We can answer that.
The podcast where we sit down with UCalgary professors, researchers and experts to get the answers to five questions submitted by you.
Episode 13: Do no harm
December 9, 2020
"First, do no harm." Taking the Hippocratic Oath is a rite of passage for medical school graduates all over the world. The oath is a foundation of medical practice, forming the first code of ethics in Western medicine.
We talk with Dr. Abdullah Saleh, a paediatric surgeon and director of the University of Alberta's Office of Global Surgery, about how medical practitioners traveling to lower-income countries can end up doing more harm than good, even though they're trying to help.
Mike MacKinnon (MM): Welcome to We Can Answer That. I'm your host, Mike MacKinnon. Each week, I sit down with an expert from the UCalgary community to ask five questions related to the topics that matter most in the world. First, "Do no harm." It's a phrase often attributed to Hippocrates, even though the Hippocratic oath doesn't contain those exact words. What it actually says is, "I will abstain from all intentional wrongdoing and harm." The oath is a foundation of medical practice, forming the first code of ethics in Western medicine. Taking the Hippocratic oath is a rite of passage for medical school graduates all over the world. Now, shifting gears for a second, most of us are familiar with the term "voluntourism," where people from high-income countries spend their vacation time in middle- or lower-income countries performing volunteer work that seems to help people at least on the surface and it results in some great Instagram posts. The medical community isn't immune from this practice. But in reality, it can do more harm than good. In this episode, we're speaking with Dr. Abdullah Saleh, a UCalgary alumnus, a paediatric surgeon at the University of Alberta and the director of their office of global surgery. We'll be talking about what global surgery entails and how unethical practices can do more harm than good in middle to lower income countries. Abdullah, thanks for being here.
Dr. Abdullah Saleh (AS): Thank you, Mike. It's a pleasure to be here.
MM: Now first, can you tell us what global surgery means?
AS: Absolutely. Global surgery is a growing and emerging practice and area of study and area of research looking at how do we improve access to surgical care and services for people all over the world? It's not just a matter of speaking about people in developing or low and middle income countries, but it's looking at any population that might have an inequitable access to surgical care.
MM: And why is it important to consider ethics in global surgery?
AS: Ethics is foundational to any practice or any intervention that might have a risk of harm. And surgery, maybe more so than other areas of medicine, has the potential to do great things and to do good, but it also has a lot of risks of causing harm. When you're looking at the most vulnerable and disadvantaged populations globally, the risk of harm to these people is very real. When it comes to looking at how do we ensure that they have access to surgical care without compromising the basic ethical tenets of providing this care, it becomes imperative that we really address and take special considerations around the aspects of ethics that relate to global surgery.
MM: And what are some of the ways that global surgery can be unethical?
AS: That's a great question, Mike. It seems that we're seeing this renaissance of this phenomenon of global surgery, where there is a heightened awareness that there is a need for improving surgical care around the world. It was pronounced as one of the big areas that needed focus from the secretary general of the UN a few years back. And the Lancet had brought up a big commission, this was back in 2015, that described the importance of global surgical care. There's been an increased involvement and an increased interest in this field, but like anything, the more people are interested in it, the more the potential for harm and the more the potential for things to be done without proper supervision, without ... maybe not supervision, maybe that's not the right word, but probably without the proper considerations of the risks of harms that can happen with this. The most basic element of this is that good intentions don't mean good outcomes. Almost everybody that gets involved in this field has the best intentions. They want to do good. They want to alleviate suffering. They want to improve care for people who don't have it and they're doing the best they can. But when you look at what really some of the pitfalls are, they include anything from the people going from high-income countries to low-income countries might not have the right training or the right credentials to be doing what they are faced with over there. The classic example would be somebody who would be very early in their training, like a medical student or an early resident in their training, going to an African country and being asked to do procedures that they would never be given the permission to do and supervise, or to ever even be allowed to do that in a Canadian and a high-income context. But because of perceptions around this person being from a high-income country, maybe that person wanting to do more and maybe using this experience to try to get those clinical skills, then, that person will be put in a situation where they might cause harm for the patients, but they also might get in a situation if there is a bad outcome of huge ethical pitfalls, legal issues, but also moral distress. If I was a medical student that I killed somebody that I've gone to try to improve their life and improve their health and I caused harm, then how am I supposed to survive that? How am I supposed to live through this? That's just one example of the wrong levels of training, but even if I was as a paediatric surgeon going over to various countries, and I might face problems that I don't normally face here or in a more real way, they might not have the equipment that I'm used to doing my procedures, that they don't have access to those. So then, I have to do a procedure that I might be very conversant in, but with equipment that I'm not used to, and that can cause harm. The same time, me going over there when they have their own surgeons might also not be helpful, but it might actually disenfranchise those practitioners there or these professionals where the community might wait now and say, "Well there are foreign doctors coming and we would rather wait for that foreigner because he's better," which is not necessarily the case. But then now there is this distrust that begins in the community that, "Oh, well, why should I go to my local surgeon when I can wait another few months and have the white knight come and rescue our community?" Those are some of the more easily understood concepts around it. But then there are aspects that we take for granted around Western ethics or even biomedical ethics that we look at in terms of the patient's autonomy or ability to make decisions around their care as an individual, which might not necessarily translate to people in different cultural or geographic locations where it might be a more communal type of consent or really it's the matriarch or patriarch of the family that makes decisions, or maybe it's a community that makes decisions around care because they have to care for that patient subsequently as a community. That's a bit of a foreign concept for us that we don't see it that way because we tend to be in a more individualistic society and culture that we make our decisions, where we make decisions for our people that we are guardians for like children or parents if they get elderly, which might not be the case in those developing contexts. Going in, not even factoring in the language barrier, just that the basis of the ethics framework that we are used to in terms of the Western biomedical ethics might not be applicable to the people that we are going to treat and that can lead to a lot of unintended harm and unintended consequences which we don't realize or they may not really be able to say. I can go on about the environmental impacts of traveling and the risks of ... or the opportunity cost of people, from here, for example, going overseas, would it be better for us to send financial support or is it better to bring somebody from a low-income country to a high-income country to train them instead of us going over there? There's no right or wrong and I think that there are experiences that are important on both sides of going to raise our awareness and to really understand the situation and how to improve it, but it's important, and I think most critically it's important, to not look at it as, "We're going to save them." I think it's important that it becomes a partnership and that there is a certain bilaterality and that it's equitable in all sense of the words, not just in the care that we're providing.
MM: Instead of big shows of teams or practitioners from other countries swooping in and saving the day, what do medical systems in middle or low-income countries actually need?
AS: That's a very good question. A lot of these health systems are overburdened and they don't have the processes or they don't have the infrastructure to be able to advance care the way we might here, or they might not have the research and quality improvement skills that we've had the luxury of being able to develop. That sometimes the aspects of looking at helping them collect their own data, looking at helping them improve their outcomes, by understanding what they are currently doing, providing opportunities for education and upskilling, providing opportunities for technology transfer, where we might have technology that would be very applicable for that setting, but it might be prohibitively expensive. That being said, there's also opportunities for us to reverse innovate, and understand how things are done in low-income countries that can be very advantageous to our systems, which are seeing rising costs and really an unsustainable trajectory in terms of the costing. Whereas we can see how they manage huge burdens of disease and maybe learn some things from them. One of the things that I've seen that has been very, very eye-opening is, as academic institutions, we have great access to medical journals and research articles to be able understand even the problems that we're researching. But in a lot of the rest of the world, the subscription or the ability to access journals is so expensive that people are unable to get this, particularly learners, and people trying to advance their research they can't access journal articles. One of the simpler things to do is to create these relationships and partnerships where an academic institution can share their library access with developing countries so that they can also benefit from that access and advance their academia locally. Another way is just to give them a voice on the global stage. We go and do research and collect data from these developing countries or low- and middle-income countries and we publish articles, we advance our academic careers, and there is a lot of benefits that we receive from that. Well, granted it's often meant in the most positive well-intentioned manner, but it's rare to see the authorship or the ownership of the data or of the research coming from the people who actually live in those communities. Being able to break some of those barriers, break some ceilings, give these researchers, these practitioners, a voice on the global stage. Bring them to conferences, sponsor them to come and present on the work, on their challenges, open up opportunities and then, on the system level, bringing people to look at how our system does things and study here for some time, even not necessarily just clinical skills, but the leadership aspects can really empower these people to go back and become the change-makers in their own communities so that we don't look at the 60 years of this development history that we've had when unfortunately have made only incremental improvements. If we are able to support these champions that are local, they'll be able to transform things and then we'll be able to learn from them. I think that's really trying to flip that paradigm and really change the narrative so that they are the ones leading the conversation, leading the dialogue. They're the ones that are speaking about their issues because they understand it better than we ever will. And then, that being said, we then have to be able to look in the mirror and look at our own disadvantaged populations here in our high-income contexts that are either in remote communities or, for example, in a Canadian context, the Indigenous populations, the inner-city populations, that new immigrants, the new Canadians and refugees that need access to care and have different barriers, but some of them are very similar. I think being able to maybe dispel some of the romantic notion of going to Africa and saving the day, but then to really look at what is the best course to try to provide the most impactful and sustainable change and with the least amount of harm and the least amount of an intended consequences. COVID has been a great way of demonstrating, "Well, what if you can't travel? Does that mean that now Africa shut down and nobody's doing any surgery?" No, they still do what they've always done. I think that's important to realize that the dialogue has been changed by the fact that we can't travel, but sometimes that might be what we need to be able to elevate the level of discourse to really start to look at it more ethically and more professionally, and looking at it more as a partnership rather than as a patriarchal, "I'm going to help you. You listen to me and then I get to talk about it and showcase it on social media and in academic journal."
MM: You raised a really interesting point about inequitable access to health care here at home. We like to tell ourselves that this country has universal healthcare, which implies everyone gets the same access, everyone gets the same level of care. What are your comments on that?
AS: It's a hard question because I think it brings up that we don't really have universal access in the sense that it was meant. There are people here in our own backyard and always the most disadvantaged that don't have the same access to care. Somebody from the Northwest territories or somebody from the Arctic Circle would take a day or two to get emergent care that people in the city would take an hour to get in and the outcomes are dramatically different. We've looked at some of the surgical conditions that we see here at the University of Alberta Hospital, there's a marked difference between how people present, in terms of, let's say, simple conditions like appendicitis. Many people present with simple, uncomplicated, non-perforated appendicitis, but people from Indigenous communities present often late, very sick or delayed in care. They might not get the same care initially or might not be taken seriously, unfortunately, until things are quite serious and they're on death's door before somebody takes it seriously and they often present, like I've seen in our emergency department, perforated, very sick, often requiring a significantly more length of stay here at the hospital. And it's significantly more expensive for everybody. For their community, now they have to be away, for the health-care system here. That's just one condition. There are the consequences of intergenerational trauma that we see in our Indigenous populations that are almost impossible to quantify. Why is it that 20 per cent of children present with hearing loss from recurrent ear infections in the Indigenous communities? One in five have hearing loss, how does that affect their ability to learn in school? What does that mean for their development, their ability to be productive in life? How much of that is actually detected? I agree with you and I think the spirit of the question that you had was that we don't actually have universal healthcare for everyone here in Canada. There are major barriers that we need to address and that doesn't mean that we have to stop doing anything overseas, but I think it has to be looked at that in the same way that it's fostered and supported that people go and medical students get trained to go overseas and get the support and there is a lot of pats on the backs for doing this kind of work. But at the same time, when you see some of our people coming from Indigenous communities to health-care system, they might not get the same level of empathy. And I think that there is a big problem there that we have to address.
MM: Now, going back to overseas work, the last time we spoke about this, you referred to medical missions, you talked about how a team will come into a hospital and take over for a week or two and perform nothing but clubfoot surgery or a cleft palate surgery or something like that. How is that problematic for the local community?
AS: It's a very important point to understand that often as surgeons and teams of surgeons that go to a hospital often in a more remote area, they are trying to get through as big of a volume of patients that are presenting with an issue that often is not addressed locally. The medical director of the hospital would want these professionals coming in, because, one, it provides care to their community. Two, it might look good for that medical director professionally, politically to be able to bring that kind of support and that might help them even address some of their own, let's say, family, if they have a child with that problem. That happens over and over again, we see that. It's not by invitation or people are coming and completely just imposing themselves in a system that it is both sides that are involved in that decision making. But when these big teams come and the focus becomes, let's say, one issue, let's say it becomes plastic surgery and repair of cleft palate in a big camp, the hospital can't stop doing everything else, because there are still patients that are coming with other problems that need surgical care. But it creates undue pressure because now you're trying to cram a year or two years' worth of cases into two weeks and the system, even with the best intentions or sometimes trying to schedule it, you disproportionately are allocating resources to that one problem for those two-week periods. And we know whether it's anecdotal evidence or real, that there are bad outcomes that happen. Patients who get delayed care because the rooms are occupied because the staff are focused on the visiting surgeons getting to do their cases. I think it's important to really look... And these are things that often we don't think about trying to do this work, but how do we do it better? How do we ask, "Well, what will be the impact on the rest of the operating room with five rooms operating for otolaryngology this one day when normally there is one room a day, what will that look like for the rest of the services?" Or for trauma surgery, can they still access the... Or how do we go about ensuring that this works? And this conversation, just having this involving the systems that we perform here when we are dealing with big surges and care can be way more beneficial than the hundred surgeries that we perform in these two weeks. That immediately strengthens the local capacity or gives them system-level interventions to bolster them. But I think most importantly is that it creates a partnership and creates a way to have a discourse that's not just about performing the surgeries and getting through X numbers. No. It's about, "How are we going to do this? How are we going to empower you?" And then most importantly, "How do we use this, let's say, short experience to train people so that we're not needed to come back anymore?" The main goal is how do we work ourselves out of the job? That should be the philosophy and that can't be done without a thorough needs assessment, without local stakeholder participation and hearing their voice. All these things need to be taken into account before any of these interventions get taken.
MM: In that vein, last question, what would you say to medical practitioners from high-income countries who want to help?
AS: Well, first I would commend them because I know that the intentions are good and their heart is in the right place to try to improve the access to surgical care or health care. And they're giving up their time, they're giving up often their vacation, they're giving up income to do this, but I would ask to please look at the considerations and the ethical pitfalls that come with doing this kind of work. I ask myself the question of, "Am I the right person at the right time doing the right thing for this particular community?" before I ever go. If any of these, there is any ambiguity or gray area, then maybe I shouldn't be going. Maybe there is a better person to either go, or more importantly, to empower locally and they can do that work. And it's not as fulfilling, it's not as nice change of scenery, it's not as rewarding in the sense of people know the good things that we're doing, but at the same time, it's the more ethical way. I think maybe the part that I'll acknowledge is that this is not easy to navigate and there is a lot of precedent and a lot of things that are embedded in why it ends up being done this way. Because doing it any other way is so hard, it's so much harder and it takes a commitment that takes so much longer than let's say the one or two weeks that somebody is able to commit this particular week, or this particular year, pardon me. That it's not for everybody to be able to do system level work or to take so many considerations. I don't want to be hard-lined about any of these suggestions, because there is no black and white in this. I think it's all shades of gray that we can look at doing the best we can, but to do so, I think means that we have to really look in and introspect to see, "Could we do this better?" And if there are ways that means that it takes us out of the equation, because then we'll enable others to rise to the occasion. Then we have to be willing to take that. We have been working with partners from all over the world for two years now to develop a framework for ethics in global surgery. That's the way to help navigate these and create those ethical challenges to be more clear and have approaches that don't rely solely on the Western biomedical ethics paradigms, but takes into account multiple different types of ethics that are more applicable for what the unique challenges that are faced with them. I would invite people to collaborate and to present their challenges and their experiences so that we can try to strengthen this framework because it's really a living document and collaborative tool that has had the input from people that we are trying to impact. The people that usually don't have a voice have, at least in some... Maybe imperfectly, have had their voices expressed and taken into account.
MM: This has been We Can Answer That. Edited and produced by Nate Luit and hosted and produced by me, Mike MacKinnon. We've been talking with Dr. Abdullah Saleh, the director of the office of global surgery at the University of Alberta, about ethics in global surgery and how being mindful of best practices can actually help the countries who need it most in their health-care systems. You can subscribe to We Can Answer That on Apple, Google, or Spotify, or by visiting ucalgary.ca/podcasts. We Can Answer That is a production of the University of Calgary. Thanks for listening.