AAP Voices Blog

Between Passion and Reality: Ethical Challenges in Global Health Work

It was my fourth year  of medical school, and I was heading to Ghana for our medical school’s global health program. The lessons I learned there were humbling, gratifying -- and nothing that can be replicated in a classroom. Upon arrival at the hospital, I was placed in the emergency department. Most of the workers and patients there spoke in broken English and with little medical vocabulary, creating a language barrier I had not been expecting.  Physicians ran past me yelling in Twi, and I stood there motionless.  What could I possibly do for these patients if I couldn’t communicate with them? 

A classmate and I were standing amidst the typical emergency department chaos when a man in his late 30s arrived on a stretcher, not breathing and with no pulse. We ran over to start CPR but were stopped by the attending who said, “Oh, don’t worry about doing CPR, he is already dead.” We both stepped back, stunned, unsure of what to do and how to hold our ethical obligation of providing lifesaving intervention. As we later learned, CPR is often not performed because the intensive care that follows is financially out of reach for many patients.
 
Before I could process what I had just seen, a man came in for a chronic obstructive pulmonary disease exacerbation. He was gasping for air with a very low oxygen saturation. I immediately asked the nursing staff to get ipratropium bromide/albuterol and give supplemental oxygen. However, the patient quickly stopped me. “No. Not oxygen. No money.” My heart sank. The nursing staff agreed and went to get him only the medication. Medically, I knew that he needed the oxygen but ethically I was challenged.  

As health care providers, our ethical framework is shaped by the principles of beneficence - acting in the patient's best interest, non-maleficence - avoiding harm to patients, autonomy - respect for patients’ choices, and justice - advocating for equitable care for our patients. These principles guide us in our care for every patient we treat and are innate in the framework of medicine.   
 
In addition to these ethical principles, other established standards guide our medical care, most significantly of which involve proper patient-physician communication. 
 
Because I did not speak Twi, my patients’ native language, hospital staff would often serve as translators, taking time away from other patients. Hospital staff did not have the time to explain the overlapping, multifaceted medical and societal norms, something I should have taken the time to understand prior to entering their community. It was also my role to advocate for my patients during my time in Ghana. Given that I did not fully understand the health system, it was challenging to advocate for my patients.  
 
I struggled over the question: should I help patients pay for their much-needed care?
In Helping Hurts: How to Alleviate Poverty Without Hurting the Poor and Yourself, Corbett and Fikkert (2009) stand firm that giving money to the material poor is not always the right or ethical thing to do. Poverty is not solely a lack of material resources but also the result of broken relationships be they spiritual, emotional, or communal in nature.  Addressing poverty should focus on empowering the poor rather than creating dependency.  

To empower the poor and truly help those patients, the root causes of health inequities must be addressed. Although millions of lives are saved via various western organizations, giving money to this patient would not address the underlying social and political issues and would not contribute to a sustainable local health system.

In fact, it could remove responsibility from local governments to care for their citizens. Partnering agencies can work with local governments to create sustainable solutions. Bypassing them undermines these partnerships.  
 
In the end, I did not give the patient money. Ethically, I felt compelled to help him. Giving the patient money would have honored the principle of beneficence. However, ultimately giving money to that patient would not have created a lasting impact. 
 
During this time, I learned that advocating for patients looks different across health systems, states, and countries. I grew to understand that the way I advocate for others is multifaceted, fluid, and must adapt to the environment that I am in 
 
By participating in this global health rotation, I learned how to be flexible and resourceful. In the U.S., we often rely on imaging and extensive diagnostics to confirm our physical exam findings. In Ghana, I observed the ease and confidence with which physicians demonstrated remarkable skill, using physical exams alone to make clinical decisions. I learned how to conserve resources and the value of clinical intuition.  

Reflecting on my experience, I would have changed my approach and prioritized learning about Ghana’s health care system and learning common phrases in the local language. I would have also prepared emotionally for the ethical tension that comes with global health work.   
 
Moral distress occurs when individuals know the ethically appropriate actions to take but are unable to take action. To mitigate this, learners on global health rotations should be offered support, such as group debriefing sessions, while in the host country and upon arrival back to their home country. The field of global health is an enriching yet ethically challenging environment to learn and practice in. 
 
For those participating in global health, I recommend you immerse yourself in the culture of the host country. Engage with fellow medical students and residents and learn how they care for patients with different resources by watching your colleagues skillfully proceed through different aspects of patient care. Take the time to consider why things are done differently and how it affects patient outcomes. When you can’t provide the quality of care that you want to, reflect on what you can do better next time. 

And above all, connect with local patients and physicians. Be ready to listen to them and partner with them to create sustainable solutions that can improve healthcare for everyone, everywhere.

*The views expressed in this article are those of the author, and not necessarily those of the American Academy of Pediatrics.