Realizing our Ethical Aspirations Program design partnership and

Realizing our Ethical Aspirations: Program design, partnership and global leadership AAFP Global Health Workshop General Session 8 Sept 2012 Susana Alvear MD Faculty, Catholic University Quito, Ecuador Medical Director, Child Family Health Internationa Jessica Evert MD Faculty, UCSF Dept of Family and Community Medicine Global Medical Director, Child Family Health International

“Ethical principles are motivated by mercy, to act ethically is to act in the best interests of both yourself and of other people. ” –Ethics and Justice, On Philosophy, 2007. onphilosophy. wordpress. com • ethics |ˈeθik|noun [in sing. ] a set of moral principles, esp. ones relating to or affirming a specified group, field, or form of conduct. • Ethos forms the root of ethikos (ἠθικός), meaning "moral, showing moral character". To the Greeks ancient and modern, the meaning is simply "the state of being", the inner source, the soul, the mind, and the original essence, that shapes and forms a person or animal; operationalizing ethics.

CFHI’s 20+ Global Sites INDIA • • • Sight for All. Ophthalmology Rotation- New Delhi Rural/Urban Community medicine. Rural Himalayas Communicable Disease - Mumbai • HIV & Public Health Challenges- New Delhi • • HIV/AIDS & Healthcare. Durban • Cultural Crossroads in Health- Oaxaca Hospice and Palliative Care in Southern India • Tropical Medicine & Rural Health- Puerto Escondido • Social Medicine and Primary Care in Cordoba Chagas- Tarija • Pediatric Health- La Paz ECUADOR • Vector-borne Diseases - Amazon • Andean Health- Quito • Urban & Rural Comparative Health. Quito/Chone • Reproductive Health. Quito • Community Medicine. Amazon • Indigenous Health. Amazon • Sonrie Dental Program - Quito MEXICO Maternal and Child Health- Pune ARGENTINA • Healthcare Challenges. Cape Town Intro to Traditional Medicine- Rural Himalayas • BOLIVIA SOUTH AFRICA • Women’s Reproductive Health- Puerto Escondido

• Motto: “Let the world change you. ” • Local practitioners are preceptors/instructors, held up as expertsnot replaced or subverted by Western faculty/physicians. • Re-investing tuition dollars/funding in communities- through direct compensation, community health projects, professional development, medical supplies recovery.

“Given this first-hand experience, I feel I have developed greater passion to become an advocate for change. Furthermore, as a future physician I will integrate myself within the community and address their needs from a diverse perspective. ” –CFHI Particpant “I liked the Centro de Salud best, I got to accompany a health facilitator out to the community, which really brought home the difficulties (extreme hills, lack of addresses) in improving health in the community. ” -CFHI Participant “I reaffirmed that I want to work with an under-served population. It also fortified my interest in family medicine… I realized that I can communicate with patients in Spanish. (more or less). Also, I became more interested in women's health (especially mental/social) after seeing a family physician talk to a woman who was being abused by her husband. ” -CFHI Particpant

Trickle Down Ethics… Organizational/Institutional Ethics Partnership Ethics Trainee’s Ethics

Sprouting Ethics… Institutional/organizati onal ethics Partnership ethics Program ethics Individual Ethics

Examining Individual Motivations to build an ethical foundation… • Motivations to which I aspire. • Motivations I can tolerate. • Motivations I’d rather suppress. Philpott, Jane. Training for a Global State of Mind. Virtual Mentor, 12; 3: 231 -236.

Individual Global Health Ethical Principles • Humility • Solidarity • Social Justice • Introspection Pinto A and R Upshur. Global Health Ethics for Students. Developing World Bioethics; Nov 2009: 1 -10.

Humility “unpretentious openness, honest self-disclosure, avoidance of arrogance, and modulation of selfinterest” 1 “Countercultural though it is, humility need not suggest weakness or lack of self-confidence. On the contrary, humility requires toughness and emotional resilience. ” 2 1. Coulehan J. Perspect Biol Med. A gentle and humane temper: humility in medicine. 2011 Spring; 54(2): 206 -16. 2. Coulehan J On Humility. Ann Int Med. August 3, 2010 vol. 153 no. 3 200 -201.

Humility • Recognizing your limitations (personal, professional, logistical) • Competence from training in developed country does not equal competence a more low resource setting. • Understanding of one’s own value is equal to another’s value. • Lack of humility can lead to neo-colonial behavior. Pinto A and R Upshur. Global Health Ethics for Students. Developing World Bioethics; Nov 2009: 1 -10.

Institutional/Organizational Ethics and Ethos • • • Consciousness Authenticity Towards Equity Justice Sustainability Professionalism

Authenticity Ecological Self (Naess, 1989) Service to the good of others is, in actuality, an enlightened form of self interest. Mutual Altruism (Mendonca, 2001) Bilaterally beneficial and represent enlightened selfinterest. Operationalizing (Ethos): -Clearly defining what experiences/projects entail and the reach -Transparency -Being honest about who’s benefitting -Saying ‘no’ to funding/projects which we are not capable of executing.

Towards Equity “When I hear of an 'equity' in a case like this, I am reminded of a blind man in a dark room - looking for a black hat - which isn't there. ” -Charles Bowen Operationalizing (Ethos): -Leveling the playing field by recognizing the value that the local reality has for you, for trainees. -Beyond hospitality and to the heart of partner’s criticism, feedback, and needs. -Recognizing the gross financial/resource inequities, while placing value on richness of culture, traditional medical approaches, health care systems that have greater equity than our own.

Partnership Ethics and Ethos Neocolonial hazard and Paternalism hazard • Ignorance of local capabilities • Cultural incompetence • Lack of solidarity • Lacking sense of social justice • Lack bilateral feedback mechanisms • Using a developing context for your own gains without attention to local gains/opportunity costs. Working Group on Ethics Guidelines for Global Health Training (WEIGHT), published recommendations in 2010

Partnership Ethics and Ethos Transparency • Financial transparency • Acknowledgement of mutual benefit Professionalism • Consistent expectations/program structure • Professional treatment of local colleagues, community, leaders/patients (explicit contacts when appropriate) • Recognition of array of skills sets necessary to host, translate, facilitate project • Professional demeanor when responding to stress, cultural clashes, and other difficulties. • Respect of local professional/licensure regulations Working Group on Ethics Guidelines for Global Health Training (WEIGHT), published recommendations in 2010.

Steering clear of the neocolonial/paternalism hazards • Asset-Based Community Engagement • Asset-Based Community Development

Types of Engagement and Community Development • Deficit Models: focus on identifying problems and needs of a population which require ‘fixing’; can breed a high level of dependence, disempowerment, even pity. • Asset Models: Accentuate positive ability, capacity, capability, existing skills to build on to address deficits; ‘internalizing’ the process and leading to local empowerment, sense of control/capability.

Asset-based Community Development • Does not mean that communities do not need additional, outside resources. • Means that outside resources will be more effectively used if locally community is mobilized, invested, and defines agenda. • Internalization: strong internal focus to ensure the primacy of local definition, investment, hope and control. • Inherently ‘relationship driven. ’ • Front-loaded efforts- communities not always readily aware that strengths are strengths or used to focusing on them. Kretzmann and Mc. Knight. Building Communities from the Inside Out. 1993.

ABCD • Defined methodology including asset-mapping • 5 types of assets: Citizens, Associations, Institutions, Land (infrastructure), Economy • Mapping---building relationships among assets ----convening assets to develop vision--leveraging outside resources to support community agenda. • More info: www. abcd. org

Ladder of Citizen Participation Arnstein, Sherry R. "A Ladder of Citizen Participation, " JAIP, Vol. 35, No. 4, July 1969, pp. 216 -224.

Perspective of a local leader: Dr. Susana Alvear • Initially motivated by internal conflict to engage in ‘global health’ after witnessing culturally incompetent care provided to Latinos who were in the US. • Responding to need of Westerners to understand Latino language and culture in order to serve the Latino diaspora. • Health as a Human Right • Core Ethical Principles of providing health care to poor: Freedom, Equality, Solidarity

Perspective of a local leader: Dr. Susana Alvear • Important partnership ethics: Liberty, Empowerment, Solidarity, Trust/Honesty • Approached by Evaleen Jones MD as a colleague and equitable partner, rather than explicit ethics-driven outreach, due to context and style of approach ethics were embedded into the collaboration.

Perspective of a local leader: Dr. Susana Alvear Two divergent approaches to initial engagement for partnership: • Impose, indoctrinate, manipulate, adopt paternalist attitude. • Observe, gather information, be present/immerse in location/culture/language/relationships.

Dra. Alvear’s wish list for global health collaborations 1. Education: Emphasize and respect ability of local experts/colleagues and community members to teach Westerners about the local reality, history, culture, medical practice. Do not subvert local practitioners in your project. 1. Flexible Service Roles: When Westerner is in service role to community, be flexible to be what community needs rather than what you are used to doing.

Dra. Alvear’s wish list for global health collaborations 3. Sustainability: Often short-term projects or even repeated short-term activities without local partnership can do more harm than good. To be sustainable you need to do evaluation of your impact and integrate your efforts into local health care resources or community leadership. 4. Evaluation: Include evaluation of human interactions, professionalism, personal transformation into evaluation processes to truly understand how trainees/faculty/others operate in the global setting.

If you follow Dra. Alvear’s wish list… These ethical qualities will be instilled in your programs, partnerships, trainees, selves: Humility Autonomy (of local individuals/community) Social Justice

Realizing your ethical aspirations…. • Engage in introspection to understand your personal ethical values and motivations. • Develop an organizational ethical code/values set. Make it visible, refer to it when making decisions. • Be conscientious of your ability to influence wider institutional/professional ethical standards through research, advocacy, and ethically-conscious program development.

More often there's a compromise between ethics and expediency. -Peter Singer Let the world change you…. . jevert@cfhi. org