QUESTIONS
Prior to class, please provide written responses to the questions below (250 words). Please submit your responses through a class comment in this section.
Where are you in your medical training? (What level and in what city/country)
What is your experience working in a low- or middle-income clinical setting? (Where, duration, and your responsibilities)
Describe one ethical conflict you have observed in your work in LMIC settings. (Consider differences in clinical practice and ethics norms, professionalism, resource access and use, cultural differences, language barriers, supervision, the impact of foreigners on local systems, social and economic power differentials, etc.)
MY ANSWERS
I am a fifth-year medical student at the prestigious University of Ibadan and am currently undergoing the clinical component of my training at the University College Hospital in Ibadan.
Over the past two years, I have been a clinical student, interacting with patients and participating in, and at times contributing to their care.
Additionally, I have engaged in research and numerous volunteering activities during my time as a student. My responsibilities as a clinical student include but are not limited to:
Taking medical histories and conducting examinations, followed by reaching a diagnosis that will be vetted by my attending physician.
Carrying out minor procedures under supervision.
Observing and assisting in surgeries.
My experience is limited to working in low- and middle-income countries (LMICs), and I have only read about working conditions in high-income countries (HICs).
One ethical concern I frequently observe is the blatant inequality in the treatment that patients receive based on their socioeconomic status. Patients from lower socioeconomic backgrounds are often treated with less respect and dignity than their more affluent counterparts.
Another significant ethical issue is the scarcity of resources, which often necessitates improvisation or the performance of a makeshift version of a procedure. This occurs frequently, and while it raises ethical questions, it has become a point of pride for my teacher, who encourages us to be resourceful by using whatever equipment is available to address a situation instead of waiting for everything needed to treat the patients.
QUESTIONS
Who are the stakeholders Dr. Charles should consider as he develops his guidance?
What does he need to know in order to successfully reduce mother-to-child transmission of HIV in this community?
What procedures can he put in place to decrease the risk of HIV-positive women being stigmatized by their partners, family, or community?
How should the infant’s well-being be balanced with maintaining the mother’s health, safety, and survival?
To what extent should Dr. Charles consider the local culture in which family decision-making and traditions about infant feeding can conflict with mothers’ efforts to decrease the risk for HIV transmission?
Might Dr. Charles want to hold public conversations with people in the community to try to change social norms, or just with village elders in order to influence values and norms counterproductive to the WHO program goals?
How might limited availability of ARVs impact this case?
MY ANSWERS
Group Response: James Iziren, Samari Sunta, Mwansa Chilufya, Tatenda Matiza, Prince.
Stakeholders Dr. Charles needs to consider are community leaders, local health officers, local health organizations, funders, staff at the hospital and the ladies partner to see the depth of the issue and implement necessary changes.
Some things Dr. Charles needs to know are the cultural beliefs, delivery methods of the mothers, and experience of the staff helping the mothers. He should also know the health systems in place and the breastfeeding practices of the mothers which all may affect the rate of transmission from mother to child.
Raising community awareness about HIV/AIDS may reduce the stigma in the community and also collaborate with community leaders to help increase awareness.
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QUESTIONS
Respond (individually) to the questions below in writing and submit it as a class comment by the end of the day. (250 words)
What are some ethical challenges visiting health care professionals and trainees from High-Income Countries (HICs) can expect to encounter when working in unfamiliar settings in Lower-Income Countries (LMICs)?
What are some ethical challenges that healthcare professionals, trainees, and patients in LMICs can expect to encounter when working with visiting healthcare professionals and trainees from HICs?
MY ANSWER
Visiting healthcare professionals from High-income countries to Low and middle-income countries can face several challenges including but not limited to;
• Language Barrier
This can lead to a lot of assumptions, and in a sector such as healthcare appropriate and understandable information is needed to make informed decisions. Without appropriate communication, this can be lost when visiting healthcare professionals in a region they are not familiar with.
• Limited number of supplies or standard equipment to carry out certain procedures.
Visiting healthcare workers from HIC to LMIC will most of the time face this challenge – This then leads to a call to either make use of the available resources which could pose a threat to the speed and progress of the mission or completely abandon the mission overall.
• Informed consent.
Because of the nature of visiting healthcare workers’ missions in these rural settings, It is often assumed that everyone who comes to seek their services has automatically consented to whatever procedure will alleviate their suffering, but this is often wrong and can be a costly assumption.
• Finding the line between truly helping out or satisfying one's interest in altruism.
Professionals working in LMIC could face some of these challenges while working with visiting professionals from HIC
• Possibility of a power play
• The concept of helicopter research – where the healthcare workers in LMIC feel their contributions will not be acknowledged.
• Other issues will include those already stated above.
QUESTIONS.
Prior to class, please provide written responses to the questions below (250 words). Please submit your responses through a class comment in this section.
How does Public Health differ from clinical medicine? Why is much of global health activity considered public health?
What are the five criteria identified in the first reading as necessary for the ethical justification of public health interventions (see p. 29)? Why are these criteria essential for maintaining public trust?
What strategies are available for controlling potential epidemics? Why are these strategies difficult to implement?
Identify and describe 2-3 programs or activities you have seen either at home or abroad that you think are public health initiatives. For each example, explain whether or not you think the activity satisfies the five ethical criteria listed in #2 above.
MY ANSWER
One of the numerous definitions of public health is “The science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts … and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.” (Winslow 1920). This definition focuses on disease prevention, life prolongation, health promotion, and the role of organized community efforts in achieving public health goals.
In contrast, Clinical medicine and all its apparatus focus on individuals, the illnesses they present, and how to cure them. It is also widely known as curative medicine. Clinical medicine’s goal is to use best practices to cure individuals who show the symptoms of a disease.
Public health’s focus is “community and population” and the factors that determine the health of such populations (Barrett et al., n.d.). Global health on the other hand looks at the cross-border health of the same population and its determinants. Though they are slightly different, they implore the same strategies for implementing various interventions. Secondly, most global health interventions are implemented at the country level, hence most global health activities are considered public health.
The five criteria stated by (Barrett et al., n.d.) necessary for the ethical justification of public health intervention are “Effectiveness, Proportionality, Necessity, Least Infringement, Public Justification”. These criteria are essential because without them policy will lack community engagement. If there is a lack of engagement, it will lead to the rejection of such interventions that emanate from such policies. Hence the need for policymakers to consider each of these criteria carefully before implementing any intervention in any community.
(AS & GK, 2023) highlighted 10 lessons learned from covid - 19 and suggested 10 ways to implement such suggestions. The challenges of implanting such strategies, especially in LMICs are numerous and need to be addressed to effectively harness the knowledge and lessons learned from covid. Some strategies to implement include; Research funding for basic medical and molecular science, Investment in infrastructure, etc.
Several Initiatives can qualify as Public Health initiatives, examples include the Ban on sales of alcohol in most places in the world to minors – this effectively balance the issue of morals and profit. Another is the various vaccination drives here in Nigeria, where it isn’t compulsory to vaccinate your ward but you will be sure to see the dangers of not being vaccinated. Lastly, there is a policy to monitor abattoirs in Nigeria to make sure only quality meat is sold to the public, this helps balance the need for profit and maintaining the quality of food that is being consumed.
QUESTIONS
Should the NGO publicize the water quality test results? What ethical concerns are raised by this question?
If the water quality results are publicized, what reaction can be anticipated from affected people? What kind of participatory approach could help to address the contamination problem?
Considering that lower water quality standards could result in more illnesses and deaths in the community, is the WHO’s approach an appropriate way to determine what is environmentally, economically, and socially possible and appropriate?
How might this well-building effort been handled more effectively?
MY ANSWER
Group Members:
James Iziren,
Samari Sunta,
Mwansa Chilufya,
Tatenda Matiza.
The NGO should definitely publicize the results to be transparent and truthful to their community, and they look forward to working toward beneficence and non-maleficence. The ethical concerns are that not publicizing the results could affect trust and the integrity of the NGO. Additionally, it is important to consider that if they publish it, the community may react with concern. On the other hand, if the information is not published, it could lead to misinformation that may harm the community. They might become ill without knowing the cause, potentially undermining non-maleficence and leading to a loss of trust in not only this NGO but in others as well.
The community could become angry and worried once they learn the truth, feeling betrayed, or believing the NGO took advantage of their situation. However, they might also work together to prevent further contamination, gain a better understanding of the sources, and find safer locations to access water, collaborating with the NGO to achieve this goal.
It is tricky because, at the end of the day, the NGO is providing more water to a larger population, reaching more areas. Yet, this effort comes with a certain percentage of associated illnesses. Ultimately, people may prefer to walk farther for clean, safe water rather than accept closer but contaminated sources.
Another approach the NGO could take to create and facilitate more water sources effectively is to base their efforts on WHO guidelines, prioritizing the specific needs of the area, such as soil conditions, contamination, and pollution risks, and developing a plan that addresses all factors affecting growth. They can start with smaller sources and conduct studies while the project is underway to ensure it is on the right track, allowing them to implement solutions on a larger scale safely.
QUESTIONS
Please respond (individually) to the questions below in writing and submit it as a class comment in this section by the end of the day. (250 words)
In what ways do covid-related interventions (masks, distancing, vaccines, etc.) satisfy the five justificatory criteria for public health policies (see #2 above)? Are any current covid-related recommended interventions not clearly justifiable according to these criteria? If so, which ones, and why?
Looking at how different countries and cultures have tried to manage the Covid-19 pandemic, discuss how differences in cultures, leadership, resources, and public health strategies might be contributing to the variable success.
MY ANSWER
Many of the interventions implemented during the COVID–19 pandemic satisfied the fie justificatory criteria for public health policies. Examples include the compulsory wearing of masks in public places, this measure was effective as it both protected those who were active carriers and those who came in contact with them. It was also proportional as the benefits outweighed the perceived infringement on morals including the popular belief that when you greet an elder, your face must be showing. At the time of the pandemic, wearing masks was necessary to limit and prevent new infections. It also didn’t infringe much on perceived freedom, and those in authority could easily justify it to the masses.
On the other hand, vaccines were not received with much acceptance and hence did not fulfill the five justificatory criteria for a public health policy. It particularly did not satisfy the condition of public justification as many individuals and sets of people did not want to take the vaccines due to various misinformation that filled the media at the point and other personal and collective beliefs.
Many nations have managed the pandemic differently and this has resulted in different levels of success that were recorded. In the US for example, where most of the culture supports data sharing and openness, the leadership structure was strong and the resources needed were available to strengthen their various interventions – they quickly overcame the pandemic. In major LMICs, vaccines could not get to them on time due to various flight restrictions and bans.
QUESTIONS
Prior to class, please provide written responses to the questions below (250 words). Please submit your answer through a class comment in this section.
Identify three kinds of global or public health activities that are not research. Identify three kinds of global or public health activities that could be considered research.
Of the ethical principles identified in the Helsinki Declaration and CIOMS Guidelines, which may be difficult to fully uphold in non-Western and/or lower income countries, and why?
What are some of the benefits of research partnerships between members of universities from HICs and LMICs? What are some of the burdens of such research partnerships for host institutions in LMICs?
MY ANSWER
Three Global/Public health activities that are not research include;
Disease Surveillance and Monitoring
Health Program Implementation
Policy Development and Advocacy
These programs focus on Regular surveillance, implementation of healthcare programs that have been developed, and Policymaking. They also include immunization campaigns, health education, and sanitation programs without systematic data collection aimed at generating generalizable knowledge.
Some of the declarations that will be difficult to uphold are;
Informed Consent - Low literacy levels, language barriers, and power imbalances can hinder participants' full understanding of study risks and benefits.
Fair Compensation and Avoidance of Exploitation - Economic disparities may lead to undue inducement, where participants enroll in studies primarily for financial compensation rather than informed choice.
Collaboration between universities in HIC and LMIC is beneficial in several regards including;
Capacity Building - Enhanced infrastructure, research skills, and academic development in LMIC institutions.
Access to Funding and Resources - HIC partners often bring financial support and technological resources that improve research quality.
Advancement of Local Health Solutions - Research findings can address region-specific health challenges and inform policies.
However, these partnerships also impose burdens on LMIC institutions such as the following.
Resource Strain - Local institutions may be overwhelmed by the demands of data collection, reporting, and logistics.
Ethical Concerns - Power imbalances may result in HIC researchers controlling data analysis and publication, limiting LMIC partners' contributions.
Limited Sustainability - Research projects may end when HIC funding ceases, leaving LMIC institutions with unfulfilled long-term health needs.
A balanced, equitable approach is crucial to ensuring mutual benefit and ethical collaboration in global health research.
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QUESTIONS
What could the research team have done before starting the study to limit the likelihood that this situation (or other confounding surprises) would arise?
How should the fact that, aside from Dr. TN, the research team members are not citizens in the country where they are conducting research, be considered in your assessment of their obligations?
How should Milena and Dr. TN prioritize their ethical responsibilities? What should they ultimately do, and why?
MY ANSWER
Group members;
James Iziren,
Samari Sunta,
Tatemda Matiza,
Nwansa Chilufa.
Before commencing the study, the research team would have engaged the local community by conducting a survey/pilot study among their study population and stakeholders - which would have made them aware of any confounders and ethical considerations to consider. They should have also put in place structures to handle ethical considerations and developed a reporting protocol. They should have also employed the services of legal advisors, to ease the need to make legal moves in the future and course of their study. They should have also developed a risk assessment and mitigation plan - and developed a protocol to address them when they arise.
It is important they handle the situation delicately as only Dr. TN is at risk of bearing the fallouts of their research finding.It is however to uphold ethical standards and with care considering all that is at stake.
It is important they publish their finding as this will alert the Ministry and other stakeholders of the results of their intervention - thereby upholding Justice. Hopefully, the ministry change its stance upon receiving the reports of the study.
The study team can also advocate for tangible change diplomatically without picking a fight with the stakeholders involved.
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QUESTIONS
Please respond (individually) to the questions below in writing and submit it as a class comment in this section by the end of the day. (250 words)
Why and how is neocolonialism often perpetuated in international research partnerships?
Why is it difficult to develop mutually beneficial research partnerships between individuals and institutions in HICs and LMICs? How can structural differences (infrastructure, time, resources), procedural differences (study design and implementation, ethics compliance), and incentives (financial, prestige, promotion) contribute to this inequality?
How might research partnerships between institutions in the global north and south be bettered structured to benefit all participants and institutions?
Neocolonialism in international research partnerships is often perpetuated through power imbalances, where institutions in high-income countries (HICs) control funding, research agendas, and data interpretation while institutions in low- and middle-income countries (LMICs) provide labor and study populations. This dynamic reinforces dependency rather than fostering equitability and collaboration.
Mutually beneficial research partnerships between HICs and LMICs are difficult to establish due to structural, procedural, and incentive-related disparities.
LMICs often lack research infrastructure, stable funding, and trained personnel, creating dependency on HIC partners for resources and expertise. Also, ethics compliance, study design, and implementation vary significantly, making alignment difficult.
HIC institutions may impose research protocols that do not align with local needs or priorities. HIC researchers may often prioritize publications, funding, and career advancement, while LMIC institutions may struggle with sustainability and direct benefits to local populations.
The unequal distribution of recognition and resources exacerbates disparities.
To ensure equitable benefits, partnerships should be structured around operating in a setting of shared Leadership - co-authoring papers and making sure local perspective is captured.
Investment - in infrastructure, training, and funding autonomy for LMIC institutions.
Joint ownership of data, equitable authorship, and transparent benefit-sharing.
Long-Term Commitment - sustainable partnerships rather than short-term, extractive research engagements.
QUESTIONS
Prior to class, please provide written responses to the questions below (250 words). Please submit your answer through a class comment in this section.
What is global health aid? How is this aid funded? What do donors expect in return?
What are three purposes of federal funding for global health?
In what ways can global health/humanitarian aid work be emotionally stressful or traumatic for medical
personnel?
MY ANSWER
Global health aid refers to financial, medical, and or technical assistance provided by governments, organizations, and individuals in high-income countries to improve health outcomes in low- and middle-income countries (LMICs). This aid supports disease prevention, healthcare system strengthening, emergency responses, and health research.
Global health aid is funded through multiple channels, including;
Government Contributions – National governments allocate funds through agencies like USAID (United States), DFID (UK), and Global Affairs Canada.
Multilateral Organizations – Institutions like the WHO, World Bank, and Global Fund pool funds from various nations.
Private Philanthropy – Organizations like the Bill & Melinda Gates Foundation contribute significantly.
Corporate Donations – Pharmaceutical companies and other corporations fund global health initiatives.
Donors usually expect - Political or diplomatic influence in recipient countries, health impact metrics, such as reduced disease burden, economic benefits, such as market access for goods, alignment with their values or policies (e.g., reproductive health funding restrictions)
QUESTIONS
1. Who is affected by the cholera outbreak? Who might have some responsibility to respond to the outbreak?
2. The U.N.’s Independent Panel of Experts concluded that “the Haiti cholera outbreak was caused by the confluence of circumstances … and was not the fault of, or deliberate action of, a group or individual.” Assume that they are correct about these facts. Does it follow that no one is morally at fault? Explain why or why not.
3. Imagine that you are providing recommendations for compensating the victims of infectious disease outbreaks, like Haiti’s. Should individual actors be held accountable, or should a no-fault compensation system be put in place? If the latter, who should provide compensation? Explain the reasons for your responses.
4. If the Haitian government has neglected its responsibilities to its citizens, does this make any difference to the help that international aid agencies should provide to Haiti in an emergency? Why or why not?
5. One possible concern with seeking compensation for the people who contracted cholera is that it may have a “chilling effect” on international assistance. For example, if aid agencies believe they are at risk of being sued for unintentionally transmitting disease, they may be deterred from working in a country in the first place. Should the Haitian government or the lawyers representing the victims take this concern into account? Why or why not?
MY ANSWER
Group: Samari Sunta, James Iziren, Mwansa Chilufya, Tatenda Matiza
1. The Haitian population in the region and those assisting in humanitarian aid were affected. Those responsible are the Haiti government and international organizations e.g. WHO and UN
2. They were asymptomatic when they went to Haiti, so they did not know they were bringing harm to the people. So they are not at fault.
3. A no-fault compensation should be placed since it was unintentional. The international organizations can assist since at this point the Haiti government may be overwhelmed due to the natural disaster that occurred.
4. It should not affect because humanitarian assistance should be based on the needs of the people during a crisis, not depending on government contribution.
5. It is a hard decision since peoples lives were affected and it would be honorable to give compensation to assist the victims. However, since this was unintentional, suing them would affect international assistance in the future so there is a need to find a balance
QUESTIONS
Please respond (individually) to the questions below in writing and submit it as a class comment in this section by the end of the day. (250 words)
What do you know (or can you imagine) about the social and medical needs of patients who are refugees, asylum seekers, or displaced in their own countries due to civil war or natural disaster?
As a physician, which of these needs would you feel most and least confident in being able to address effectively?
How can you take care of yourself when you find yourself emotionally exhausted, discouraged, or overwhelmed?
MY ANSWERS
Patients who fall in the category of refugees, asylum seekers, and internally displaced persons (IDPs) often experience extreme hardships that affect their social and medical well-being. Socially, they face discrimination, lack of employment opportunities, housing insecurity, language barriers, and social isolation. Many struggle with trauma, loss of loved ones, and legal uncertainties about their residency status. Medically, they are at high risk for infectious diseases due to poor sanitation, malnutrition, and inadequate healthcare access. Mental health issues such as PTSD, anxiety, and depression are prevalent due to experiences of violence or displacement. Women and children face additional vulnerabilities, including sexual violence, maternal health risks, and lack of pediatric care. Addressing these needs requires a multidisciplinary approach, including emergency medical care, vaccination programs, trauma-informed mental health services, and social support systems to foster integration and stability.
As a future physician, I would feel most confident addressing issues involving clinical care like handling infectious diseases, malnutrition, and acute injuries, as these conditions rely on clinical expertise and resource mobilization. Additionally, I will be able to help out with public health interventions like vaccination campaigns and maternal-child healthcare are areas where I could contribute effectively. However, I would feel least confident in handling issues in areas where I am not an expert like mental health concerns, particularly severe PTSD and trauma-related disorders, as they require specialized psychiatric care and long-term psychosocial support. Addressing legal and social integration challenges is another area where I will struggle, as these require expertise in law, policy, and social work.
I believe working with displaced populations can be emotionally taxing, leading to burnout, compassion fatigue, and moral distress. To take care of myself, I would potentially prioritize self-care strategies, including seeking peer support, engaging in reflective practices, and maintaining a work-life balance. Regular debriefing sessions with colleagues, counseling, and mindfulness exercises can help process difficult experiences. Setting realistic expectations about my impact and practicing self-compassion are crucial to avoiding frustration. Additionally, I would advocate for institutional support, such as mental health services for healthcare providers and adequate rest periods during humanitarian missions.
Finally, staying connected to my motivation—why I chose this path—can help sustain resilience and long-term commitment.
Ethical questions in global health are both complex and ever-evolving. Who decides what health interventions are prioritized in resource-limited settings? Should high-income countries dictate global health policies, or should decision-making power be more equitably distributed among local communities? How do we balance respecting cultural traditions with advocating for evidence-based medical practices? When conducting research in low-income countries, how can we ensure that local populations truly benefit, rather than being subjects of "parachute research" with little lasting impact? Is it ethical for pharmaceutical companies to charge exorbitant prices for life-saving drugs while millions in the Global South cannot afford them?
Beyond these pressing concerns, deeper ethical questions arise; Should scarce medical resources be allocated based on need, or should they go to those most likely to survive? When responding to public health crises, do governments have the right to impose restrictions on personal freedoms in the name of collective safety? How do we ensure that aid programs do not create dependency but instead foster long-term self-sufficiency? And, perhaps most critically—who truly holds the moral responsibility for ensuring health equity across the world, and are we doing enough to fulfill that duty?