Trouble Abroad - Recap and Commentary

The responses provided so far have been phenomenal, both insightful and provocative.  I am truly impressed.  As mentioned by several of my colleagues, many of these cases are deeply personal, not only because they involve highly vulnerable populations, but also because they may put clinical providers in harm’s way.  When we begin to discuss ethics, especially global health ethics, there is often no single correct answer to a given scenario.   We often deal with hard science and hard facts but sometimes you just have to go with your gut and do what you think is right.  If you missed the first case and initial discussion, check it out here.

Q1: How do you respond to the request from the OB/GYN chairman (at a rural hospital in South Africa) to draw blood (no gloves available) from an HIV-positive woman in labor?

By Werneuchen (Own work) [Public domain], via Wikimedia Commons

By Werneuchen (Own work) [Public domain], via Wikimedia Commons

The responses were generally split on this one, which is what I was expecting.  This is a very difficult scenario, but very real and there are many variations on this theme.  Dr. Kircher brings up the issue of personal protection, “I have a duty to protect myself, my family and my future patients that overrides a routine blood draw in this case.”  He mentions that while he would stand by his beliefs, he would not use the sterile gloves which were a valuable resource.  Finally, he thinks big picture and mentions contacting “international agencies, media, my home program”, or anybody that could help the situation.  Problem solving and adaptability is definitely critical in situations such as these.

A few others noted that they would probably perform the blood draw sans gloves.  Dr. Grosso makes the point that this is not an isolated situation and that many countries in sub-Saharan Africa have extremely limited resources, including adequate barrier protection in the form of gloves (only 75% of hospitals had sterile gloves available to their workers the majority of the time and NONE had sterile gloves 100% of the time).   Dr. Summers reports an extremely low (CDC quote of 0.23%) risk of HIV transmission via a needle-stick injury and Dr. LaFollette provides evidence that the particular disease in question matters (HepB 30% transmission rate vs. ~0.3% for HIV). 

Dr. Richardson beautifully expresses how our actions may differ depending on our location, the situation, and the emotional pressures of a particular moment:  “Sitting in my air conditioned apartment, my initial reaction was that the personal risk and associated consequences are too great to justify performing this procedure and I should refuse the Chair’s request…However, I also imagine that if I were in this situation in real life (with my current level of training in medicine in general and resource-poor settings in particular), it would be very difficult to maintain these boundaries…If I’m unwilling to do the blood draw, what do I really have to offer that hospital?”

“Interacting with vulnerable populations who are marginalized or oppressed and who subsist in extreme poverty often drives individuals to pursue global health work.  No matter the location around the globe, this work is often fraught with ethical dilemmas that can be exceedingly difficult to manage for an inexperienced Western provider.  One often prominent difficulty is how to manage local expectations, since there is a fine line between practicing beyond one’s abilities and having a “cop-out” mentality and not performing anything one has not been trained to do.” (Selvam 2015)

This is a true personal case from when I was doing a research fellowship abroad (after 3rd year of medical school).  In the midst of a prolonged strike, I realized that using a valuable resource such as sterile gloves was an untenable option.  I acknowledged the situation and considered refusing to perform the procedure, however I made the calculated decision (I felt proficient with this particular procedure, I didn’t have any skin breaks, patient was lying still, etc.) to draw the blood barehanded with help from the nurse.  But there were other procedures which I ended up refusing during the strike:  1)performing a lumbar puncture without gloves/any sterile equipment (2)suturing an episiotomy (with gloves) but with a large suture needle in hand and no needle driver.  In these situations the nurses and providers were very understanding and I was able to assist the team in other ways. 

Q2/Q3/Q4:  What options do you have for helping a child in your research study who presents for follow-up malnourished and being fed only black tea?  Do you try to admit the child to the hospital?  How do you decide whom to help and whom not to help?  From a research standpoint, how do you address the mother and baby since they are both in your study?

Unfortunately, this is another real life case that I encountered during my clinical research fellowship.  Dr. Toth eloquently describes the multifold emotions at play so I have included his response verbatim:  

“$200 seems like a pretty small sum to actually save a life, and at first pass it seems like an easy decision to make this small individual sacrifice to accomplish that goal. In the moment, as one stares at this human in front of you, it seems pretty simple and humane to pony up the cash instead of sentencing him to a not-too-distant death. In the emotionless, impersonal confines of my computer desk I doubt that decision. This child is going to die whenever my support lapses or he leaves the hospital, and may likely die in-house eventually even if you pay for his admission. I think that you have a responsibility to share these realistic expectations with the mother, and she may elect to return home, be with family, and not be in a hospital. This is one of the cruelest examples of management of scarce resources you could present, but realistically you can’t do everything for everyone, and if this effort is overall futile you need to focus your finances, time and medications elsewhere.”

This case raises complex issues such as global health disparity, learned helplessness, research ethics, and respect for enrolled participants.  Even though the patient in this scenario was a subject in my study, I considered it a potential gross violation of research ethics to not intervene.  After reviewing the situation with my local adviser, we decided to purchase formula for the patient and exclude him from our study.  We recommended admission for the child but the family deferred, citing financial concerns.  We encouraged the family to bring the child back for future follow-up visits.  Even though we intervened, I still look back with some misgivings that perhaps we could have done more to change the outcome for this child.

However, how do we decide whom to help and whom not to help on a larger scale?  Will treating this child in the short term, without making sustainable changes to his family’s ability to obtain an income, actually make a difference?  Dr. Betham makes some excellent suggestions in this vein:  “Can I work with the mom to find out if she has skills we could put to use through micro-lending?  Can I buy a goat for the family with $200?  What would they need to get a sustainable source of food?  How can we optimize her health?”

We are fierce patient advocates but must be cognizant of the downstream effects of our actions.  Always treat the patient that sits in front of you, however think broadly about determinants of health and how to create sustainable change.

Q5:  Is the compensation provided (2kg bag of mielie meal) excessive and/or do you think it unduly influenced the patient to return?

This question caused some confusion but I mainly raise it in consideration of the ethics of research design.  We generally exclude vulnerable populations such as prisoners, minors, and the cognitively impaired in research, except in specific cases.  We also generally avoid over-compensation for participation in studies to avoid unduly influencing participation.  Giving a $15 gift certificate to someone to return to the ED in the US for a study seems reasonable.  But try giving them $500 to come back.  This probably wouldn’t get through an IRB.  Why?

Our study IRBs (both US and South African) approved the compensation of foodstuffs such as mielie meal.  Interestingly, when we spoke to participants, many admitted that the only reason they came to the follow-up visit was to get the food that we provided.  In our case, the interventions we were performing were benign:   weight/height measurements, head/arm circumference, cognitive/development testing, etc.  However, what if we were doing more invasive testing or questionable/unproven drug administration?  Would the participants still have come even if they were at higher risk for injury or death?  Having appropriate compensation and not unduly influencing patient participation is another added layer to protect research participants.