Medical volunteering abroad

John A. Crump, MB ChB, MD, DTM&H

McKinlay Professor of Global Health

President’s Dream Colloquium

Simon Fraser University

17 September 2015

Overview• Definitions• Domains of global health engagement ethics

considerations– Learning– Research Case studies– Service

• Global health research versus volunteering• Ethics principals to guide medical volunteering

abroad

Definitions• Volunteer– A person who freely offers to take part in an

enterprise or a task

• Medicine– Focused on health care of individuals

• Global health– Focused improving health for all people in all

nationsBoard of Global Health. 2009. National Academies Press, 2009

Koplan JP, et al. Lancet 2009; 373: 1993-5

Domains of global health engagement

Service

Learning Research

Global health trainingMedical electivesTropical medicine

‘expeditions’

Medical volunteerismHealthcare ‘missions’

Medical ‘voluntourism’

Global health research fellowships

Collaborative research

‘Research’

‘Service’

‘Learning’

DukeEngage provides full funding for…Duke undergraduates…to pursue an immersive summer of service in partnership with a U.S. or international community. As of summer 2011, more than 1,400 Duke students have volunteered through DukeEngage in over 50 nations worldwide…

Limited data on scale• By 2008 of 129 accredited MD-granting US medical

schools and their parent universities, 60 (47%) had established initiatives, institutes, centers, or offices for global health

• Participation in global health experiences by graduating US and Canadian medical students– 1978: 5.9%– 2001: 10.8%– 2004: 22.3%

Drain PK, et al. Acad Med 2009; 84: 320-5Shah S, et al. J Med Ethics 2008; 34: 375-8

Limited data on scale• North American residency programs offering international

rotations– Family medicine 1998: 195 (45%) of 429– Emergency medicine 2001: 72 (71%) of 102– Pediatrics 1995 (US and Canada): 41 (25%) of 161– Pediatrics 2006 (US): 55 (52%) of 106

• US fellowship programs, 2010– 80 global health fellowship programs were identified: 31

emergency medicine, 14 family medicine, 11 internal medicine, 10 pediatrics, 8 interdisciplinary, 3 surgery, and 3 women's health

Nelson BD, et al. Pediatrics 2008; 122:28-33

The need for ethics guidelines• Ethics issues for clinical research conducted across

international borders have received considerable attention

• Less attention has been given to ethical issues associated with education and service initiatives of burgeoning global health programs

• A growing literature raising ethics concerns and pointing potential solutions

• Until recently, no formal guidelines available

Crump JA, et al. JAMA 2008; 300: 1456-8

Key questions

• Who is benefiting?

• Who is burdened?

• Are costs being addressed?

• Are long-term benefits being realized and measured?

• Are opportunities bi-directional?

• Is ‘mutual and reciprocal benefit’ being sought?

Stakeholders

• Trainees

• Patients and the community

• Sending institutions

• Host institutions

TraineesBenefits

• More likely to care for the poor and ethnic minorities

• Change focus from sub-specialty training to primary care medicine

• Report improved diagnostic skills

• Express increased interest in volunteerism, humanitarianism, and public health

• Tourism opportunities• Lack of rigorous oversight

Burdens

• Stress and guilt related to being thrust into activities unprepared

• Health risks in the healthcare environment e.g., bloodborne infections

• Health risks in the community e.g., motor vehicle crashes

Gupta AR, et al. Am J Trop Med Hyg 1999; 61: 1019-23Smith JK, et al. Ann Fam Med 2006; 4: S32-7

Wilknson D, et al. BMJ 1999; 318: 139-40

Case study: ensuring safety•Dr. Gothard’s home institution wishes him to gain clinical experience in the management of drug resistant tuberculosis

•Through a colleague, he arranges a one-month clinical attachment in rural KwaZulu-Natal, South Africa, at a small district hospital managing MDR and XDR tuberculosis

•Dr. Gothard learns that while patients with suspected tuberculosis are managed on a dedicated, well ventilated ward, that clinical staff do not use personal protective equipment

• In order to avoid tuberculosis infection, Dr. Gothard comes to ward rounds on his first day wearing a Powered Air Purifying Respirator (PAPR) that he obtained in London prior to departure

• Hosts and patients talk quietly among themselves

Points to ponder

• What ethics and practical issues does this scenario present for Dr. Gothard, his local colleagues, his sending institution, his host institution, and the patients that he cares for?

• How can this situation be managed to mitigate ethics and safety concerns?

Patients and communityBenefits

• Trainees paying close attention

• Providing a useful service

Burdens

• Trainees lack of experience recognizing serious or unfamiliar conditions and skills in performing procedures

• Trainees lack of experience working with limited diagnostic services

• Trainees exceeding skills and training

• Local staff using presence of trainee to take a break

• Cultural and language barriersDeCamp M. Hastings Cent Rep 2007; 37: 21-3

Case study: exceeding level of training

•Dr. Doherty is a pediatrics house officer whose home institution participates in an exchange program with a hospital in Tanzania

•While in Tanzania, he is eager to gain experience in invasive diagnostic and therapeutic procedures since he has not had the opportunity to learn these at home as they are done by more senior team members

•Upon arrival in Tanzania, Dr. Doherty learns that his local supervisor had just left for a 3 month course in Vancouver and the clinical service is being run by the junior staff

• His first day on the ward is extremely busy

• A child is admitted with suspected meningitis; Dr. Doherty is asked to perform a lumbar puncture, a procedure that the has not yet been trained to do

Points to ponder

• What problems with the design of the training program does this example highlight?

• How should Dr. Doherty deal with this situation?

Sending institutionsBenefits

• Promote global health issues

• Develop global health workforce

• Lure talented trainees interested in global health

• Strengthen training programs

• Attract philanthropic giving• Collect tuition at home while

training costs borne by others

Burdens

• Responsibility to ensure trainees are safe and learn

• Avoid harm to host institutions and communities

• Improve situation at host institutions

• Compensate direct and indirect costs of training program

Host institutionsBenefits

• Potential for collateral benefits from relationship with sending institution

• Develops a network of alumni

• Receiving a useful service

Burdens

• Responsibility to patients, clients, communities to deliver a service

• Trainee orientation and support

• Direct and indirect costs• Maintaining service after

trainee departs• Less attention for local

trainees

Crump JA, et al. Am J Trop Med Hyg2010; 83: 1178-82

http://ethicsandglobalhealth.org/

Domains of global health engagement

Service

Learning Research

Global health trainingMedical electivesTropical medicine

‘expeditions’

Medical volunteerismHealthcare ‘missions’

Medical ‘voluntourism’

Global health research fellowships

Collaborative research

Scale of volunteer tourism

• Rapid growth since 1970s

• Organizations offering volunteer tourism experiences– 1987: 75– 2003: 275

• 2008: >1.6 million volunteer tourists spending about USD 2 billion/year

• Medical volunteering a leading volunteer activityAndereck K. J Travel Res 2012; 51: 130-41

Brown S. Curr Issues Tourism 2005; 8: 479- 6Tourism Research and Marketing. Volunteer tourism: a global analysis, 2008. ATLAS

Case study

• A cardiac surgery team at an academic medical center in western Europe wishes to provide voluntary surgical services to a tertiary medical center in East Africa

Case study

• A cardiac surgery team at an academic medical center in western Europe wishes to provide voluntary surgical services to a tertiary medical center in East Africa

• The site was selected due to proximity to Mount Kilimanjaro

• The East African medical center have greater need for training in trauma surgery, but hope that hosting the cardiac surgery team might lead to other opportunities

• The East African medical center has a cohort of patients with valvular and congenital cardiac disease, but no specialist cardiologist or cardiac surgeon

• The team visits for 2 weeks and completes 30 surgeries

Points to ponder

• Is this activity intrinsically altruistic and therefore free from ethical concerns?

• If there are ethical concerns, what might they be?

• How could concerns be mitigated?

Should medical volunteering be subject to ethical scrutiny?

• No, medical volunteering abroad is intrinsically noble or altruistic

• Yes, efforts may be – Self-serving– Raise unmet expectations– Ineffective– Burdensome– Inappropriate

DeCamp M. Hastings Cent Rep 2007; 37: 21-3Suchdev P, et al. Ambul Pediatr 2007; 7: 317-20

Jesus JE. Ann Emerg Med 2010; 55: 17-22

Case study: impacts on infrastructure

• During the 2 week visit by the cardiac team, all elective surgery was canceled and some emergency surgery delayed due to use of operating room space and local staff

Case study: benefits and risks

• Cardiac patients required monitoring of renal function and anticoagulation post-operatively, but such laboratory services were not available

Evolution of ethics in international clinical research

• 1990s: Placebo-controlled trials in prevention of mother-to-child transmission of HIV– Was the use of a placebo justified when clinically

proven regimens were available in developed countries?

– How should informed consent be obtained?– What counted as exploitation?– Do sponsors have obligations to the community

after the trial ends?Angell M. N Engl J Med 1997; 337: 847-9

New reports and guidelines for international clinical research

US National Bioethics Advisory Commission (2001)

Nuffield Council on Bioethics (2002)

Council for International Organisations of Medical Sciences (2002)

Revisions to the Declaration of Helsinki

Is medical volunteering fundamentally different from clinical research?

• Shared complex history or potential or actual malfeasance

• Not reasonable to assume that volunteer work exclusively benefits the target community, whereas research intends to benefit others

• Volunteering requires research to identify needs and to measure impacts

• No clear distinction for host communities

Volunteering and basic ethical principals

• Beneficence– What counts as a benefit?– How do we know that there was a benefit and measure it?

• Non-maleficence– How do we measure risks, costs, and harms?– How to weigh benefits against risk?

• Respect for persons– Does the community want the volunteer and their enterprise?

• Justice– How was the host community selected?– How was the intervention chosen against competing interventions?

What makes volunteering abroad ethical?

Emanuel EJ, et al. J Infect Dis 2004; 189: 930-7Suchdev P, et al. Ambul Pediatr 2007; 7: 317-20

Ethical clinical research

1. Collaborative partnership2. Social value3. Scientific validity4. Fair selection5. Favorable risk-benefit6. Independent review7. Informed consent 8. Respect for participants

Sustainable volunteering

1. Mission2. Collaboration3. Education4. Service5. Teamwork6. Sustainability7. Evaluation

Ethical principals to guide medical volunteering abroad

• Statement of purpose– Toward global health equity through an

expression of mutual caring and the relief of suffering

DeCamp M. HEC Forum 2011; 23: 91-103

Establish a collaborative partnership

• Shows respect towards individuals in target community

• Empowers the community• Assumes reasonable knowledge of language and

culture

DeCamp M. HEC Forum 2011; 23: 91-103

Ensure fairness in site selection

• Health needs outstrip supply• Clear reason for selecting the local target

community• Is ‘outside’ help really needed?

DeCamp M. HEC Forum 2011; 23: 91-103

Commit to benefits of social value

• Mostly answered by the host community• Is the work desired by the host?• Is the work feasible?• How are short- and long-term benefits being

measured?

DeCamp M. HEC Forum 2011; 23: 91-103

Educate local community and volunteers

• Ensure that education operates in both directions• Educational benefits to volunteers should not

become an end in themselves

DeCamp M. HEC Forum 2011; 23: 91-103

Build capacity of local infrastructure

• Local infrastructure should not be damaged• Build on and improve infrastructure• Both physical, empowerment of the community’s

voice, and human capacity

DeCamp M. HEC Forum 2011; 23: 91-103

Case study: evaluating outcomes

• 28 of 30 patients are alive and doing well when the team leaves

• Over the following 12 months, 8 of the surviving patients develop complications, some from monitoring, some requiring surgery

Evaluate outcomes

• Medical volunteering abroad is often justified based on intended outcomes

• Outcomes should be measured• Findings should inform modification of efforts

DeCamp M. HEC Forum 2011; 23: 91-103

Engage in frequent ethical review

• From clinical research– Independent– Formalized process– Repeat assessments

• Additional dimensions– Type of institution– Type of intervention– Type of relationship with local community

DeCamp M. HEC Forum 2011; 23: 91-103

Case study: doing things better

AcknowledgementsKilimanjaro Christian Medical Centre

Ahaz T. Kulanga, MBAJohn F. Shao, MD, MSc, PhD

Naval Medical Research Detachment PeruSilvia M. Montano, MD, MPH

Chulalongkorn UniversityKiat Ruxrungtham, MD

Makerere UniversityNelson K. Sewankambo, MB, ChB, MMed, MSc

Duke UniversityJohn A. Crump, MB, ChB, DTM&H

London School of Hygiene and Tropical MedicineJohn D. Porter, MB, BS, MD, MPH

Johns Hopkins UniversityJeremy Sugarman, MD, MPH, MAAlan C. Regenberg, MAMatthew DeCamp, MD

Bioethics Research IndiaAnant Bhan, MD

Stanford UniversityMichele Barry, MD

Fogarty International Center, NIHPierce Gardner, MD

Emory UniversityJeffrey P. Koplan, MD, MPH

Doris Duke Charitable FoundationElizabeth Myers, PhD

BMJKirsten Patrick

Financial supportWellcome Trust Medical Humanities Programme (WT089272MF)Doris Duke Charitable Foundation