Ethical Considerations for Short-term Experiences by Trainees in Global Health

Academic Global Health Programs are Burgeon-ing.¹ According to a recent review of the Web sites of 129 accredited MD-granting US medical schools² and their parent universities, almost half (60; 47%) have established initiatives, institutes, centers, or offices for global health. These programs announce goals that include reducing disparities in global health through a combination of research, education, and service. In part responding to student demand and enthusiasm,³ many programs provide short-term training and service experiences in resource-limited settings. Nevertheless, there are important ethical considerations inherent to sending individuals from resource-replete settings for training and service experiences in resource-limited settings. However, unlike clinical research conducted across international borders, which has attracted considerable attention in the lay and scholarly literature,^4,5 much less attention has been given to ethical issues associated with education and service initiatives of global health programs.^6–8 We describe some of these issues so they can be addressed explicitly by those engaged in global health education and service initiatives to facilitate the goals of providing medical students, residents, and other trainees in disciplines related to global health the opportunity for international experience while minimizing unintended adverse consequences.

Global Health Educational Opportunities

Enormous variation in life expectancy and risk for preventable illness and death is observed both in country-level comparisons and among individuals within countries, with the world's poor bearing the brunt of illness and premature death.⁹ The goal of reducing such health disparities worldwide through research, education, and service is commendable and has an ethical basis in the principle of justice, as well as the duty to assist.^10,11 Accordingly, it makes sense that universities in more prosperous settings might bring to bear their substantial technical expertise, energy, talent, research capability, and resources on global health challenges and disparities.

Because a primary function of a university is to educate, one means of embracing a global health agenda is to ensure that students are aware of global health issues and have the opportunity to experience them firsthand. Accordingly, some programs supplement classroom teaching with field experiences in resource-poor countries. Field experiences may be framed as training opportunities for the student, as service-oriented visits that benefit the host,⁶ as foundations for a career focused on or oriented toward global health,¹² or a combination of these factors. Such health-related experiences in settings in which illness and death are highly prevalent, financial and material resources are constrained, infrastructure is damaged or absent, and personnel are stretched in number and capacity may provide powerful lessons about global health disparities. However, such experiences raise an array of ethical issues and challenges that involve multiple stakeholders, including patients or other intended beneficiaries in the host country, trainees, local staff and host institutions, and the sending institutions.

Considerations for Patients and Other Intended Beneficiaries

In many settings that involve the education and training of clinicians, there can be benefits and burdens for patients' well-being. On one hand, having students simply paying close attention to these patients may be beneficial. On the other hand, those in training may lack experience in recognizing serious or unfamiliar conditions and skills in performing particular procedures. In resource-constrained health care settings, trainees from resource-replete environments may have inflated ideas about the value of their skills and yet may be unfamiliar with syndromic approaches to patient treatment that are common in settings with limited laboratory capacity. These challenges may be compounded by language barriers impeding communication, cultural barriers to understanding the meaning of patients' statements or actions,¹³ lack of mutual understanding of training and experience, and the possibility that inexperienced or ill-equipped short-term trainees are given responsibilities beyond their capability. Each of these factors may further compromise patient safety and limit the benefit of service efforts by trainees outside of clinical settings.⁶ In addition, overburdened local staff may see the presence of short-term trainees as an opportunity to take a break or to allocate their effort to other activities. This can leave patients without a trained clinician familiar with the local spectrum of disease and in local diagnostic and management algorithms.

Implications for Trainees

Although the benefits of global health experiences for trainees have been documented,¹² a number of unintended consequences warrant consideration.⁷ In some resource-poor settings, trainees may be thrust into patient-care settings or other health-related activities for which they are not yet prepared. Although this may be exciting, it can result in considerable stress and guilt over actions taken. Trainees may also place their own health at risk. Risks to trainees occur both within the health care setting (eg, for blood-borne infections in environments with limited capacity for providing postexposure prophylaxis)¹⁴ and outside the health care setting (eg, motor vehicle crashes in countries in which road safety is poor).

Issues for Local Staff and Host Institutions

Local staff and institutions have fiduciary obligations toward the clients that they serve and to the health care institutions to provide safe and effective health care within the constraints of their environment. Some short-term global health experiences can pose a threat to meeting such obligations. For example, time may be expended by the need to orient trainees to an unfamiliar environment with respect to essentials (such as food, housing, and transportation), as well as securing formal or informal translation services that may distract local staff from their regular duties. Other drivers may add to this tension, such as the unaccounted-for costs associated with hosting trainees that may include paying for visas, food, and incidental costs not covered by the sending institutions or the trainees.

Host institutions may lack the capacity to monitor and document the benefits and costs that the trainee brings to the host institution. However, even if they did, they may be reluctant to approach the sending institution for fear of disrupting the relationship that may be providing another form of benefit to the institution, such as developing training opportunities for local staff or the donation of equipment. Further, trainees may also experience understandable tensions between their service and training obligations and being in an exotic location that provides opportunities for tourism. The combination of opportunity and a lack of rigorous oversight can lead to global health experiences being further reduced in duration by sightseeing. Although taking advantage of tourism opportunities in the host country can be personally rewarding, it can be hugely expensive in local terms and may take the trainees away from the responsibilities they do have and cause local staff to doubt the seriousness of trainees' commitments to learning and the appropriate use of funds.

Thus, how such tourism experiences are balanced with short-term service experiences can raise complicated issues. Addressing this set of issues explicitly may not be culturally appropriate in some settings in which it might be considered impolite not to accept the request to host foreign trainees or to indicate that the trainee's presence was anything but helpful. Conversely, if a trainee does provide some useful service, it may be difficult to replace this service when the trainee departs, potentially leaving a gap in service delivery.¹⁵ On the positive side, the training experiences might serve as a recruiting tool for the host institution, especially if the sending institution commits to an ongoing relationship with the host institution.

Considerations for Sending Institutions

Sending institutions in wealthier countries have a fiduciary obligation to ensure that their trainees are safe and learn from their experiences. Despite the rush to develop programs that provide service and education opportunities in resource-limited settings, such programs are difficult to do well, are replete with hidden costs, and require substantial expertise to establish and maintain. As such, sending institutions have a moral obligation to ensure that the patients and host institutions in which these programs take place are at minimum not left worse off as a result of this collaboration, but they arguably also have a moral obligation to help improve care and service delivery. Mutual and reciprocal benefit should be the goal. Achieving this goal requires that sending institutions completely account for the direct and indirect costs, both monetary and social, of having trainees work in these settings short term and ensure fair compensation for them, either in kind or by reimbursement.

Sending institutions clearly stand to benefit in multiple ways from developing sound global health programs that include short-term service and training opportunities. First, the institution may help attract attention to global health disparities. Second, for some trainees, the opportunity may form the foundation of a career working in resource-poor settings or on related issues. Third, the training experience may strengthen the position of a university to recruit the most talented trainees who are interested in a global health experience.¹ Fourth, the training experience may provide trainees with an opportunity to learn about health and culture in ways that may be impossible in their home countries.¹² Fifth, sending institutions may benefit financially from some short-term training programs because of the appeal of global health programs to philanthropists or the collection of tuition while trainees are abroad. Nevertheless, benefits should not trump responsibilities for ensuring that these training programs are beneficial to the relevant stakeholders.

Sending institutions have limited resources for benevolent assistance and thus should address the vexing questions of justice concerning how best to use those resources. For example, what would the resources used in short-term training experiences accomplish if they were directed to longer-term efforts involving experienced faculty working alongside partners in the host country? Sending institutions should also ask and document whether the goal of truly benefiting host institutions in poor countries is actually being achieved.

Moving Forward

Global health programs that include short-term training opportunities are associated with a range of ethical issues for all stakeholders. Although such programs are frequently conceived on the basis of justice, beneficence, and the duty to assist, they should be reframed to accommodate mutual and reciprocal benefit. The collection of systematic data within the context of existing short-term global health experience programs is urgently needed to inform host and sending institutions about the true costs of these programs so that they can be addressed.

In addition, efforts should be directed at developing a means of assessing the potential benefits and harms to patients or other intended beneficiaries in the host country and to trainees. While such data are being collected, it would be useful for those engaged in short-term global health training programs to begin to outline ethical guidelines for these programs that include a set of appropriate responsibilities for monitoring to ensure that the many disparities that underpin poverty are not exacerbated or even exploited by one party in this complex relationship. Ultimately, formal ethical guidance, such as that afforded in the research setting, should be developed.