Journal Club 10-04-21 : Health Equity, Medical Tourism, and Maternal Mortality in LMICs

Welcome back! The first GEMS LP  journal club of the season took place on October 4th, 2021. During each meeting, we discuss a journal article, a global health clinical topic, and a book chapter from one of two books: An Introduction to Global Health Delivery by Joia Mukherjee or Reimagining Global Health: An Introduction by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico.

The goal of journal club is to expose our mentees to fundamental global health concepts and their applications in the real world. Having a diverse cohort of participants allows for lively and engaging discussion based on each participants’ life experiences. Below is a summary of each section presented at journal club. Be sure to join us at our next meeting, taking place November 8th, 2021.

Many of the global health disparities that exist today are a result of centuries of exploitation of developing countries that can trace its roots to the slave trade. As slavery ended in the 19th century, the extraction of people was replaced with the extraction of resources as European nations divided up Africa amongst themselves. By the 20th century, centuries of exploitation had robbed newly independent countries of the resources needed to provide healthcare for their citizens. Newly liberated countries came to rely on Western monetary institutions for loans, which often came with strings attached. Loans from the World Bank and the International Monetary Fund limited the amount of public expenditures on vital healthcare infrastructure, medication, and personnel. Healthcare in developing countries was further undermined by the neoliberal policies promoted by Western countries beginning in the 1980s. Developing countries were compelled to fund healthcare through above-cost user fees, which reinforced unequal access to care and widened healthcare inequality. The neoliberal approach also championed the concept of sustainability, which focused on low-cost preventative care instead of treatment. By the 1990s, this approach had led to widening healthcare inequity between the developed and developing worlds.

An alternative approach advocated for the right to health of every individual as envisioned in the Universal Declaration of Human Rights. The 1978 Alma Ata Declaration proposed that the fulfillment of these rights belongs to the international community through international collaboration. The past several decades has seen an increasing movement towards this idea and away from one based on economics. An example of this would be the recognition in the 1990s that citizens of developing nations with HIV are inherently as deserving of treatment as those from developed nations. By taking an approach rooted in human rights, the international community was able to lower the cost of HIV medication and provide treatment for patients in the developing world.

Discussion Questions:

·Reflect on prior medical service trips you may have gone on or may be offered by your university. In what ways do these trips reflect the legacy of colonialism? How can we “de-colonize” global health in medical education? 

·Should all medical interventions in lower-income and developing countries be “sustainable”? 

Medical tourism is a modern practice in healthcare that is exacerbating global health inequity. For centuries, people of higher socioeconomic classes commonly visited higher developed countries to receive care for their medical ailments. Their journeys are much more expensive than an ordinary citizen could afford but with the advent of air travel and a rapid development of the middle class with a larger share of disposable income, many more people are travelling for medical services today than ever before. The propagation of medical tourism is exacerbating the divide in quality of care in developing countries. As private hospitals primarily attract international patients, they attract more doctors with higher salaries and benefits paid for by medical tourists’ bills. This develops a positive feedback loop that continues to neglect the care of the poorest patients who need the most advanced care and rely on public hospital systems that are already overburdened. Rather than focusing on bettering the care of public hospitals and working for the native populations, private hospital systems and governments encouraging medical systems are further dividing the health gap between socioeconomic classes and contributing to health inequity.

Discussion Questions:

What are some ethical issues developed by private healthcare systems motivated by financial incentives?

• How can medical professionals in our country educate patients about the risks of medical tourism?

 

Global health disparity is apparent in the care of pregnant individuals, with 94% of all maternal deaths occurring in low and lower-middle-income countries. A leading cause of maternal and perinatal mortality in these regions is hypertensive disorders of pregnancy, especially pre-eclampsia and its spectrum of diseases. Crucial to the screening and diagnosis of these disorders are regular antenatal care and assessment of risk factors, such as advanced maternal age, obesity, diabetes, and existing hypertension. For pre-eclampsia and eclampsia, the WHO has released evidence-supported recommendations for both preventative measures, such as calcium supplementation in areas with low intake, and treatment, such as using magnesium sulfate over other anticonvulsants. In low resource settings, some of the barriers that hinder the care of pregnant individuals with hypertensive disorders are a shortage of specialty-trained healthcare workers, inadequate transportation to healthcare facilities, limited antenatal care, and traditional cultural practices. While much work still needs to be done in tackling many of these challenges, especially in improving basic obstetric emergency treatment at primary community settings, innovative strategies such as task-shifting to train community health workers (CLIP initiative) in providing regular antenatal care and community cost-sharing schemes to eliminate financial barriers to obstetric care in Mali have been shown to have positive outcomes.

Discussion Questions:

· What other non-health related barriers may contribute to maternal mortality?

· What roles can emergency services/emergency medicine physicians play in improving the outcome of obstetric emergencies?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings, the next of which is taking place November 8th, 2021.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Brian Elmore, MS4

Brian Elmore, MS4

Medical University of South Carolina

Jai Shahani, MS2

Jai Shahani, MS2

Rutgers New Jersey Medical School

Luxi Qiao, MS4

Luxi Qiao, MS4

Washington University School of Medicine

Sources:

  • Mukherjee, Joia. “Chapter 1: The Roots of Global Health Inequity.” An Introduction to Global Health Delivery: Practice, Equity, Human Rights, Oxford University Press, New York, NY, 2018.
  • Mutalib, Nur & Ming, L C & Yee, Esmee & Wong, Poh & Soh, Yee. (2016). Medical Tourism: Ethics, Risks and Benefits. Indian Journal of Pharmaceutical Education and Research. 50. 
  • 261-270. 10.5530/ijper.50.2.6.
  • http://ijper.org/sites/default/files/10.5530ijper.50.2.6.pdf
  • WHO. Maternal mortality evidence brief, 2019.
  • WHO. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia, 2011.
  • Fournier P, Dumont A, Tourigny C, Dunkley G, Drame S. Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in rural Mali. Bull World Health Organ 2009; 87: 30-8
  • von Dadelszen P, Vidler M, Tsigas E, Magee LA. Management of Preeclampsia in Low- and Middle-Income Countries: Lessons to Date, and Questions Arising, from the PRE-EMPT and Related Initiatives. Maternal-Fetal Medicine 2021; 3(2): 136-50.
  • Firoz T, Sanghvi H, Merialdi M, von Dadelszen P. Pre-eclampsia in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2011; 25: 537-48.
  • Milne F, Redman C, Walker J, et al. The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community. BMJ 2005; 330: 576-80.

 

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Journal Club 10-04-21 : Health Equity, Medical Tourism, and Maternal Mortality in LMICs," in International Emergency Medicine Education Project, November 1, 2021, https://iem-student.org/2021/11/01/health-equity-medical-tourism-and-maternal-mortality-in-lmics/, date accessed: December 4, 2021

Understanding Authorship

Understanding Authorship

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 3rd episode is “Understanding Authorship”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

Cite this article as: Arif Alper Cevik, "Understanding Authorship," in International Emergency Medicine Education Project, October 20, 2021, https://iem-student.org/2021/10/20/understanding-authorship/, date accessed: December 4, 2021

Practicing ethically in research

Fundamentals of Research in Medicine - Episode 2

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 2nd episode is “Practicing ethically in research.”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

Cite this article as: Arif Alper Cevik, "Practicing ethically in research," in International Emergency Medicine Education Project, October 6, 2021, https://iem-student.org/2021/10/06/research-ethics/, date accessed: December 4, 2021

What makes a physician a good researcher

Fundamentals of Research in Medicine - Episode 1

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The first episode is “What makes a doctor a good researcher.”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

Cite this article as: Arif Alper Cevik, "What makes a physician a good researcher," in International Emergency Medicine Education Project, September 22, 2021, https://iem-student.org/2021/09/22/good-researcher/, date accessed: December 4, 2021

VIP-EM POP QUIZ: What do you do?

During your emergency care career, you will not be able to avoid seeing the so-called VIP (very important…) patients from time to time. Whether it’s a VIP according to someone else higher up, general society or even your own perceptions actually does not matter – the end game is one and the same.

The best time to ponder and prepare regarding your future approach to VIP patients is now – before you are in the midst of the actual situation.

Now, if you are an idealist, things may seem blatantly easy. You shall and you of course will evaluate each one of your patients the same, regardless of anything about them! It may in fact feel insulting if someone were to insinuate that this case deserves or requires that “special” or “above and beyond” care. Doesn’t that imply that all of your other patients so far have been getting just average or so-so treatment?

A VIP patient is like a parcel box that arrives with a “handle with care” stamp. And the question is – are we not caring that way already?

Unfortunately, that is now how things may appear to others – exactly why patients and family members put on institutional badges or start mentioning names as you walk in the room. In a short while, random suits whom you have never met or knew existed descend from upstairs to “check on things”, as they seek you out to shake hands and make eye contact. And the general atmosphere affecting not only yourself, but also your nurses and everyone around slowly starts to resemble the buzz felt near a transformer booth.

The ethics and the philosophy of VIP-EM (I’m patenting the podcast name if you’re not) would take up a heavy volume.  For our purposes, we will make it simple:

VIP-EM situations will potentially push you toward one of two things:  either withholding what you normally would have done, or doing what you otherwise wouldn’t have done. 

Let’s take an example of either situation to illustrate.

  • A secretary of a hospital network CEO arrives with her 3-week old having a fever at home. Someone had called the charge nurse ahead of time, and they are given a priority room, ahead of others. The baby looks fine and is, oh, so cute! You, unfortunately, know what needs to happen, and so does the useless WBC count.  But…lumbar punctures hurt, and the mother is seeking out in your eyes the permission to defer it. So you send the happy baby home to its life-saving next day pediatrician follow up appointment and its Listeria meningitis demise…or do you?
  • A local TV station news anchor, and a friend of the Chief of the surgery department, pulls a shoulder while attempting a muscle up as part of the new IM-50X weight loss program. Physical exam findings are minimal, the XRay is normal and there is no concern for any neurological or vascular injury. You are requested to order a STAT MRI and to perform a shoulder steroid injection. Instead of the orthopedist on call, a special sports specialist catering to the town football team will be arriving in 3 hours to evaluate the patient, who will continue to hold up the ED bed. You will of course be prescribing narcotics for home…or will you?

Thinking about such hypothetical scenarios now to understand who you are and how you would behave will serve you well when the time comes. Regrettably, such education is often omitted from official medical school “handling difficult patients” curricula and cultural sensitivity training.

While I’m not an ethics professor, I do think there are three special circumstances within the entire VIP conundrum to consider.

The first is about returning someone injured in the line of public service to active duty. Whether it’s a colleague with a needle stick, a fireman needing clearance from minor inhalation or a police officer inadvertently embedded with a taser dart by one of his own – if you can return them to work rapidly and ahead of others, you should probably do it. First heal the healer goes a long way not only in major disasters, but in everyday life as well. It’s the basic utilitarian argument.

The second has to do with taking extra steps to ensure someone’s privacy.  If the patient is the kind of a persona who has paparazzi following them day and night, going the extra mile to create conditions of confidentiality that are no more than usual is probably okay.

Third, I do want to mention that while the sense of entitlement to extra or special care among the VIPs may be prevalent, the latter trend does not encompass everyone. Just like you will never plant the seed of suicidality by asking a patient if he or she is suicidal, you are unlikely to offend a potential VIP by asking directly if it is okay for you to treat them as everyone else. You will be amazed, but quite a few people who have to carry out their lives in full view of the public or are subjected to immense professional responsibilities never want to be treated differently in the first place.  Getting what I call a brief “fame holiday” may in fact be therapeutic and exactly what they need.

There are very few things in EM that are both deadlier and more unfair than VIP-medicine. Anticipating and mitigating potential fallout before it happens is a tough skill to learn. Knowing that such situations are unavoidable is the first step.

Last, while dignitary emergency medicine (DEM?) is not (yet) a legitimate EM fellowship, you can certainly read more about what’s being thought on this topic within the general medical field:

Al Mulhim MA, Darling RG, Kamal H, Voskanyan A, Ciottone G. Dignitary Medicine: A Novel Area of Medical Training. Cureus. 2019 Oct 22;11(10):e5962. doi: 10.7759/cureus.5962. PMID: 31799098; PMCID: PMC6863586.

 

Cite this article as: Anthony Rodigin, USA, “VIP-EM POP QUIZ: What do you do?,” in International Emergency Medicine Education Project, May 10, 2021, https://iem-student.org/2021/05/10/vip-emergency-medicine/, date accessed: December 4, 2021

Recent Blog Posts By Anthony Rodigin

Social Media Ethics for Medical Professionals

ethics

From Twitter to LinkedIn, every single one of us use social media every day. While using social media is not an obligation (obviously), imagine how you would be surprised by someone who has no social media account. Our posts on social media are meant to be there forever, carefully protected from deletion by Terms and Conditions of the social media site we used. Once you shared a post, it takes its place in the digital world as our footprint. “Who cares?”, you might ask. Well, the answer is EVERYBODY. Employers routinely check social media accounts of the individuals to grasp an opportunity to “reveal” their identities and and use this data in recruitment processes. Advertising companies are using our “share/like” data to select  “suitable” ad contents for us. States constantly monitor the soical media contents of their citizens.

In one sense, social media profiles are like the diaries of the past. However, there is a fundamental difference: While diaries are meant to be a confidante of the individual, social media “diaries” are notoriously verbose speakers ready to ruin us.

Statements

American Medical Association’s (AMA)  “Professionalism in the Use of Social Media” webpage emphasizes some basic (yet vital) rules. They can be summarized as follows:

  1. Physicians should be aware of patient privacy standards at all times, and must refrain from posting identifiable patient information online.
  2. When using social media for educational purposes or to exchange information professionally with other physicians, follow ethics guidance regarding confidentiality, privacy and informed consent.
  3. Physicians should use privacy settings to safeguard personal information and content to the extent possible, but should realize that once on the internet, content is likely there permanently. Thus, physicians should routinely monitor their own internet presence to ensure that the personal and professional information about them is accurate and appropriate.
  4. If physicians interact with patients on the internet, they must maintain appropriate boundaries of the patient-physician relationship.
  5. Physicians should consider separating personal and professional content online.
  6. When physicians see content posted by colleagues that appears unprofessional they have a responsibility to advise against it. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.
  7. Physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students) and can undermine public trust in the medical profession.

World Medical Association (WMA) issued a statement on the professional and ethical use of social media in 2011 which has some additions to the rules mentioned above:

  1. Physicians should study carefully and understand the privacy provisions of social networking sites, bearing in mind their limitations.
  2. Physicians should consider the intended audience and assess whether it is technically feasible to restrict access to the content to pre-defined individuals or groups.
  3. Physicians should adopt a conservative approach when disclosing personal information as patients can access the profile. The professional boundaries that should exist between the physician and the patient can thereby be blurred. Physicians should acknowledge the potential associated risks of social media and accept them, and carefully select the recipients and privacy settings.
  4. Physicians should provide factual and concise information, declare any conflicts of interest and adopt a sober tone when discussing professional matters.
  5. Physicians should draw the attention of medical students and physicians to the fact that online posting may contribute also to the public perception of the profession.
  6. Physicians should consider the inclusion of educational programs with relevant case studies and appropriate guidelines in medical curricula and continuing medical education.

British Medical Association’s (BMA) “Ethics of Social Media Use” page has detailed information on both benefits and risks of social media. Its “Social Media, Ethics and Professionalism Guidance” emphasizes the arguably most important reminder: “You are still a doctor or medical student on social media”. Touché!

Tips from Experts

The rules and codes are of course very important in theory. However, experts in this field will know best how to apply them in practice. For this article, we asked the leading names of the #FOAMed World the following question: “What is your FIRST RULE while using social media?”

Here are their answers:

Skin in The Game

“If you haven’t somehow got skin in the game, your opinion is probably worthless and/or unwanted.”

– Karim Brohi [*]

Stick to the Science

“Dr. Sapna Kudchadkar’s basic Twitter rules applies to all social media.

Always remember “a tweet is forever” it does not disappear.

Stick to the science and be collegial are my rules.”

-Yonca Bulut [*]

Dr. Sapna Kudchadkar’s Basic Twitter Rules

“Don’t ever give specific medical advice or try to diagnose online.

Don’t write about actual patients or cases.

Don’t ever sacrifice collegiality due to a difference of opinion.

Don’t forget to cite the source.

Don’t tweet slides of unpublished data.”

-Dr. Sapna Kudchadkar

No regrets!

“I never post anything I might regret in the future.”

-Shanta W. [*]

Vice Versa

“Don’t just try to project the best version of yourself on social media. Try to become more like the better version of yourself that you want to project on social media.”

-Elias Jaffa [*]

THINK

“One word: THINK. T: Is it true? H: Is it helpful? I: Is it inspiring? N: Is it necessary? K: Is it kind?”

-Manrique Umana McDermott [*]

Know the Rules

“So many important things to consider….one of the bigger ones is know your institution’s rules and guidelines… Most have them—some are strict and some aren’t. But know the rules. Many institutions literally have someone assigned to watch social media output among employees.”

-Rob Rogers [*]

A Force for Good

“Be a force for good in the world. Don’t say anything you wouldnt say in front of my mother & chair.”

-Seth Trueger [*]

Once You Write…

“Every single letter is a long lasting prey of the web.”

-Nicolas Peschanski [*]

Not an Online Hospital

“1- Patient privacy rules are also valid here.

2- Social media is not an online hospital.

3- Social media is not a scientific journal.

4- Social media is not a suitable platform to debate with colleagues.”

-Fatih Beşer

Think Before You Speak

“The best tweets are the ones you don’t ever send. You should consider not sending the vast majority of tweets.”

-Bruce Lambert [*]

Conclusion

“What should I be known for?” A social media account that you have shaped around this simple question will undoubtedly lead to incredible opportunities. In any case, there is no escape from using social media.

By carefully reading and implementing the rules mentioned in this post, you can prevent social media from doing you more harm than good.

Cite this article as: Ibrahim Sarbay, Turkey, "Social Media Ethics for Medical Professionals," in International Emergency Medicine Education Project, April 26, 2021, https://iem-student.org/2021/04/26/social-media-ethics-for-medical-professionals/, date accessed: December 4, 2021

Suicide – An Emergency Priority of Public Health Care

Suicide An Emergency

A significant number of emergency department visits annually arise as a result of intentional self-harm. Although no accurate description explains what leads to suicide or what comes after, it is a multifaceted phenomenon of public health urgency during a global health crisis. In the United States alone, suicide is the 10th leading cause of death and worldwide claims up to 800,000 lives each year. The international community must unite to come up with solutions to prevent the loss of life, as every single life lost is one too many.

With the COVID-19 pandemic, such an emergency naturally affects both individuals’ health and well-being and the communities in which they live. Unprecedented times unleash various emotional reactions from isolation, grief and trauma to other unhealthy behaviours, noncompliance with public health guidelines and the exacerbation of mental health conditions. While those who’ve been emotionally, sexually or physically abused in the past are more vulnerable to the psychosocial effects of a crisis, supportive interventions such as the Zero Suicide program and Cognitive Behavioural Therapy designed to promote wellness and enhance coping should be implemented [1]. 

In honour of World Suicide Prevention Week, and World Suicide Prevention Day held on the 10th of September every year, it is important to raise attention to the global importance of suicide prevention. Suicide impacts all people and particularly the world’s most marginalized and discriminated groups. It is a huge problem in developed countries and just as serious in low-and middle income countries where resources and access to healthcare professionals are scarce. In many regions of the world, the taboo and stigma surrounding suicide persist, causing people in need of help to be left alone. 

Suicide prevention with awareness campaigns ought to be prioritized on the global health and public policy agendas as a major public health issue. Routine screening for suicidal ideation by health care professionals providing care should identify and assess suicide risk among populations. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), risk factors of suicide include mental illness, substance use diagnoses, trauma or conflict, loss, family history of suicide, and previous suicide attempts [2].

Effectively implementing suicide prevention strategies at the populational, sub-populational and individual level requires ensuring patients’ lethal means are restricted, reduced, and that all accesss to weapons of self-harm are removed from the nearby environments. Healthcare providers should keep up to date with new developments, research, and technologies screening for suicidal ideation, allowing them to effectively serve patients beyond their clinics’ walls. Key to prevention are strong physician patient relationships that help ensure care transitions allow for physicians to act as supportive contacts reaching out with calls, texts, letters and visits to their patients particularly when services are interrupted. With access to technology the role of psychiatrists, and psychologists may continue uninterrupted as telemedicine serves as an effective platform providing patients with access to care, even during lockdowns. Besides these objectives, greater awareness and education into the community means encouraging the responsible portrayal of suicide in mainstream media. A sensitive issue of this magnitude ought to be communicated responsibly placing special attention to not trigger susceptible individuals. With school based interventions, professionals may act sooner before worsened prognosis’ effectively ensuring that access to peer support services is available. 

Suicide prevention is a responsibility of healthcare systems, medical professionals and communities. All countries must stand in solidarity and unify in collaboration to battle this common threat as preventing the tragic loss of life to suicide is of utmost importance. 

References & Further Reading

  1. In Health and Behavioral Healthcare. (n.d.). Retrieved September 14, 2020, from http://zerosuicide.edc.org/toolkit/treat/interventions-suicide-risk 
  2. Psychiatry Online: DSM Library. (n.d.). Retrieved September 15, 2020, from https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596 
Cite this article as: Leah Sarah Peer, Canada, "Suicide – An Emergency Priority of Public Health Care," in International Emergency Medicine Education Project, October 19, 2020, https://iem-student.org/2020/10/19/suicide-an-emergency-priority-of-public-health-care/, date accessed: December 4, 2021

Developing Clinical Research Ethics in the Developing World

Developing Clinical Research Ethics in the Developing World

“You are a research fellow working on a clinical trial for cryptococcal meningitis (CM) in Ugandan AIDS patients. If a patient is diagnosed with CM and enrolled in this trial, they receive free care for treatment duration and reimbursement for non-medical expenses. Seventy-five percent of this population lives on less than two dollars per day and cannot afford these costs otherwise. A woman presents with CM symptoms, but after testing her cerebrospinal fluid, she is instead diagnosed with deadly bacterial meningitis. She cannot be enrolled in the trial and is too poor to buy antibiotics. ”

What do you do?

I recently presented this case at a classroom discussion about global health research ethics. When this dying woman’s mother pulled on my lab coat and pleaded for help one day at the government-run Mbarara Regional Referral Hospital (MRRH), where I worked as a clinical research fellow for nearly a year, I did not know what to do, and neither did my peers.

Like many global health-oriented physicians, my career began with short-term medical mission trips as a pre-medical student. However, I found these trips to be self-serving and unsustainable; indeed, the ethical shortcomings of these trips have long been argued because often participants’ benefits outweigh those receiving of their “help.“[1] Thinking research might be a way to develop an ethical global health career, I completed a summer clinical research project in India, which I found more productive and substantial than short-term mission trips. Galvanized by the belief I could change the world through ethical research, I applied for the clinical research fellowship in Uganda.

Ultimately, I found my experience as ethically fraught as the short-term missions I swore to avoid. I am not alone in these sentiments: others have noted that AIDS in Africa has paradoxically been both a source of significant tragedy and significant academic opportunity. Unfortunately, these opportunities are distributed unevenly, producing fresh inequalities. In their efforts to reduce suffering in Africa, some global health researchers have inadvertently capitalized on the intellectual opportunities provided by those same African sufferers.[2]

At MRRH, where the shortages of gloves, saline, and basic medications reflect the hospital’s poverty and its patients, research-based medical care is often the only care people receive. Academic collaborations between western and sub-Saharan African institutions enable African researchers to publish in journals viewed by western audiences. As of 2017, patients presenting to MRRH with tuberculous meningitis or CM were enrolled in American-run clinical trials and treated without charge by experts with effective medications. Western-based surgical teams have improved MRRH’s surgical capacity, where sophisticated procedures are now performed with modern equipment. In 2004, after multinational research programs dedicated to tackling AIDS, tuberculosis, and malaria (ATM) worldwide were launched in the late 1990s, clinics started supplying HIV-positive Ugandans with free antiretrovirals and other services, causing a significant decline in HIV-related mortality.[3]

However, inequities in patient care are apparent in the areas of MRRH that have not yet benefitted from foreign research dollars, particularly the intensive care unit and the emergency department. The two working ventilators in the hospital are usually occupied by neurosurgical patients. Deaths due to trauma and road traffic accidents in Africa cause the loss of more life-years than AIDS and malaria combined [4], which is also true at MRRH. Like the woman in the case above, patients suffering from other non-ATM infectious diseases are sometimes victims of these inequalities at MRRH.
This unequal distribution of research wealth in a resource-limited setting such as MRRH troubles me. At MRRH, often, patient care follows research dollars; when the money runs out, so does the patient care. The Declaration of Helsinki requires control groups to receive the ‘best’ current treatment, not the local one – and while in developed countries the difference between ‘best’ and ‘local’ may be small, in settings like MRRH this difference is profound and may result in severe ethical consequences.[5]

In March of 2018, I watched a presentation by researchers who conducted a CM clinical trial in eastern Uganda, similar to ours at MRRH. A conference attendee voiced concern that the trial had violated the Helsinki Declaration, since many participants in the control group had not received any treatment. The presenter responded that the standard of care treatment for CM at this hospital was often no treatment, because the hospital had nothing to treat its patients. And, in late 2017 when the CM clinical trial at MRRH ended, CM patients there no longer received free treatment.

Uganda is often cited as the success story in sub-Saharan Africa in its efforts to reduce its HIV burden, largely due to funding from large international research programs.[6] But perhaps these trials reveal that acceptance of this ethical relativism in clinical research could result in the exploitation of underserved populations abroad for research programs that could not be performed in the sponsoring country.[5] Researchers must first be aware that conducting clinical research in resource-limited settings may create as many inequalities as it alleviates, particularly where the minimal standard of care for certain conditions is lacking. Secondly, research is often the conduit for medical care for impoverished people, which in turn creates unique ethical issues.

How can we global health researchers mitigate some of these ethical quandaries? I suggest that before embarking on clinical research (particularly in underserved areas), researchers assess their site’s health care needs and risk of patient exploitation, and that teams include medical anthropologists and epidemiologists well-versed in the local population’s health care needs and their receptiveness to clinical research. At MRRH, this was not a requirement of institutional review board approval for studies, so research teams must take this responsibility onto themselves.

Billions of people worldwide have benefitted from the discoveries that clinical research provides. Unfortunately, historically in our quest for valuable intellectual resources, those benefits have sometimes come at the cost of human exploitation. To maximize the benefit of clinical research for all involved, global health researchers must ensure this exciting and evolving field grows in an ethically sound manner.

References

  1. Roberts M. Duffle Bag Medicine. The Journal of the American Medical Association. 2006;295(13):1491-2.
  2. Crane JT. Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science. Ithaca and London: Cornell University Press; 2013.
  3. Wendler D, Krohmal B, Emanuel EJ, Grady C. Why patients continue to participate in clinical research. Arch Intern Med. 2008;168(12):1294–9.
  4. Hulme P. Mechanisms of trauma at a rural hospital in Uganda. Pan Afr Med J. 2010;7:5.
  5. Angell M. The Ethics of Clinical Research in the Third World. N Engl J Med. 1997;337(12):847–9.
  6.  Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Uganda [Internet]. 2004. Available from: http://data.unaids.org/publications/fact-sheets01/uganda_en.pdf
Cite this article as: Sarah Bridge, USA, "Developing Clinical Research Ethics in the Developing World," in International Emergency Medicine Education Project, September 21, 2020, https://iem-student.org/2020/09/21/clinical-research-ethics/, date accessed: December 4, 2021