourage participants to reflect upon some of these issues through discussion on the following questions:

  1. How is conducting research in LMIC different from in Canada?
  2. What constitutes ethical research design in this context?
  3. What is the impact of my outsider status on my design & interpretation of my study?
  4. How can I achieve my personal goals (collecting enough data for thesis) in the face of challenges in the field?
  5. What is informed consent in this context?
  6. Can research partnerships with LMIC colleagues ever really be equitable?
  7. If my fieldwork lasts only three months, how can I build a sustainable partnership?
  8. Who benefits from my research?
  9. What do I do with my results?

Those interested in reading further on some of these topics are encouraged to visit the following websites:

  1. The Nuffield Council on Bioethics
  2. The International Development Research Centre
  3. Research Matters
  4. Canadian Coalition for Global Health Research
  5. The Global Forum for Health Research


Ways of seeing & implicit assumptions

  1. What are the world views & assumptions implicit in our use of terms like development, poverty, sustainability, aid, health etc...? Once exposed, are we still willing to uphold their implications?
    1. development
      "development" as "To unfold more fully, bring out all that is potentially contained in" [OED] OR "... progression from a simpler or lower to a higher or more complex type; to evolve." [OED] Which is the sense that applies in the context of "international development"? in theory? in practice?
    2. sustainability: Sustainable for how long? In what sense? At what price?
      "You find a stranger who is cold, shivering. You can give him a match and he might be warmed for a few seconds; set him on fire and he will be warm for the rest of his life." - Anonymous
    3. poverty
      The lack of wealth... What kind of wealth? Material, financial, social, cultural, creative, spiritual, artistic, environmental...
    4. help
      "There is no odor so bad as that which arises from goodness tainted. It is human, it is divine, carrion. If I knew for a certainty that a man was coming to my house with the conscious design of doing me good, I should run for my life, as from that dry and parching wind of the African deserts called the simoom, which fills the mouth and nose and ears and eyes with dust till you are suffocated, for fear that I should get some of his good done to me, -- some of its virus mingled with my blood. No, -- in this case I would rather suffer evil the natural way. A man is not a good man to me because he will feed me if I should be starving, or warm me if I should be freezing, or pull me out of a ditch if I should ever fall into one. I can find you a Newfoundland dog that will do as much. Philanthropy is not love for one's fellow-man in the broadest sense." -Henry David Thoreau, Walden
    5. Categories: Low & Middle Income, Low-Resource ...
      A category label implies a very strong judgment about what is most essential, for the purposes of the discussion at hand, about the items in the category. What is the implied essential trait for the categories and labels we use in our global health work (to indicate other individuals, groups, regions)?
  2. Are we (young, energetic, talented, beautiful but inexperienced people) acting as the agents of processes we do not sufficiently understand? How well do we know our mentors? How well do we understand their intentions?
  3. Are we supporting the aspirations of other peoples towards our own environmentally destructive & unsustainable life styles & institutions?
    • What keeps (or used to keep) the people here healthy? What happened to it? Would Western style "health care" be much help when it's such a weak determinant of health in those western countries themselves?


Health, Culture & Ethnocide

  1. What does cultural sensitivity mean in practice? Polite respect for the amusing but dispensable quaintness of other cultures?
  2. To what extent does "health" really mean the same thing in different places and cultures? "... a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." (from Preamble to the Constitution of the World Health Organization) This definition seems general enough but all of the key terms are highly culture-specific. Given this, in what sense and to what extent can "health" be a "global common ground"? Whose version of "health" is "Health for All" referring to in theory? in practice?
    "Although there is neither consensus nor sufficient data yet available, there is little doubt that these initiatives have contributed to widespread improvement of health conditions, considerably improving the chances for survival in various population groups who had been previously plagued by disease, famine and early death." [33 - emphasis added]
    How is there "little doubt" in the absence of both "consensus" and "sufficient data"?
    "In recognizing health as a basic right and an absolute human need, it’s obvious we have the absolute obligation to provide health for all as best as we can, this being one reason for putting the poor and most disadvantaged first." [33 - emphasis added]
    The two uses of "health" here have significantly different meanings. The first ("health as a basic right") is unconstrained. The claim that all people, regardless of culture, want to have health, be healthy, is trivially true if we define health as a state of 'complete physical, mental and social well-being' as defined by those people themselves. The second instance ("providing health") however, fixes that definition of health to whatever paradigm is applied by the provider. So the "health" that is provided may have little resemblance to the "health" that the community wanted. The community may think of health as safe drinking water separated from sewage, food security, a cohesive community and household in tune with its surroundings, looked kindly upon by ancestor spirits who can be given their due respect. The intervener may start clinics.
  3. How do we go about understanding the suffering & needs of those with vastly different views of the world? How do we know what health means for them? How do they understand illness & death?
  4. What are the potential risks of our presence & activities in light of our uncertainty & ignorance? Are they likely to be outweighed by the benefits? How do we make an educated guess?
    • To what extent are we contributing to "cultural imperialism" and ethnocide?
      "... even those of us sympathetic to the plight of indigenous people view them as quaint and colourful but somehow reduced to the margins of history as the “real world,” meaning our world, moves on. Well the truth is, the 20th century, 300 years from now, is not going to be remembered for its wars or technical innovations, but rather as the era in which we stood by and either actively endorsed or passively accepted the massive destruction of biological and cultural diversity on the planet. The problem isn't change. All cultures, through all time, have constantly been engaged in a dance with new possibilities of life. And the problem is not technology itself. The Sioux Indians did not stop being Sioux when they gave up the bow and arrow any more than an American stopped being an American when he gave up the horse and buggy. Genocide, the physical extinction of a people is universally condemned but ethnocide, the destruction of a people's way of life is not only not condemned it is universally, in many quarters, celebrated as part of the development strategy.
      "... These are not dying peoples, on the contrary if you have the heart to feel and the eyes to see you discover that the world is not flat, the world remains a rich tapestry, it remains a rich topography of the spirit. These myriad voices of humanity are not failed attempts at being you, failed attempts at being modern, they are unique facets of the human imagination, they are unique answers to a fundamental question: what does it mean to be human and alive? and when asked that questions they respond with 6000 different voices and collectively those voices become our human repertoire for dealing with the challenges that will confront us in the ensuing millennia. Our industrial society is scarcely 300 years old. That shallow history should not suggest to anyone that we have all the answers to all the questions that will confront us in the ensuing millennia."
      "The myriad voices of humanity are not failed attempts at being us they are unique answers to that fundamental question, what does it mean to be human and alive? and there is indeed a fire burning over the earth, taking with it not only plants and animals but the legacy of humanity's brilliance. Right now ... of the 6000 languages that were spoken the day you were born fully half are not being taught to children, so you are living through a time when virtually half of humanity's intellectual, social and spiritual legacy is being allowed to slip away. This does not have to happen, these peoples are not failed attempts at being modern, quaint and colourful, destined to fade away by natural law. In every case these are dynamic living peoples being driven our of existence by identifiable forces. That is actually an optimistic observation because it suggests that if human beings are the agents of cultural destruction we can also be and must be the facilitators of cultural survival." -Wade Davis (2008) The Worldwide Web of Belief and Ritual


Addiction


Picture:

Intentions & Feedback

In our own experience two themes seems to underlie most of the issues: Our intentions and the nature and sources of the feedback we receive for our work.

We find that all too often we have grossly underestimated or dismissed the negative impacts of our presence while making crucial decisions. These impacts have only come to light (or we have only allowed ourselves to see them) much later.

This in turn seems to result from

  1. an insufficiently clear or insufficiently honest understanding of our real intentions for engaging in this kind of work, and the assumptions and world views implicit in our intentions.
  2. relying on unreliable and highly biased sources of feedback to tell us whether we should proceed at the outset and whether we succeeded in the end.



Presenters

Kelly Anderson is a third year UWO medical student and the National Officer of Global Health Education for the CFMS. She completed a postgraduate program in international project management and subsequently worked for the National AIDS Commision in Rwanda. Once home, she worked for Right To Play International hiring and sending staff around the globe to engage in locally-run sport and play programs for HIV prevention in refugee settings.

She started the Global Health Mentorship Project for medical students in Canada and co-authored the AFMC National Recommendations for Pre-Departure Training. She sits on the board of the Global Health Education Consortium as well as the US/Canadian Joint Initiative for Global Health Education Standards.


Azad Mashari is currently a resident physician in Anesthesiology at the University of Toronto. His field experiences in global health include 8 months in Southern Cambodia as a senior medical and research student and a 2 month summer project as a junior medical student in Tamil Nadu, India. His current interests include the health of marginalized populations in Canada and environmentally sustainable models of health and health care.


References

  1. Jorg Steiner, The Bear Who Wanted to Be a Bear, 1st ed. (Heryin Books, Inc., 2007).
  2. Nikko Snyder, “The complexities of hope,” Ascent, 2007, http://www.ascentmagazine.com/articles.aspx?articleID=282&page=read&subpage=past&issueID=38.
  3. Meas Nee, Towards Restoring Life in Cambodian Villages (Phnom Penh: JSRC, 1999).
  4. Ivan Illich, “To Hell with Good Intentions” (presented at the Conference on InterAmerican Student Projects, Cuernavaca, Mexico, April 20, 1968), http://www.swaraj.org/illich_hell.htm.
  5. William Easterly, White Man's Burden, 1st ed. (Penguin Paperbacks, 2007).


Additional References

1. Hans A. Baer, Merrill Singer, and Ida Susser, Medical Anthropology and the World System: Second Edition, 2nd ed. (Praeger Paperback, 2004).

2. Nicholas Banatvala and Len Doyal, “Knowing when to say “no” on the student elective: Students going on electives abroad need clinical guidelines,” BMJ : British Medical Journal 316, no. 7142 (May 9, 1998): 1404–1405, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1113113.

3. Walden Bello, Deglobalization: Ideas for a New World Economy, Revised. (Zed Books, 2005).

4. Walden Bello and Tom Engelhardt, Dilemmas of Domination: The Unmaking of the American Empire (Metropolitan Books, 2005).

5. S. Bezruchka, “Medical tourism as medical harm to the Third World: Why? For whom?,” Wilderness Environ Med 11, no. 2 (2000): 77-8.

6. R. Bishop and J. A. Litch, “Medical tourism can do harm.,” BMJ 320, no. 7240 (2000): 1017.

7. John Cavanagh et al., Alternatives to Economic Globalization, 1st ed. (Berrett-Koehler Publishers, 2002).

8. Ha-Joon Chang, Kicking Away the Ladder: Development Strategy in Historical Perspective, 1st ed. (Anthem Press, 2002).

9. Ha-Joon Chang, Bad Samaritans: The Myth of Free Trade and the Secret History of Capitalism (Bloomsbury Press, 2007).

10. Wade Davis, “Cultures at the far edge of the world” (presented at the TED Conference, Monterey, California , February 2003), http://www.ted.com/index.php/talks/wade_davis_on_endangered_cultures.html.

11. Wade Davis, “The worldwide web of belief and ritual” (presented at the TED Conference, Monterey, California , February 2008), http://www.ted.com/index.php/talks/wade_davis_on_the_worldwide_web_of_belief_and_ritual.html.

12. Gustavo Esteva, “Development,” in W. Sachs (Ed.) The Development Dictionary: A Guide to Knowledge as Power (Zed Books Ltd, 1992), 272.

13. Daniel Goleman , “Why aren’t we all Good Samaritans? ” (Monterey, California , March 2007), http://www.ted.com/index.php/talks/daniel_goleman_on_compassion.html.

14. T. Grennan, “A Wolf in Sheep’s Clothing? A Closer Look at Medical Tourism’,” Medical Ethics 1, no. 1 (2003): 50-54.

15. Timothy C Hardcastle, “Ethics of surgical training in developing countries,” World Journal of Surgery 32, no. 7 (July 2008): 1562, doi:10.1007/s00268-007-9449-9, http://www.ncbi.nlm.nih.gov/pubmed/18228090.

16. Koss-Chioino, Medical Pluralism in the Andes, 1st ed. (Routledge, 2002).

17. Meas Nee, Towards Restoring Life in Cambodian Villages (Phnom Penh: JSRC, 1999).

18. Andrew D. Pinto and Ross E. G. Upshur, “Global Health Ethics for Students,” Developing World Bioethics (2007).

19. Kevin M Ramsey, “International surgical electives: reflections in ethics,” Archives of Surgery (Chicago, Ill.: 1960) 143, no. 1 (January 2008): 10-1, doi:143/1/10, http://www.ncbi.nlm.nih.gov/pubmed/18209147.

20. Kevin M Ramsey and Charles Weijer, “Ethics of surgical training in developing countries,” World Journal of Surgery 31, no. 11 (November 2007): 2067-9; discussion 2070-1, doi:10.1007/s00268-007-9243-8, http://www.ncbi.nlm.nih.gov/pubmed/17896129.

21. David W Robertson et al., “What kind of evidence do we need to justify humanitarian medical aid?,” Lancet 360, no. 9329 (July 27, 2002): 330-3, doi:12147390, http://www.ncbi.nlm.nih.gov/pubmed/12147390.

22. Wolfgang Sachs, The Development Dictionary: A Guide to Knowledge as Power (Zed Books Ltd, 1992).

23. Vandana Shiva, Staying Alive: Women, Ecology and Development (Zed Books, 1989).

24. Vandana Shiva, Monocultures of the Mind: Perspectives on Biodiversity and Biotechnology (Zed Books, 1993).

25. Vandana Shiva, Earth Democracy: Justice, Sustainability, and Peace (South End Press, 2005).

26. Henry David Thoreau, Walden; Or, Life in the Woods, 1st ed. (Dover Publications, 1995).

27. Jim Yong and Joyce V Millen, Dying For Growth: Global Inequality and the Health of the Poor, 1st ed. (Common Courage Press, 2002).

28. Jill Eisen, “Sick People or Sick Societies,” Ideas - The Best of Ideas (Toronto: Canadian Broadcasting Corporation, March 2008).Part 1 | Part 2.

29. American Medical Association. Virtual Mentor. 2006; 8 (12):795-884.

30. Garten, Ariel. Neuroscience of Morality. Great Ideas, TVOntario. 2007

31. Mashari, A. Healing and Distance. 2007. http://www.straightjacketstudio.com/node/17

32. Anderson, K. and Hamadani, F. What is Our Responsibility? Global Health Ethics in Practice. Presentation at Canadian Federation of Medical Students Conference 2007.

33. Duncan Pedersen, “At the crossroads between global health and local cultures: a critical perspective,” in Lolas F., Martin D.K., Quezada A. (Eds.) Prioridades en Salud y Salud Intercultural, 1 (Santiago de Chile: CIEB and Universidad de Chile, 2007), 141-162.

34. James A. Trostle, Epidemiology and Culture, 1st ed. (Cambridge University Press, 2005).

35. Nuyens, Y. (2005). No Development Without Research: A challenge for research capacity strengthening. Global Forum for Health Research: Geneva.

36. Dubois-Flynn, G. (2007). Ethics in Research in Low and Middle Income Countries (LMIC). CIHR PopNews, 13: 6

37. Nuffield Council on Bioethics. (2002). The ethics of research related to healthcare in developing countries. Nuffield Council on Bioethics: London.

38. Nuffield Council on Bioethics. (2005). The ethics of research related to healthcare in developing countries: a follow-up Discussion Paper. Nuffield Council on Bioethics: London.

39. Aboud, F. (1998). Health Psychology in Global Perspective. SAGE Publications: Thousand Oaks

40. Rachel Mandleson, “Helping the world. And me,” Macleans on Campus, September 19, 2008, http://oncampus.macleans.ca/education/2008/09/19/helping-the-world-and-me .

41. John A. Crump and Jeremy Sugarman, “Ethical Considerations for Short-term Experiences by Trainees in Global Health,” JAMA 300, no. 12 (September 24, 2008): 1456-1458, doi:10.1001/jama.300.12.1456, http://jama.ama-assn.org.myaccess.library.utoronto.ca.

42. Paul Collier, The Bottom Billion: Why the Poorest Countries are Failing and What Can Be Done About It (Oxford University Press, 2008).

43. Dambisa Moyo, Dead Aid: Why Aid Is Not Working and How There Is a Better Way for Africa (Douglas & McIntyre, 2009). Interview: http://www.guardian.co.uk/society/2009/feb/19/dambisa-moyo-dead-aid-africa

44. T. Pogge, “World poverty and human rights,” Ethics 19, no. 1 (2005).

45. M. Ravallion, “How Not to Count the Poor: A Reply to Reddy and Pogge,” World Bank. www. worldbank. org/research/workpapers (2002).

46. S. G. Reddy, T. W. Pogge, and World Bank, How not to count the poor (Columbia University, 2005).

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