ETHICAL CHALLENGES OF SHORT TERM MEDICAL

BRIGADES: STSG MODELDr. Tom Young, Jim and Suzanne Elliott Professor, UK Pediatrics

Dr. Janeth Ceballos, Associate Professor of Pediatrics, UK Pediatrics

Dr. Cristian Carrion, Physician CSHH, Ecuador

FACULTY DISCLOSURE

• Faculty have no disclosures or relevant financial relationships to report

EDUCATIONAL NEED/PRACTICE GAP

Gap: Lack of awareness in addressing ethical challenges of short term medical brigades

Need: Exist significant need to understand potential harm and develop best practices so that medical brigade teams minimize harmful impacts on patients and communities served and maximize positive contributions to brigade members, patients and the community that is being served

OBJECTIVES

Upon completion of this educational activity, you will be able to:

1) Describe potential harms to patients and communities served during

short term medical brigades

2) Describe ethical practices that enhance positive outcomes to the

brigade team and community that is being served

3) Apply ethical principles in brigade planning

EXPECTED OUTCOME

1) Identify potential harms to patients and communities

served during short term medical brigades

2) Incorporate ethical practices in brigade planning that

enhance positive outcomes to brigade team and community

that is being served

STSG medical team 2017 - Ecuador

CASE PRESENTATION

• RM - spring break service learning trip to a Central American country.

• Team: 40 dental, medical, nursing, occupational therapy, and pharmacy

students and 2 faculty members from each of those disciplines.

• 3-day free clinic – local school

• No other health services available in the community.

• Acute illnesses

• Advanced pathologies rarely seen in the United States.

WHAT DO YOU THINK IT WOULD BE?

HARMS/DANGERS

- Medical personnel not familiar with

local pathology

- Language barriers and cultural biases

- Interventions not addressing the “real

problem”

- Violence/safety concerns

- Exposure to diseases

BENEFITS

- Community access to medical services

not available

- Learning opportunities

- International/Intersectoral

collaborations

Tsáchila child fishingEcuador

7 SINS

#1 Leaving a mess behind

#2 Failing to match tecnhology to local needs and abilities

#3 Failing of NGOs to cooperate and help each other, and to cooperate and accept help from military organizations

#4 Failing to have a follow-up plan

#5 Allowing politics, training, or other distracting goals to trump service, while representing the missions as "service"

#6 Going where we are not wanted, or needed and/or being poor guests

#7 Doing the right thing for the wrong reason

Welling, D.R., Ryan, J.M., Burris, D.G. et al. Seven Sins of Humanitarian Medicine. World J Surg 34, 466–470 (2010).

OPERATION SMILE

#1 Leaving a mess behind

- Assess carefully what can be done in the field with limited resources and time

- Be able to say “NO”- Never allow providers to do more than what

they should be doing- Don’t concentrate on “numbers” (consider

patient safety and proper monitoring)- Consider minimally invasive interventions:

removal of abscessed teeth, ingrowing toenails, fitting eyeglasses

Photo taken from https://www.operationsmile.org

#2 Failing to match technology to local needs and abilities

-Assess local resources and needs

-Avoid training high skills interventions that require technology not available in the host area

Photo taken from https://surgery.med.uky.edu

STSG oral health education -Ecuador

#3 Failing of NGOs to cooperate and help each other, and to cooperate and accept help

Taken from: https://theonebrief.com

-Assess local resources and needs

-Work with local and non-local NGOs working in the area to meet same goals

-Avoid competing for services/funding

#4 Failing to have a follow-up plan

STSG Medical Brigade Ecuador

-Going to one location to provide services and technology but not going back to assure changes made were able to be sustainable

#5 Allowing politics, training, or other distracting goals to trump service, while representing the missions as "service"

STSG Medical Brigade Ecuador –Cultural integration-

-Voluntourism

-Short term trip providing services in high quantity affecting quality

-Avoid doing something that “looks good” but hurts the community in a long term

#6 Going where we are not wanted, or needed and/or being poor guests

STSG medical brigade, Ecuador

- Wait for an official request to go into an area of need

- Do what the local people want and not what we think they need – needs assessment

- Let local officials be in charge and coordinate services with them

- Get local confidence and understanding on local requierements

#7 Doing the right thing for the wrong reason

STSG medical brigade, Ecuador

- Assess our motivations for doing a humanitarian mission- Desire to go on an unusual vacation- Bragging for having done a “first”- Desire to perform a large number of

complex cases quickly- Gain fame- Free trip to “exotic land”- Get advantage in academia

STSG VIDEO

CORE ETHICAL PRINCIPLES

Information resources :

• Hoping to Help: The Promises and Pitfalls of Global Health Volunteering, Dr. Judith

Lasker

• Guidelines for responsible short-term global health activities: developing common

principles, Globalization and Health: 2018, 14:18, pg 1-9 Lasker et all

• The ethics of medical volunteerism, Stone et al, Med Clin N Am, 2016, 237-246

• Short-term Medical Service Trips: A Systemic Review of the Evidence, Am J Public

Health, July 2014, e38-e 48

Principle 1: Community Collaboration

STSG - Ecuador

• Essential principle • Local champion • Needs assessment before planning trip

with community partners • Do not assume that you know what is best,

you do not!

Principle 2: Preparedness

STSG - Ecuador

• Preparing team, especially learners • Required student course at UK STSG• SUGAR PREP • Cultural humility

• Interpreters • Equipment needed: lab testing, electric

available, PPE, • Supplies, medicines ( used in country

serving) Why?

Principle 2: Preparedness

• Immunizations needed, prophylaxis: CDC Travel site for details .

• Medical records: paper, EMR (Backpack EMR, Open EMR) - Who Keeps them, local access

• Knowledge about probable diseases to encounter and treatment

• Provider Handbook: Culture, medical issues, treatment guidelines

Principle 3: Continuity of Care and Sustainability

CMHH - Ecuador

• Critical to have local follow up and referral sources .

• Need to provide support for partners for follow up expenses .

• Ongoing support of community partners .• Return to same sites for continuity .• STSG supports year round health center

(CMHH) with in country foundation Hombro a Hombro

Principle 4: Competence

STSG Medical BrigadeEcuador

• Learners should have the same supervision they have in US

• Do not treat beyond your competence unless no alternative for patient health

• Work with local providers to address unique local heath issues

Principle 5:

Focus on Prevention

STSG Medical BrigadeEcuador

Prevention can have most significant impact in the long run .Examples :• Anemia screening and iron supplements • Fluoride varnish for caries prevention (tooth paste

and toothbrushes also) • Blood pressure screening • BMI screening • Health Education: nutrition, lifestyle• PT proper lifting techniques• Mental health screening PHQ-4, if resources

available

Principle 6:

Inter-professional care

STSG Medical BrigadeEcuador

• Rarely can we meet the needs of patients with a single discipline .

• Inter-professional teams can provide more comprehensive care and cross training for team members .

• STSG teams include :• Medicine, Pharmacy, Nursing, Public Health,

Dentistry, Physical Therapy, Mental Health • At times we have added : Communication

specialists, nutritionists

Principle 7:

Measure outcomes

• Are you making a difference in the population you are serving ?

• Surveys :• Community health: Less anemia,

hypertension treated, water safer • Partner supported • Trainees

• Focus groups • Needs assessments updated

100% community in Santo Domingo supports UK Partnership health center Child health needs are significant •Only 21% children had up to date Immunizations •50% children were malnourished, stunted •75% are anemic (lowers IQ) •Over 60% had been ill in the past 2 weeks •No health care facilities in community of 20,000

Tsáchila men painting hair with AchioteSanto Domingo, Ecuador

PROSPECTIVES FROM HOST COMMUNITY

• Harms

• Language Barriers

• Patient confidentiality breaches (during the medical visit due to

lack of space/makeshift patient rooms)

• Paternalism

• False expectations of follow-up and support

• Treatment changes

• Follow-up difficulties

PROSPECTIVES FROM HOST COMMUNITY

• Benefits

• Free specialized medical care

• Free medications and procedures

• Follow-up and specialized support

• Comprehensive care

(multidisciplinary care)

• Support on highly complex medical

cases (International collaboration)

• Interdisciplinary learning

• Strengthening inter-institutional

cooperation

• Intercultural learning

• Service expansion of the local clinic

Tachilas CommunitySanto Domingo, Ecuador

STSG ECUADOR BRIGADE AND COVID 19

• March 14th to 21th STSG had medical brigade scheduled.

• Feb 29th first woman tested positive in Guayaquil

• In March 6th, first confirmed case in Lexington – State of Emergency was declared in KY.

• By March 8th there were 15 confirmed cases in the Guayaquil area (1 hour south from

brigade location)

• March 8th STSG brigade was cancelled

• On 14 March, Ecuador's government announced the closure of its borders to all foreign

travelers due to the spread of the coronavirus.

BRIGAGE CHALLENGES IN A PANDEMIC:DO NO HARM

• Travel issues: Flight safety, mask on plane, hand sanitizer , Host/Volunteer countries travel protocols and guidelines.

• Team safety: PPE available, testing available, quarantine issues, distancing, access to water for hand washing, safe housing

• Host safety: protect host country for bringing in virus, PPE, face coverings patients, host knowledge of virus, host fears, testing available, referrals available, hospital capacity

STRATEGIES DURING THE PANDEMIC

• Communication with the community and stakeholders

• needs, safety, procedures

• Asses and adapt medical brigade program protocols as necessary

• Anticipate and monitor impact of Covid-19 on program operations

• Review the program finances and implications

VIRTUAL BRIGADES

QUESTIONS?