Medical students abroad: a risk for resource-poor countries?

Something that I have been noticing lately is an increasing numbers of American university students -- both graduate and undergraduate -- doing research or a clinical elective abroad. The push for students to 'go global' is being strongly encouraged by our university and is reflected in the creation of new institutions and initiatives. As university IRB co-chair, I am seeing more more and more proposals of student-led studies to be conducted in Ghana, Haiti, Namibia or Indonesia. Sending students out to do research or gain practical experience in developing countries is part of a general trend in the United States and Europe. Note that, in this context, 'global' often boils down to students of (relative) affluence furthering their education by engaging with the foreign poor.

This phenomenon has a lot of positive aspects. It is obviously good that students have the opportunity to broaden their perspectives and gain experience by working or doing research abroad. It at least goes some small way in countering the medical 'brain drain', i.e. physicians from developing countries seeking greener pastures in better-off countries. But as Suneel Bhat argues in the September 27th issue of The Lancet (subscription required, goddammit), we should be concerned about the potential risks posed to patients when young doctors-in-training work abroad as part of their educational programs. The primary concern, according to Bhat, is that the doctors-in-training may be in a position where local institutions or patients expect or demand that they render medical services that they are not yet qualified to deliver. There are, however, many unknowns in this area: we don't know how much developing countries actually benefit from the presence of budding first-world physicians, in relation to the benefits reaped by patients in the developed world whose physican has (so to speak) cut his or her teeth on patients in resource-poor countries. We also don't know the incidence of malpractice and medical error committed by doctors-in-training working abroad. Maybe the incidence is not very high; maybe it is significantly high, but there may be no mechanism for reporting, or perhaps local medical institutions profit by being hosts of foreign medical students and therefore don't raise a fuss. It is hard to say.

Probably the most controversial part of the paper is where Bhat raises the spectre of ethical review. Given at least the potential risks, Bhat asks, might the activities of foreign medical students be subject to something like the ethical review of research? Unfortunately, Bhat does not say how that would actually work when you are talking not about researchers, but clinicians-in-training. How could their clinical activities be subject to something like ethical review abroad, when such activities are not under similar scrutiny at home? What is lacking with medical student activities abroad (and also student research abroad) is often lack of direct and authoritative mentorship -- the worst case being when a student is sent to some village to fend for him/herself. If the competence of the student is still limited, the villagers have serious and complicated health problems, and local health care resources are scarce, then the risk of 'adverse events' increases, possibly traumatic for both the budding physician and patient.

Hat tip: Lilian's Muli Bwanji blog. Lilian, an ex-student of mine, is currently in Lilongwe (Malawi) working on her PhD in Epidemiology.

The New Journal of Medical Ethics blog

The Journal of Medical Ethics (JME) has recently launched a new blog. According to Soren Holm, Editor of the print version of the JME, the blog is meant to be a place for bioethics reflection and commentary, book reviews and conference reports, as well as information about what the JME and its sister publications are doing. As far as I know, it is the third blog-that-is-attached-to-a-big-bioethics-journal after the American Journal of Bioethics blog and the Bioethics Forum of the Hastings Center. Besides Holm, JME bloggers include Iain Brassington and David Hunter, who write in a pleasant, breezy and humorous style, but who also seem well-equiped to bite into complex bioethical issues when the spirit takes them. Together, they seem intent to explore the gamut from careful analysis to delicious gossip.

It is way too early to judge this baby blog, but I have put a permanent link to it under Cool Bioethics Blogs and Sites Around the World, in the vain hope that the JME will publish all manuscripts that I send to them from now on.

The Global Bioethics Blog marches on

Careful readers of this blog (with obviously way too much time on their hands) may have noticed, if they scroll all the way down to the bottom, that this blog is supported by a National Institutes of Health/Fogarty International Center bioethics grant. This is true, in a way: that grant pays a good portion of my salary, and I write this blog (albeit way after official working hours). And the grant also permits me to work in the Democratic Republic of Congo, an engagement with Central Africa that acts as inspiration and fodder for many of these posts.

Last December, the grant was up for renewal and I was busy writing a new proposal for it. While doing so, I wondered about the fate of the Global Bioethics Blog if the renewal was unsuccessful. Maybe I would start up a new blog, in a more personal style. Maybe I would give blogging up entirely, as my time might be eaten up by efforts to scrape up funding from other sources. For those of us paid largely by 'soft money', unsuccessful grant applications are synonymous with unemployment. And bioethics grants are very few and far between.

Well, it looks like it is not coming to that. Notification came in last week that our project has been approved for funding. So as long as the US federal government does not go entirely bankrupt, we are set for the next four years. If they are anything like the last four years, it will be quite a ride.

A new ethics code for recruitment of foreign-educated nurses

The American population is aging, and as it does, there will be increased demand for health care resources, including human resources. Even though the greying of America has not really kicked in yet, there is already a perceived shortage of nursing staff. The American Association of the College of Nurses has a long list of indicators of current nursing shortages and how the gap between demand and supply is likely to widen significantly in the coming decades.

One common response to this situation is to hire nurses from elsewhere, and this is increasingly occuring, such that some nursing stations in US hospitals are starting to look like United Nations gatherings. But the hiring of foreign-educated nurses is an ethically charged practice. These nurses often come from countries where the shortage of health care workers is much worse than in the United States. In the US, there are roughly 9 nurses per 1000 population. In Ghana, there is 0.74 per 1000 population; in Malawi, 0.59; in Uganda, 0.55. You get the picture: recruiting foreign-educated nurses to work in the United States is very likely to have very negative consequences for health systems in resource-poor countries.

Last week, a myriad of stakeholders issued the first code of ethics in regard to this issue in the United States, entitled Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the United States. The code is directed to agencies that recruit and/or employ foreign-educated nurses, such as third-party recruitment firms, staffing agencies, hospitals, long-term care organizations and health systems. The code is divided into two sections: minimum legal/ethical standards that such agencies can voluntarily agree to, and 'best practices' that such agencies can pursue as aspirational goals.

In this reader's opinion, the code is painfully non-binding and unambitious. In the first section, it basically asks agencies hiring foreign-educated nurses to voluntarily obey established laws in the United States, such as the Fair Labor Standards Act or the Americans with Disabilities Act. Perhaps it aims to remind such agencies that foreign-educated nurses, with legitimate work visas, are covered by such laws, something that you would think (or hope) is obvious. In the second section, which recruiting and employment agencies don't even have to voluntarily agree to, there is some reference to the impact of recruiting nurses from foreign countries, and some suggestions to soften the impact, such as seeking partnership agreements with local health institutions, establishing scholarship funds, sending money to foreign health care organizations and allowing nurses to periodically return home to provide technical assistance. One aspirational goal is to avoid active overseas recruitment in countries where there are fewer than 2.5 health care workers per 1000 population. If that piece of guidance were to be followed, there would be much less recruitment of nurses from African countries, because that would rule out Angola, Benin, Burkina Faso, Burundi, Cape Verdi, Central African Republic, Chad, Comoros, Ivory Coast, the Democratic Republic of Congo, the Republic of Congo, Equatorial Guinea, Eritea, Ethiopia, the Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, São Tomé and Príncipe, Senegal, Sierra Leone, Sudan, Tanzania, Togo, Uganda, Zambia and Zimbabwe. Which leaves you with Botswana, South Africa, Gabon, Mauritius, Namibia, Seychelles and Swaziland, where you can apparently recruit in good conscience.

The Code is a fair cry from a recent Lancet article that floated the idea that recruitment of health care workers from sub-Saharan Africa could be regarded -- in the light of its likely consequences -- as a criminal act. An act that should be robustly discouraged by enforceable laws. The Voluntary Code, on the other hand, seems to contain little to discourage the current brain drain status quo. It assumes -- or rather hopes -- that the relevant agencies will do the right thing, even if it is not in their own economic self-interest, out of the sheer goodness of their hearts.

Shameless self-promotion, somewhat connected to the nursing theme: this blog was selected this week as a Top 50 Medical Professor blog by the Nursing School Search website. Awhile back, the Online Nursing Degree Directory website also named this blog in its list of the top 100 Academic Medical Blogs. We greatly appreciate this recognition from the nursing community, and if we could increase your numbers by a snap of the fingers, we most certainly would.

Bioethics and brains in India

India is a land of contrasts. There is its well-known and longstanding cultural, religious and linguistic diversity. On top of that, India has emerged as one of the world's most rapidly industrializing societies, an important outsourcing location for multinational corporations -- including pharmaceutical companies and their clinical trials -- and a popular destination for medical tourism. At the same time, a quarter of the nation's population (282 millon people) still earns less than $0.40 per day.

The isolated enclaves of 'first-world' health care within India are also giving rise to some difficult bioethical challenges. The Times of India reports that in government hospitals in Chennai, no brain deaths are being reported, and hence no organ transplants of brain dead patients are taking place. Brain death is the medical precondition for organ transplant under India's Tranplantation of Human Organs Act (1994). So why are brain deaths not being reported? The article gives two revealing reasons. First, establishment of brain death requires performing an EEG on the patient, and the technicians who perform this do not work nights. But what about those patients that seemingly lose brain stem function during the day? This is apparently where the other reason comes into play: local doctors do not see brain dead patients, even when an EEG establishes the absence of function, as really dead. Even when the function of vital organs is dependent on machines, the sheer fact that the heart is still beating and the lungs are still pumping spells -- for local physicians -- the continuing presence of life. The head of one of the hospitals, in order to encourage doctors to 'buy in' to the idea of brain death, plans to hold a campaign asking doctors to pledge their own organs in the event they should become brain dead. Best of luck with that: they would probably rather die -- in the old fashioned, cessation of heart and lungs sense.

Another recent controversy in India involves the brains of the living, in this case the brains of criminal suspects. Aditi Sharma was accused of poisoning her former fiance with arsenic while they were eating at a McDonalds in the city of Pune (A fascinating story in itself, no doubt.). She denied the accusation of murder, but agreed to participate in a Brain Electrical Oscillations Signature test (BEOS), developed by neuroscientist Champadi Raman Mukundan. When details of the crime were read out to her, sections of Ms. Sharma's brain lit up. The prosecutor used this data to successfully argue that Ms. Sharma had "experiential knowledge" of the murder, i.e. that while she denied it with her words, her brain activity showed that she was the murderer.

Could this new biotechnology play a role analogous to DNA testing as an independent way to establish or disprove criminal guilt? Scientists are skeptical, but law-enforcement and counter-terrorist agencies are interested. In theory, such technology could do away with the practice of torture aggressive interrogation, and the pleasure of the sadists who conduct it. In practice, unless the BEOS is quasi-infallible, it will be a new faciliator of wrongful conviction.

World Health Organization releases report on social determinants of health

This week, the World Health Organization released a report entitled Closing the gap in a generation: health equity through action on the social determinants of health. The idea that the health of individuals and populations is determined a host of factors -- such as gender, income, social status and power, race, living conditions and workplace environments -- has to some extent entered into common sense. There are some who believe health is more a matter of genetics, luck and individual choice. But it is becoming more obvious, as more studies are done and more is known about dramatic disparities in health within and between nations, that man-made policies, social structures and cultural practices have a major impact on health. What is less acknowledged is the implication: improving health requires a commitment to social justice, i.e. healthier societies are more equitable ones.

Here is where things get murky, even for those who have seen health disparities firsthand and are strongly attracted to the integration of public health, bioethics and considerations of justice. That there are vast differences globally in infant and maternal mortality or life-expectancy has growing empirical support. And this situation is intuitively unjust. But it is hard to articulate precisely what makes it unjust, and what 'doing justice' might mean. The title of the WHO report would indicate that justice would be served by narrowing the differences, but the nature of this goal is unclear. Raising (say) the life-expectancy of Zimbabweans and lowering that of Swedes and Danes? That seems unfair to the latter. Raising all life-expectancies to that of Japan (82 years)? That would be a more positive way of doing justice, but the idea of doing so 'in a generation' seems wildly optimistic. Anyway, it seems unrealistic to expect that in the future countries would all have equal health indicators. Maybe doing justice means just improving the health of populations up to a certain (to be determined, somehow) threshold of decency, rather than trying to make them all equal.

I have only looked over the report briefly so far, but as far as I can see, there is no ethical discussion about the meaning of 'equity' as a goal or ideal (the word 'ethics' or 'bioethics' only appear a couple of times). The concept is used throughout, but not defined or submitted to any serious analysis. This seems a pity, because if you don't know where you want to go, it is hard to know where your analyses and interventions are supposed to be taking you.