ETHICS IN GLOBAL HEALTH: BEYOND HIPPOCRATES Scott Loeliger, MD, MS Mark Stinson Fellowship in Global and Underserved Health Contra Costa Family Medicine Residency Evaleen Jones, MD Child Family Health International (CFHI) Stanford University Medical School TUFH INTERNATIONAL CONFERENCE Bogota, Colombia 30 September, 2008

OBJECTIVES Review the historical context of ethics within medical training and practice. Understand the place of ethics within the “new” medical professionalism. Incorporate the concepts of ethical behavior and practice into service learning activities. Encourage open discussion about current controversies and new generation focus on global health work. Ethic behavior focused on clinical/individual practice versus ethical choices regarding families, communities and organizations. Awareness if current paradigms, models, controversies. Vertical vs horizontal, 15 by 15, etc. "MDG" redirects here. For other uses, see MDG (disambiguation).List of UN Millennium Development Goals in the United Nations Headquarters in New-YorkThe Millennium Development Goals (MDGs) are eight international development goals that 189 United Nations member states and at least 23 international organizations have agreed to achieve by the year 2015. They include halving extreme poverty, reducing child mortality rates, fighting disease epidemics such as AIDS, and developing a global partnership for development.[1]

Historical Perspectives Hippocratic Oath The Declaration of Alma Ata (1978) (4th Century BC) Declaration of Helsinki (1964-2004) Universal Declaration of Human Rights (1948) Millennium Development Goals (2000) The New Hippocratic Oath (1966) “Whereas the traditional concept of international health focuses on bilateral interactions between well-to-do and poor countries, the concept of GLOBAL Health reaches beyond the rich-poor dichotomy and geographic borders to the forces that separate the powerful, free, privileged population from the population that is powerless, unfree, and humiliated. In its acceptance of human diversity, global health is an expression of support for human rights. And with human rights as a key value, global health ethics thus provides moral guidance for world health systems and governance’ Traditional Ethics: prevention, diagnosis, and treatment Global Health: state of physical, social, mental and spiritual well-being that extends beyond the absence of physical disease and infirmity Health-related concerns of social science: inequality, discrimination, health care rights, population displacement, poverty environmental practices and technology transfer, access PHC, Financing, education, and networking. 1997 WHO Policy Statement: “Health for All in the 21st Century (must be) built on the genuine expressions of moral obligations to protect the vulnerable and to mitigate inequities...with science-based and socially-sensitive methods. 1978 Int’l Conf. Primary Health Care, convened by WHO and UIDEF in Alma Ata (Kazakhstan, USSR) : PHC FUNDAMENTAL component of health care with equity and the right to Health care as core features. The Universal Declaration of Human Rights (UDHR) is a declaration adopted by the United Nations General Assembly (10 December 1948 at Palais de Chaillot, Paris). The Guinness Book of Records describes the UDHR as the "Most Translated Document"[1] in the world. The Declaration arose directly from the experience of the Second World War and represents the first global expression of rights to which all human beings are inherently entitled. It consists of 30 articles which have been elaborated in subsequent international treaties, regional human rights instruments, national constitutions and laws. The International Bill of Human Rights consists of the Universal Declaration of Human Rights, the International Covenant on Economic, Social and Cultural Rights, and the International Covenant on Civil and Political Rights and its two Optional Protocols. In 1966 the General Assembly adopted the two detailed Covenants which complete the International Bill of Human Rights; and in 1976, after the Covenants had been ratified by a sufficient number of individual nations, the Bill took on the force of international law.[2] Article 25 Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

Ethical Principles Primum non Nocerum to Primum non Tacere. Physician Charter on Medical Professionalism. Healing in the context of Social Justice. Residents with Skills – Helpful or Dangerous? One can’t discuss global health ethics without addressing poverty, inequity and injustice. Maco ethics: Public Health Ethics: general public safety city, state, country level Micro ethics of medicine (provider patient relationship) Meso ethics: operates at institutional levels Equitable distribution is not enough, health equity is the extent by which disadvantaged populations can EXERCISE their human right to justice and fairness in the context of achieving well-being. Jonathan Mann “the central insight from a decade of hard work against AID is that societal discrimination is at the root of individual and community vulnerability to AIDS and other major health problems of the world.” (and lack of respect for fundamental human rights and dignity) The primary cause of ill health is POVERTY... "MDG" redirects here. For other uses, see MDG (disambiguation).List of UN Millennium Development Goals in the United Nations Headquarters in New-YorkThe Millennium Development Goals (MDGs) are eight international development goals that 189 United Nations member states and at least 23 international organizations have agreed to achieve by the year 2015. They include halving extreme poverty, reducing child mortality rates, fighting disease epidemics such as AIDS, and developing a global partnership for development.[1]

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Physician Charter American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine 1. Primacy of patient welfare: Stresses altruistic dedication to the well-being of the individual patient. 2. Patient autonomy: Urges physicians to facilitate patient involvement in treatment decisions. 3. Social justice: Calls upon physicians to work actively toward equitable societal distribution of health care resources. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243-6. [PMID: 11827500]

The Physician Charter: Physician Charter Construct for Medical Professionalism Social justice MP Patient Autonomy Patient Welfare Gender-based heath disparities (culture, race, ethnicity) Gender Apartheid The Millennium Development Goals (MDGs) were developed out of the eight chapters of the United Nations Millennium Declaration, signed in September 2000. The eight goals and 21 targets includeEradicate extreme poverty and hungerHalve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day.Achieve full and productive employment and decent work for all, including women and young people.Halve, between 1990 and 2015, the proportion of people who suffer from hunger.Achieve universal primary educationEnsure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling.Promote gender equality and empower womenEliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015.Reduce child mortalityReduce by two-thirds, between 1990 and 2015, the under-five mortality rate.Improve maternal healthReduce by three quarters, between 1990 and 2015, the maternal mortality ratio.Achieve, by 2015, universal access to reproductive health.Combat HIV/AIDS, malaria, and other diseasesHave halted by 2015 and begun to reverse the spread of HIV/AIDS.Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it.Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.Ensure environmental sustainabilityIntegrate the principles of sustainable development into country policies and programmes; reverse loss of environmental resources.Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss.Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation (for more information see the entry on water supply).By 2020, to have achieved a significant improvement in the lives of at least 100 million slum-dwellers.Develop a global partnership for developmentDevelop further an open trading and financial system that is rule-based, predictable and non-discriminatory. Includes a commitment to good governance, development and poverty reduction—nationally and internationally.Address the special needs of the least developed countries. This includes tariff and quota free access for their exports; enhanced programme of debt relief for heavily indebted poor countries; and cancellation of official bilateral debt; and more generous official development assistance for countries committed to poverty reduction.Address the special needs of landlocked and small island developing States.Deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term.In cooperation with developing countries, develop and implement strategies for decent and productive work for youth.In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.In cooperation with the private sector, make available the benefits of new technologies, especially information and communications. Erika Shimahra, Master’s of Education, Stanford University, 2006

Embedding Ethics in Residency Formal learning and didactics. Pre-experience preparation. Consideration of ethics in underserved local communities. Understanding complexities of global realities, institutions, processes and programs. Self- study and self-reflection. Ucsf course - wiki/module - incorporated Practical preparation – summer courses Politics, research decisions, institutions

Models of Service or Service Learning Short term clinical work combined with tourism. Attachment to clinical research project. Longer term work with NGO’s or Universities. Advisor/Teacher or Medical Corps? Who chooses research focus, who decides priorities University focus displacing local opinions and needs Drop outs, longer term Individuals without connections –

Conflicts in Conscience All done in the name of Hippocrates is not right. Physician centered paradigm can distort true health improvements. Resource poor areas require careful attention to appropriate strategies. Attention to the Immediate versus the Sustainable.

THE BRAIN DRAIN We are going there, who’s coming here? Raised expectations without means to correct health manpower deficiencies. True professional exchanges, joining the growing global debate (Global Health Workforce Alliance).

Primary Care and the Medical Home Do They Want What We Want Translating “Ours” to “Theirs.” While working in health care, how to attend to social injustice and underlying factors of poor health. Training leaders, followers, co-conspirators or colleagues? Respect for emerging literature and research from abroad.

NGO CODE OF CONDUCT Recently developed (2007-08). Included input from APHA, Partners in Health, Physicians for Human Rights, Save the Children, AMREF, GHETS, WHO, World Bank and others. Most recent consultation in Kampala during March global forum on human resourses for health. Next consultation at APHA meeting in October, 2008

ARTICLES OF NGO CODE OF CONDUCT FOR HEALTH SYSTEMS STRENGTHENING I. NGOs will engage in hiring practices that ensure long-term health system sustainability. II. NGOs will enact employee compensation practices that strengthen the public sector. III. NGOs will pledge to create and maintain human resources training and support systems that are good for the countries where they work. IV. NGOs will minimize the NGO management burden for ministries. V. NGOs will support Ministries of Health as they engage with communities. VI. NGOs will advocate for policies that promote and support the public sector.

Ethics and Research Global health research may have some ethical flaws. Interventions determined by narrow research goals may not be sustainable. Article 25 of Universal Declaration of Human Rights. WMA and Declaration of Helsinki. The Universal Declaration of Human Rights (UDHR) is a declaration adopted by the United Nations General Assembly (10 December 1948 at Palais de Chaillot, Paris). The Guinness Book of Records describes the UDHR as the "Most Translated Document"[1] in the world. The Declaration arose directly from the experience of the Second World War and represents the first global expression of rights to which all human beings are inherently entitled. It consists of 30 articles which have been elaborated in subsequent international treaties, regional human rights instruments, national constitutions and laws. The International Bill of Human Rights consists of the Universal Declaration of Human Rights, the International Covenant on Economic, Social and Cultural Rights, and the International Covenant on Civil and Political Rights and its two Optional Protocols. In 1966 the General Assembly adopted the two detailed Covenants which complete the International Bill of Human Rights; and in 1976, after the Covenants had been ratified by a sufficient number of individual nations, the Bill took on the force of international law.[2] Article 25 Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection What’s news? CCPH (now located in Wisconsin) Committee on Ethics in Community-Based research--- IRB protocol adjustments, etc

UNDERSERVED HEALTH CARE Think Global, Consider Local. Incorporate the Experience into Your Future Practice Work in Your Milieu to Integrate Service Learning into the Medical School and Residency Experience. In Your Medical Bag: Stethoscope – Check; Ophthalmoscope-Check; Sansome Guide – Check; Language Dictionary – Check; Ethical Guidelines-Check? Handouts -- case scenarios Take notes, chapter (25 copies)

CASE SCENARIOS #1 Filling In – A Little Knowledge is a Dangerous… #2 Vertical Projects – We Only Do… #3 Ignoring Bureaucratic Barriers #4 NGO/Institutional Short Time Work Do number 3. review, cite a few questions

Resources Markle, W, et al. editors. Understanding Global Health. McGrawHill Medical, 2007, 362pp. Evert, J., et al. Developing Residency Training in Global Health: A Guidebook. San Francisco: Global Health Education Consortium, 2008. 119pp. O’Neil, E. Awakening Hippocrates: A primer on health, poverty and global service. AMA, 2006. 502 pp.