Socially Responsible Approaches to Global EngagementFirst, Do No Harm

Shafik Dharamsi, PhDAssociate Professor, Family Medicine

& Lead Faculty Global Health Network

Liu Institute for Global Issues

GRS Lecture 2013

A Vision of Students Today

Professor Michael Wesch

http://www.youtube.com/watch?v=dGCJ46vyR9o

“What motivated you to participate?”

‘Voluntourism’ – LIC need lasting efforts to improve their circumstances, not feel-good field trips.

What do you know about the culture, language, and local perspectives of health and illness?

And what about imperialism, colonialism, power, privilege, resentment for brain drain of local physicians and nurses only to have students of the colonizers come here to learn and practice on the natives, among other such unspeakable things.

Power & PrivilegeSimply Go Somewhere and Do Something

http://www.oprah.com/world/How-to-Volunteer-During-Your-Vacationhttp://www.guerrillaaid.com/

javascript:void(0);http://images.hostelworld.com/images/webres/TheSunVoluntourism_2.jpg

“Guerrila Aid is a style of volunteerism – simply go somewhere and do something, while teaching others to do the same.”

“Regardless of the amount of time you have to offer, zeros on your paycheck or previous working knowledge of international aid—you can make a difference!”

Guerrilla Aid

Modernizing approaches to health in impoverished communities in developing countries

You spend several weeks planning for a health project that you will implement in a low income country. You plan to work at the village level in areas where there is little or no access to dental healthcare. You’ve invited dental students to come with you.

You will teach children about good oral hygiene and proper diet, and the dental students will also set up a temporary tent clinic where they can extract decayed teeth.

You will also do research on the effectiveness of regular tooth brushing on oral health outcomes. You bring with you boxes of toothbrushes and toothpaste (from a generous corporate donor) to give to the children.

You begin to handout toothbrushes and toothpaste to all the children all of whom are very pleased and excited to receive them.

The next day, a few village elders approach you and express concern and discontent about the toothbrushes.

They explain that they use a chewstick called miswak that has been used in their community for over a hundred years and it works very well, and it has an important place in their culture.

What do you do?

You go to the nearby internet cafe and do a Medline search to find several articles on the miswak.

The research indicates that “miswak use was at least as effective as tooth brushing for reducing plaque and gingivitis, and that the antimicrobial effect of S. persica is beneficial for prevention/treatment of periodontal disease” (al-Otaibi, 2004)

WHAT HAVE YOU DONE?

Our professional solutions often ignore the complexity of the human condition.

Professional training tends to nurture a certain arrogance in which knowledge and skills are seen as the prerogative of

professionals, giving us a certain superiority.

The poor and vulnerable are commonly seen as uninformed and backward, having only themselves to blame for both

their poverty and poor health.

Professionals do not know their realities.

Worse…

professionals do not know that they do not know!

Murray Dickson, 1993

“People from all over the world come here to study our community. They do tests and ask us a lot of questions. They then go away and get their (titulos) degrees, and nothing improves for the community...”

Salinas de Guaranda, Ecuador

Yassi A, Breilh J, Dharamsi S, Lockhart K, Spiegel JM. The Ethics of Ethics Reviews in Global Health Research: Case studies applying a new paradigm.

J Acad Ethics. 2013 11:83-101.

S. Dharamsi, PhD

Who’s interests are being served?

Garbage dump in Curgua, Ecuador, which was polluting the river that is the source of drinking water for Guaranda (pop. 20.000)

Waste pickers are exposed to health risks (e.g. fecal matter, blood, volatile organics, hazardous chemicals)

Non-existent infrastructure gives them no access to clean water or sanitation

There are 50 people in a village where you’re volunteering in rural Zimbabwe who have been exposed to a lethal agent:

25 people need one pill to prevent death

25 people need two pills to prevent death

You have 50 pills...

Crockett M, Dharamsi S, Pakes B, Sauvé S. Workshop on Global Child Health: Ethics, Education and Current Concepts. Canadian Pediatric Society (CPS). 90th CPS Annual Conference. Edmonton, Alberta. June 19-22, 2013.

A – One pill to 25 who need 1,then 2 pills to other 12.

B – Random selection

C - Give one pill to everyone.

D – Women and children!

E – Case by case

Global vs. InternationalWhat is the Difference?

Concern about practices,

policies and systems in

countries other than one’s own;

Stresses difference between

countries;

Focused on foreign aid activities

Disease control in LMICs

Medical missionary work

“Saving the World”

Concern about practices, policies

and systems that transcend

national boundaries, class, culture;

Stresses the commonality of

development issues;

Focus on collective action;

Interdependence;

Social determinants;

Focus on personal practices

that contribute to inequities

Global vs. International

Global Health vs. International

This is typical of the "poverty porn" that is perpetuated by well-meaning students that forget the dignity of people.

“This is Africa”

Shah S, Wu T. The Medical Student Global Health Experience: Professionalism and Ethical ImplicationsMed. Ethics 2008;34;375-378

After finishing my first year of medical school, I participated in a trip to Mexico. Before flying to Mexico, I was not given any cultural, medical, or other training, nor could I speak Spanish. Upon arriving, I was assigned to a clinic where there were hundreds of patients but only one physician. I remember vividly seeing a frail 11–year–old boy with polyuria, polydipsia and nocturia.

My lack of medical training limited my differential. With only a scattered history and no other tests, I told him to limit caffeine intake and see if that helps. Thinking back, he could have had a urinary tract infection, any number of renal abnormalities, or worse, I sent him out without ruling out diabetic ketoacidosis.

And while I was seeing patients by myself, other first year medical students were performing surgeries in the other clinics and later bragging about it.

(Anonymous student, personal communication, 2 January 2006)

They come in the name of helping

A Film by Peter Brock

http://www.baibureh.org/

A call for respect and humility

United Nations Human Development Report 1998,

(Chapter 1, p.37)

Global Priority $U.S. Billions

Cosmetics in the United States 8

Ice Cream in Europe 11

Perfumes (Europe & US) 12

Business entertainment (Japan) 35

“It is not inequalities that kill people…

it those who are responsible for these

inequalities that kill people.”

Navarro V. What we mean by social determinants of health. Int J Health Serv. 2009;39:423-441

The Cost of Cheap

“The comfort of the rich rests upon an abundance of the poor”

Voltaire (1694-1778)

Need for ethical analysis and critical reflection

Saving Africa: A critical study of university student viewpoints on advocacy and outreach initiatives. Journal of Global Citizenship and Equity Education. Submitted June 2013.

Objectives

1) to gain a better insight into the students’ experience of advocacy,

2) how they think about their advocacy work,

3) what they see as appropriate practices, and

4) their sense of the ethical issues around advocacy.

Methodology

Carspecken, P.F. (1996). Critical Ethnography in Educational Research: A Theoretical and Practical Guide. New York: Routledge.

Kincheloe, JL and McLaren, P (2005) ‘Rethinking critical theory and qualitative research’ in NK Denzin and YS Lincoln (eds), The Sage handbook of qualitative research, Thousand Oaks, Sage Publications.

Smith, L.T. (1999). Decolonizing methodologies: Research and indigenous peoples. New York: Zed Books.

Methods

Setting – Canadian Research Intensive University

Individual Interviews – Undergrad Student Executives from 5/7 Clubs (Africa Focus)

Interviews audio-taped and transcribed verbatim

Analysis - coding and categorizing narrative accounts and organizing categories into key themes.

Findings

Themes

1. Knowledge about the issues;

2. Oversimplification;

3. Homogenisation;

4. Trade-offs and competition; and

5. Ethical engagement.

Knowledge

There are times when people aren’t as aware as they should be. Not all students will be able to answer questions when perhaps they should. [...] We don’t expect everyone to be an expert [...] There are times when people should know more probably, at least the stuff we’re promoting directly.

I just find that even for a lot of clubs, the execs themselves don’t know enough about the issue – if they get questions about it, they don’t really know what they’re talking about. They know the general gist of it, why it’s a good thing, but if you ask them more, they’re a little blank.

Oversimplification

You need the simplification to get the general message out to a larger group of people, because if you make it too complicated attention spans don’t catch on to that as easily as to a short, striking message that you can instil into their hearts.

It’s something that draws people’s attention. Whether it’s ethical…I’m ok with that method of advocacy, because I think there’s a place for it. I don’t think it’s ethically wrong to tell, as long as you’re not lying, I think it’s ok to show a part of the story, for your advantage, even if it’s not the whole story. You weren’t claiming it to be the whole story. You want to give people the resources to find the whole story if they want to; encourage them to, but it’s ok to show a part of the story as a starting point.

Homogenization

They [students] just think it’s one big problem spot, Africa. That’s where all the poor people live and that’s why we need to help them.

When people hear about fundraising clubs, this image of starving children in Africa, that’s what the media bombards them with. To be honest, that’s what a lot of [our club’s] own promotional materials have; African children looking very thin, very fragile, and that’s how they promote [an event]. A lot of people grew up with that perception and that’s pretty much their limitation of what Africa, as the entire continent, is like.

Trade-Offs and Competition

Homogenisation is kind of a problem, but it’s a trade-off. Easy marketing message equals homogenisation, but if you try to make it a little more complicated, you don’t know how well the idea will sell.

Ethical Engagment

It seems to me that this is stuff that you could pretty easily incorporate it into a first-year course. Just get people to write an essay on the ethics of developmental work.

I do think it would be fantastic to have a group come in to do a workshop, even a focus group, just to find out more about what their needs are, to help them move forward, because obviously ethics is huge.

"All animals are equal,

but some animals are more equal than others."

Animal Farm (1945), George Orwell

Conclusions

• Ethicize: (v.) To think, act, speak and live ethically; to view learning, teaching, working and research through a critical and ethical lens and to put critical ethical reflection into the practice of being a student, staff, faculty member and citizen, both at home and abroad.

Critical Consciousness

Ensuring that ethical considerations have a permanent place in our work through critical self-reflection

Not a singular focus on the self, but a stepping back to understand one’s own assumptions, biases, and values, and a shifting of one’s gaze from self to others and conditions of injustice in the world.

This process, coupled with the resultant action, is at the core of the idea of critical consciousness.

Ethics & Global Engagement

Ethical Global Engagement

Respect for Human Dignity

The cardinal principle of ethics in global engagement is respect for human dignity.

This principle aspires to protect the multiple and interdependent interests of the person—from bodily to psychological to cultural integrity.

Ethics, Global Health & Medicine

Global Engagment & Respect for Human Dignity: A Moral Imperative

The selection and achievement of morally acceptable ends; and

Morally acceptable means to those ends.

It is unacceptable to treat persons solely as means, (mere objects or things), because doing so fails to respect their intrinsic human dignity and thus impoverishes all of humanity.

The welfare and integrity of the individual must remain paramount in all human relationships

Respect - for the history, context, values and cultures of communities with whom we engage

Relevance – to history, context, values, culture and community is critical for the success;

Reciprocity - multidirectional sharing and exchange of experience and knowledge among collaborating partners;

Responsibility - fostered through active and rigorous ethical engagement and participation.

Kirkness VJ, Barnhardt R. First Nations and Higher Education: The Four R's -Respect, Relevance, Reciprocity, Responsibility. Comparative Education Research Centre, The University of Hong Kong; 2001.

"It really boils down to this: that all life is interrelated. We are all caught in an inescapable network of mutuality, tied into a single garment of destiny. Whatever affects one directly, affects all indirectly.” MLK

Mutuality

http://www.vancouversun.com/life/food/named+justice/8910662/story.html

A Tea Named for Justice

A Call for Engaged Scholarship

“In many fields, skills have become ends. Scholars are busy sorting, counting, and decoding. We are turning out technicians....

But the crisis of our time relates not to technical competence, but to a loss of social and historical perspective, to the disastrous divorce of competence from conscience....

Once professionals begin to practice, they stop thinking beyond the technical aspects of their work....

Professionals must be able to make judgments that are not only technically correct but also ethically and socially considerate.

Ernest Boyer

College,1987

Transformative Learning -Engaging Head Hands & Heart

“...curricula that is immunized from the human condition and devoid of story, attachment and meaning.”

Phelan 2004

Human Dignity

Global Education & Respect for Human Dignity: A Moral Imperative

The selection and achievement of morally acceptable ends; and

Morally acceptable means to those ends.

It is unacceptable to treat persons solely as means, (mere objects or things), because doing so fails to respect their intrinsic human dignity and thus impoverishes all of humanity.

The welfare and integrity of the individual must remain paramount in all human relationships

Respect is demonstrated toward cultures and communities;

Relevance to culture and community is critical for the success;

Reciprocity is accomplished through interdependence;

Responsibility is fostered through active and rigorous ethical engagement and participation.

Kirkness VJ, Barnhardt R. First Nations and Higher Education: The Four R's -Respect, Relevance, Reciprocity, Responsibility. Comparative Education Research Centre, The University of Hong Kong; 2001.

• Ethicize: (v.) To think, act, speak and live ethically; to view learning, teaching, working and research through a critical and ethical lens and to put critical ethical reflection into the practice of being a student, staff, faculty member and citizen, both at home and abroad.

What kind of learning do students need to meet emerging challenges in the workplace, in a diverse democracy, and in an interconnected world?

Higher education needs to engage in developing “responsible” learners whose “sense of social responsibility and ethical judgment” is marked by “intellectual honesty,” “responsibility for society’s moral health and for social justice,” and a discernment of ethical consequences of various decisions and actions

Association of American Colleges and Universities (AAC&U)

Transformative Learning

Can’t go back to seeing the world in the same way…

Never being able to be in the world in the same way…