Ethics and Short-term Global Health Clinical Experiences Abroad: Past. Present, and Future

February 26, 2021

February 24, 2021

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00:02Good evening, welcome to another.
00:05Session in our program for biomedical ethics.
00:09Before I introduce our guest speaker,
00:12Doctor Matthews Camp,
00:13I want to remind you of that we will
00:17be having another session in two weeks.
00:20Where are other associate
00:21director Doctor Sarah Camp?
00:23Well, by the way,
00:25my name is Jack Hughes.
00:27I'm going to associate director of
00:29the Program for Biomedical Ethics,
00:31Doctor Mercurio.
00:32Your usual host is unable to attend tonight.
00:36In two weeks, Doctor Sarah Hall will
00:39be talking to us about the ethics
00:43ethical considerations in nutrition.
00:45Are we what we eat two weeks after that on,
00:50well, actually a few weeks after
00:53that on March the 24th?
00:56Max Jordan Tiako will be talking
01:00to us about the how racism shapes
01:06undergraduate medical education.
01:09Well,
01:10the ethical case for structural change so.
01:15Be sure to join us if you can.
01:18It is my pleasure to introduce
01:20tonight's speaker, Doctor Matthew Camp.
01:23Doctor camp Doctor Decamp is a
01:27graduate of Purdue University.
01:29He's a graduate of Duke University,
01:31where he obtained his medical degree
01:34and his doctorate in philosophy.
01:36He trained in internal medicine
01:39at the University of Michigan.
01:41He did a postdoctoral fellowship at
01:43Johns Hopkins University in Baltimore.
01:46He was a Greenwall fellow in bioethics
01:49and health policy in general,
01:51internal medicine,
01:52and he is currently associate professor.
01:55In the Center for Bioethics
01:57and Humanities and the Division
02:00of General Internal Medicine.
02:02He's a practicing internist.
02:04He's a health services researcher and
02:07a philosopher, Doctor Camp employees,
02:09both empirical and conceptual
02:11methods to identify and solve cutting
02:14edge problems at the interface of
02:16healthcare policy and bioethics.
02:18His research has emphasized specifically
02:21engaging patients in healthcare,
02:23organizational decision making,
02:24ethical decisions in the use of social media.
02:28Big data and global health.
02:32With a particular focus,
02:34as will be evidenced tonight on
02:38short term global health education.
02:42And the ethics of saying.
02:44Alright,
02:45so he is currently a Co principal
02:48investigator on Greenwall Foundation
02:49grant examining ethical issues
02:51arising in mass Drug Administration
02:54of antibiotics globally.
02:56For the sake of reducing childhood mortality.
02:59In addition,
03:00with funding from an NIH
03:03bioethics supplement,
03:03he has served as ethics and engagement
03:06advisor for the Palliative Care Research
03:09Cooperative Group and conducted
03:11research on engaging patients and families,
03:14and.
03:15End of life.
03:17Imperative care research.
03:18He is also an award winning teacher
03:22and mentor as I think will be
03:25evidenced by his presentation tonight.
03:28All right, back to the camp.
03:30We are delighted to have you
03:32all the way from Denver.
03:36Take it away, please.
03:37Great thank you for that introduction.
03:39I really appreciate the opportunity
03:41to talk to all of you tonight about
03:44short-term global health ethics.
03:46I'm going to. Share my screen.
03:51Get this going and swap it out for us.
03:57So again, I really appreciate
03:58the opportunity over the next.
04:00I guess hour or so and prior to the Q&A.
04:04I hope that explore a little bit.
04:07The past President,
04:08future of ethics and short-term
04:09global health clinical experiences,
04:11and I really hope in this presentation
04:13as a little something for everyone.
04:16You know, I hope there's
04:18something for philosophers who
04:19are interested in conceptual work,
04:21empirical bioethics researchers,
04:22medical educators,
04:23social scientists, and so on.
04:24Hope to touch on a lot of that,
04:27and I hope that we'll have a
04:29good amount of time for questions
04:32and answers afterwards.
04:34Just some housekeeping issues,
04:35no relevant active conflicts of interest.
04:37I did receive an honorarium for
04:39work on a paper that appears in this
04:42presentation from the ACP on this
04:44topic and my global health research
04:47has been funded by a couple of
04:49groups that death also mentioned,
04:51I think in the intro.
04:54So what I want to do today?
04:56Well,
04:57I'm hoping to give you a little
04:58bit of a brief background on what
05:00short-term global health is or
05:02how it's typically thought of.
05:04I'll describe how we got to where we are.
05:07That is the past.
05:09I'll spend some time talking
05:10about where we are,
05:12especially in terms of ethics,
05:14education and our thinking around
05:15short-term global ethics.
05:17And then Lastly,
05:18hint at where we are and where
05:21we should be going.
05:22I just as a note,
05:24I'll frequently use the word
05:26trainees in this presentation,
05:27but this isn't really meant to
05:29be only about undergraduate or
05:30graduate medical trainees per say.
05:32Think it's important to remember
05:34that in global health.
05:36Even seasoned practitioners can be
05:38trainees in some sense that they are
05:42new to the global health setting.
05:44So let's jump right in and
05:46talk about this concept.
05:48Them short-term global health.
05:50I think that classicly,
05:52we think of these activities as weeks
05:54to months long trips from a high
05:57income country to a lower middle
05:59income country to provide care.
06:01It certainly I was first exposed
06:04to short-term global health when
06:06I went to Honduras back in 2001.
06:08But I think if we look closely at
06:11these terms and these concepts,
06:13reality is more complicated.
06:14So let's look at short-term.
06:16Well,
06:17there's no real standard definition
06:18of what counts is short term,
06:21and in fact really interesting.
06:22Lee, in some of the surveys we've done,
06:25if you ask people what counts as short term,
06:28the answer is basically whatever
06:30is shorter than what I've done.
06:32So if you've been abroad for a month,
06:35a couple weeks, a short term,
06:37six months amonth is short term.
06:40A year, well,
06:41six months is still a short term
06:44global health experience.
06:46Let's look at the next concept
06:48of global Global.
06:49As you can imagine,
06:50is also kind of hard to define
06:53because we might think about issues
06:55abroad versus underserved areas.
06:57Locally that will come up in
06:59the presentation today and this
07:01mantra of local is global.
07:03How how global is global.
07:04When we talk about short-term global
07:07health activities and Lastly, of course,
07:09health health is a complicated concept.
07:11When we talk about engaging
07:13in healthy activities,
07:14is it health care delivery only?
07:16Is it public health versus
07:19education and so on.
07:20So a lot of complexity.
07:22I think around the definitions of
07:25short term global health experiences.
07:28Now, short term global health experiences
07:30are sometimes in the news and not
07:32always for the best of reasons.
07:34To give you a couple of news
07:36stories over the past several years.
07:38Here's a story about an American
07:40with no medical training.
07:41Ran a Center for malnourished kids in Uganda,
07:44and is accused in the story of
07:46contributing to the deaths of around 105.
07:49An article in the Scientific American
07:52about the trouble with medical voluntourism
07:54one thing that sometimes one term that
07:57is sometimes used to describe this activity.
08:00Or Lastly,
08:01this somewhat cheeky article called
08:03#instagramming Africa,
08:04the narcissism of Global Voluntourism,
08:06and if you look closely at the lower right,
08:10lower right,
08:11you'll see that the Onion mocks
08:14voluntourism joking that a six day
08:16visit to a rural African village
08:18can quote completely change a
08:21woman's Facebook profile picture.
08:23So a lot of controversies sometimes
08:25bubbling in to the popular press
08:28around short-term global health.
08:30Activities.
08:32If we look more academically,
08:34we can see that there's been somewhat
08:36of a meteoric rise of interest
08:38in this type of global health.
08:40This is just a graph showing
08:42citations by year using the medical
08:44subject heading medical missions.
08:45We might say this is an archaic
08:48subject heading,
08:48but it is what it is and you can see.
08:52Great interest,
08:53increasing interest in short term
08:55global health over the years with
08:58probably an interesting story to
09:00be told about why there are these
09:02blips around 1970 in the 1990s,
09:04perhaps around HIV AIDS and then
09:07exploding into the 1st and 2nd
09:09decade of the 21st century.
09:11So a lot of interest in this topic
09:15interested appears to be growing.
09:18And as many of us know,
09:20we know that many medical students
09:22continue to participate in
09:23global health electives,
09:25even if we've seen a decline recently.
09:27These are data from the medical
09:30school Graduation Questionnaire
09:31where there is a question about
09:33activities participated in one of
09:35which is a global health experience,
09:37and you can see more than 30%
09:39in 2015 reported participating
09:41in a global health elective.
09:43Now that had been actually arise,
09:45an increase over the past five or ten years.
09:48In advance of 2015,
09:50and then we've actually seen a
09:53little bit of a decline since
09:552015 down to around one in four.
09:58Now of course, one in four is still.
10:00One in four.
10:01And that's a significant number
10:03across the country,
10:04emphasizing why we need to think
10:06about ethics in these activities.
10:08Why we're seeing this trend reversal,
10:10I think it's hard to know.
10:12We'll probably see, again,
10:14a little bit of a decrease in
10:16participation because of covid,
10:18and this is just something we'll
10:21have to follow overtime.
10:23What about short-term global global health?
10:25By the broader numbers,
10:27who really lack precise estimates?
10:29I think their challenge because of
10:31disseminated, unregulated nature
10:33of many global health activities,
10:35but still most people believe
10:37short-term global health activities are
10:39completed by hundreds of thousands,
10:41if not millions of volunteers annually.
10:44They likely involve hundreds of millions or
10:47even several billion dollars US each year.
10:50They frequently include research
10:51and or service activities,
10:53both clinical and non clinical
10:56or public health alike.
10:58As I mentioned, they range in
11:00duration from a few weeks to months.
11:02And they really are a global phenomenon.
11:05We're talking a lot about the
11:07US pier tonight, but in fact,
11:0940% of medical students in the United
11:11Kingdom engage in this sort of an experience.
11:15So it really is a global issue
11:18underscoring the importance of making
11:20sure we addressed ethics when it
11:22comes to short-term global health.
11:24That's a super fast overview and summary
11:27of what short-term activities are,
11:29and I want to shift and talk about the past.
11:33How do we get to where we are today
11:35in our thinking in our activities
11:39around short-term global health?
11:41Well, we may see this as a new phenomenon,
11:44but in fact if we trace the history
11:47of short-term global health,
11:48we can quickly get back to medical
11:51missions of the 19th century.
11:53And while I'm not a historian,
11:55you look at this literature.
11:56I think there are three themes that emerged.
11:59One is that these activities
12:01are frequently values driven.
12:03That is,
12:03the work is often motivated by appeals
12:05to ethical values like need for
12:08duty or social justice, and so on.
12:12A second is the concept of
12:14training involvement,
12:15really from the 19th century to HIV
12:18aids the 20th students and trainees have
12:21really always been participating in
12:23these sorts of short-term global health.
12:26Medical mission type activities.
12:28So although we emphasize the numbers today,
12:31this really isn't a new phenomenon.
12:34And Lastly,
12:35a theme of complex and can
12:37sometimes conflicting dynamics.
12:38This is a picture of Albert Schweitzer,
12:41well known for building hospitals in Gabon.
12:43But if you look closely at some
12:46of the writings of people around
12:48this time in this history you
12:50can see elements of service with
12:52undercurrents of racism and colonialism.
12:55And I circled this just to highlight
12:57it because we'll come back to it.
13:00Come back to these concepts later
13:02in the talk.
13:06Now when I summarize the pass,
13:08I actually like to think that
13:11I'd like to emphasize what I see
13:13as evidence of moral progress.
13:15A shift in how we think
13:18about short-term activities,
13:19from altruism to charity, to justice.
13:21Let's look at this in detail.
13:24Altruism. We often think of,
13:26is giving something away at cost to oneself.
13:29And that's really important right
13:31to for something to be altruistic,
13:33it needs to come at cost to oneself.
13:37But when it came to short-term
13:39global health activities abroad,
13:40people started to realize wait a minute.
13:44Individuals benefit from these
13:45activities from an education perspective
13:47and experiential perspective,
13:49and attitudinal perspective.
13:51So maybe what this really is about
13:54is something more akin to charity,
13:56which we think of as giving something away.
14:01But then there's another pause
14:03when we realized wait a minute,
14:05and some of these activities
14:07as will soon learn.
14:08Individuals can often cause harm.
14:10You saw that in some of the news stories
14:12about voluntourism in the situation
14:14of the malnourished kids in Uganda,
14:17and as individuals can cause harm.
14:19Maybe we need to think about
14:21this a little differently,
14:22as something like justice that is
14:24giving to others what they are do.
14:27And I hope to suggest over
14:29the next slide or two.
14:31Is it really?
14:32We really have made a shift from
14:34altruism to charity to justice,
14:36and I'll leave as a question mark
14:39food for the end of the talk,
14:41what the next stage of moral
14:44progress might be.
14:46Now,
14:46if I can convince you of this shift
14:49from charity to altruism to justice,
14:52this actually could be pretty important.
14:55From the standpoint of philosophical ethics,
14:57because we think of obligations
14:59of charity somewhat different
15:01than obligations of justice,
15:02obligations of charity are imperfect,
15:04that is,
15:05they are not stringent for his
15:08obligations of justice are perfect.
15:10That is, we're fully obliged to do them.
15:13We tend to have significant discretion.
15:16Over obligations of charity,
15:18how much to give what to give,
15:21but less discretion over
15:23obligations of justice.
15:25And then Lastly charity.
15:26It could be said sometimes sees
15:29the recipient or the receiver as
15:31an object of charity as opposed
15:33to a subject of justice.
15:35Now here subject is being used
15:37in a slightly different way than
15:40we might think of as a research
15:42subject in research ethics.
15:44This is subject as a stance
15:46of subjects of justice,
15:48which is different than being an object now.
15:51As you can imagine, philosophers disagree.
15:55About this good and my own PhD advisor,
15:58Alan Buchanan.
15:58Some have said that, in fact,
16:01if we institutionalized obligations of
16:02charity, they would be just as stringent,
16:05just as perfect as obligation of justice.
16:08But of course,
16:09that's not exactly the world we live in,
16:12and so this shift,
16:13I think,
16:14may be important in how we think
16:16about the ethics of global
16:19health short-term activities.
16:20And I think one simple way of
16:23viewing this distinction and this
16:25progress over the past 20 years is a
16:27rejection of the something
16:29is better than nothing.
16:31Approach to global health ethics.
16:33I think a really important change,
16:35a change that I've seen when
16:37I teach students and trainees
16:38and offer training sessions
16:40about short-term global health.
16:42I feel like I've really seen this
16:44shift away from the idea that
16:47something is better than nothing.
16:51How about a bit more of history
16:53and more descriptive history
16:55of how we got to where we are?
16:57This is an abridged history.
16:59It's not complete, but I think in the
17:01early 1990s and early 2000s there was
17:04a clear recognition of ethics related
17:06to short-term global health activities.
17:08In especially this concept
17:10of unintended harm.
17:11So if we look at the medical literature,
17:14you'll see articles in JAMA in the New
17:16England Journal articles I contributed to.
17:19Based on my experience in
17:21Honduras and even Health Affairs.
17:23And I think this quote on the lower
17:26left illustrates it quite well.
17:28This is from the New England Journal.
17:30There's profound need in the
17:32community or right now.
17:33The vast amount of donated time,
17:35energy, and money does more to
17:37Stoke the egos of the Americans.
17:40Clear expression of unintentional harms.
17:41Questionable motives when it comes,
17:43their short term global health
17:45activities need were appearing,
17:46I think, importantly,
17:48in the mainstream medical literature.
17:51What issues were flagged?
17:52Well,
17:53there were a lot of them differences
17:55in cultural norms,
17:56especially around gender and how
17:58those should be managed abroad.
18:01What does consent look like
18:02in different cultures?
18:03What are the unintentional harm such as
18:06side effects of medications we might give
18:08when it's a clinical experience abroad?
18:11Is it OK to do things abroad
18:13that you wouldn't do at home?
18:14We'll talk about that a little bit later.
18:16What are the burdens on the host?
18:19For example, the need for translation,
18:21the need for airport transportation.
18:23It could take away from the host,
18:26usual obligations there
18:27in the local community.
18:29What about this savior complex?
18:31The idea of saviors coming from
18:33a high income country to a lower
18:36middle income country to save the
18:38day and come in and swoop in.
18:40As some might see a savior complex to be.
18:45How about sustainability?
18:46Is this just a one time treatment
18:48for a longer term problem?
18:50What happens after the team leaves?
18:53What about the fungibility of resources?
18:55Is it better that I went to Honduras,
18:58or should my plane ticket had been
19:00spent instead on a donation to an NGO
19:02or a local organization that could
19:04provide services in the community already?
19:07What about different standards of care?
19:09And so on.
19:10So lots of issues being flagged
19:12in these anecdotal reports,
19:14case level reports about the ethics
19:16of short term global health,
19:17and let's look at one of these in detail.
19:21This issue of standards of care.
19:23A year or two ago,
19:25a friend of mine actually sent me a
19:27text message and this is the way it looked.
19:30But I tell you I'm in Ethiopia
19:32when I respond.
19:33No, he says anyway, Med group here.
19:35Wondering if we should use expired
19:37meds one month old we brought them.
19:40I'm sure you ethics guys have
19:41some view on that and I respond.
19:44So you're asking,
19:45is it OK to use expired medications?
19:47You could imagine being abroad
19:49on the clinical outreach trip
19:50and you see a patient.
19:52Maybe they have a bacterial infection.
19:54You only have one antibiotic with you,
19:56but it's expired and the
19:58question here what are the?
20:00Yes, I'm using expired
20:02medications in this setting.
20:04Is it only about whether
20:06it works technically?
20:08Is only about whether the community
20:10is informed and as chosen or said.
20:12It's OK to use?
20:13Or is it about none of these things?
20:17Now this is a really interesting
20:19case because I think it's an
20:21example of this pervasive problem of
20:23defining standards in global health.
20:25The historical legacy of HIV trials,
20:27rotavirus vaccine treatment versus
20:29prevention of HIV in Africa,
20:30and so on.
20:31I think weigh heavily in how
20:33we think about standards,
20:35but there are also more recent
20:37debates about the use of less
20:40expensive or less effective
20:41medications to an article in The
20:44Lancet from just a few years ago.
20:46Put on the spectrum.
20:47No one hand bioethicist appeals to
20:50the greatest good for the greatest
20:53number and perhaps informed choice
20:55justifying the use of less expensive or
20:58less effective medications globally.
21:00On the other hand,
21:02groups like MSF or Doctors Without Borders,
21:05criticizing what they described
21:07as the ethics of resignation,
21:09that is being too quick to accept the
21:12status quo and not demand change.
21:15Asking more fundamental
21:16structural questions about well,
21:17why is it the case that less effective?
21:21Less expensive medications
21:23are being used globally.
21:26Now of course,
21:27for some of us the concern is not is
21:30just as much about how we come to a
21:33decision and what our actions mean,
21:35not just what exactly they are.
21:38But if we go back to my friends initial
21:40question about expired medications,
21:42it turns out that guidance has
21:44existed from the World Health
21:46Organization for many years on
21:48exactly this topic in this guidance.
21:51Generally speaking,
21:51says that expired medications
21:53should not be used.
21:54There are some possible exceptions
21:56here related to the specific health
21:58facilities being aware of the
22:00limited shelf shelf life and so on,
22:03but this is an example where in some
22:05ways there can be a disconnect between
22:08the way we think about things ethically,
22:11the way things are in practice,
22:13and the fact that there actually
22:15has been guidance on this
22:17particular topic for many years.
22:19In some cases appealing
22:20to notions of justice.
22:22Right,
22:22but it's just wrong to have a
22:24double standard and to treat people
22:26differently in this particular context.
22:30So let's go back to that story.
22:33That story of how we got
22:35to being where we are.
22:37We moved from the 2000s into the 2010
22:39where we create now ethics guidance.
22:42So go back to those cases.
22:44Many of the anecdotes
22:46say here are the issues.
22:48We need ethics guidance to help
22:50us think through how to manage
22:52these issues abroad, and in fact,
22:55the academic community responded,
22:56so there was guidance promulgated by
22:59Pinto and Upshur on Global Health.
23:01Ethics for students will talk
23:03about that a little bit later.
23:05Ethics and best practice guidelines for
23:08training experiences in global health,
23:10otherwise commonly known as the weight
23:12guidelines and then a publication
23:14I recently contributed to as well
23:16so the academic community responds.
23:18And create ethics guidance to help
23:21us for how to conduct ourselves in
23:24short-term global health activities.
23:27In fact,
23:27it maybe got to a point where
23:29we had too much of a good thing.
23:32So in this review of 27 Yes 27
23:35published ethics guidelines,
23:36there was actually need to distill
23:38all the guidelines down into
23:40five basic principles,
23:42and this is last year at all,
23:44and you can see them here.
23:47Appropriate recruitment and preparation
23:48host partner that defines the program,
23:50including the need to be addressed.
23:54Sustainability and continuity.
23:55Respect for governance and legal
23:57standards and regular evaluation
23:59of program impact on the host.
24:01So five sort of core meta level
24:05principles that came out of the
24:0827 published ethics guidelines.
24:10Now we can go into these in detail.
24:12Maybe we will on the Q&A period.
24:15But just to point out,
24:16I think if you look closely
24:19at these principles,
24:20you see that they look a lot
24:22more like obligations of justice.
24:24As I described them earlier and
24:26they do obligations of charity,
24:28so again hoping to convince
24:30you that there's been a shift.
24:32Positive shift in how we think about the
24:36ethics of global health in the short term.
24:39Setting.
24:41So that's sometimes men
24:43talking about the past.
24:45And now I want to shift gears and talk
24:48about the present and and describe
24:50a bit more about where I think we
24:53are now in our thinking and our
24:55education about short-term global health.
24:58Well,
24:59Fortunately building on these
25:01ethics guidance documents there is
25:03now widespread recognition of the
25:05need to prepare and prepare for the
25:08ethics in short term experiences.
25:10This is the World Medical Association
25:12which a few years ago landmark
25:14statement encouraging and recommending
25:17appropriate predeparture briefings,
25:18which include training and ethics
25:21and lots of other issues now stated
25:24very clearly as a requirement
25:26for programs in short term.
25:28Well will help.
25:31So the training now exists,
25:33but we might ask, well, does it work?
25:36So one systematic review.
25:37A few years ago identified 17 ethics
25:40training resources and it found that
25:43most of these eight use case based learning.
25:46Some of the others included
25:47were just guidelines.
25:49There is really no evaluation
25:51above Level 3 evidence which
25:53they described as non randomized
25:55case series or cross sectional
25:57studies. And they noted there was an
26:00ethics emphasis on the following themes,
26:03beneficence and nonmaleficence,
26:04with the example being exceeding
26:06one's level of training.
26:08A theme of respect,
26:10avoiding posting photographs online.
26:12Adapting to local culture,
26:14example being inappropriate dress or
26:17different cultural norms around dress.
26:19Issues of justice such as Manageing
26:21donated resources that I mentioned
26:23related to drug donation guidelines.
26:25So there's a systematic
26:27review of some of these.
26:29These ethics training
26:30resources that are out there.
26:33Now, our own systematic qualitative
26:35synthesis identified 14 primary
26:37research studies that examined what
26:39trainees actually experience abroad.
26:40So here the question is slightly different.
26:43The question is,
26:45how much do we really know and from whom?
26:49In our study.
26:50In total there were less than 200 medical
26:54trainees represented in the literature.
26:57Think back to how many hundreds,
27:00thousands,
27:0010s of thousands people.
27:02Participate in these sorts of activities
27:04and the whole literature appears to
27:06be less than 200 medical trainees,
27:08and there's an asterisk on that
27:10bullet because I think this is
27:12changing and it's changing rapidly
27:14as we start to learn more about the
27:16types of ethics challenges that
27:18trainees experience abroad that,
27:19at least at this time of very narrow,
27:22I would say snapshot of who's
27:24represented in the literature.
27:26Now,
27:26while many ethics themes were
27:28well represented,
27:29inconsistent with some of the
27:31training resources, others were not.
27:33Sustainability was a concern that
27:35tends to be hard to direct to
27:38address in an education program.
27:40Issues of moral distress were
27:42trainees know the right thing
27:44to do while they're abroad,
27:46but because of internal or external
27:48constraints or unable to do the
27:51right thing and they experience
27:53distress at that time and afterwards.
27:56Then Lastly,
27:56managing issues of social hierarchy
27:59are real challenge for trainees
28:01and unfamiliar environments is
28:02how to manage social hierarchies
28:04while they are abroad.
28:06So a suggestion here that the
28:08literature is not built on a very
28:11robust evidence based when it
28:12comes to understanding the precise
28:15challenges that trainees may
28:17experience while they are abroad.
28:21Now I want to take a moment and
28:24highlight what I see as three recent
28:27efforts around evaluating the
28:28effectiveness of ethics training,
28:30and I'm going to start with
28:32the Wiscconsin sugar program.
28:34This is part of the simulation used for
28:37global away rotations or sugar program.
28:39These educators develop 8 paper
28:41based simulations that were
28:43used in two half day sessions.
28:45They evaluated it with 51 medical residents
28:47who found the simulations useful.
28:50You can see scores of.
28:52Nearly four and a half out of
28:54five on a 5 point Likert scale,
28:57they believed the simulations
28:59would change their preparation
29:00plans and they were reported
29:03experiencing significant emotions.
29:04I think echoing that concept of
29:07moral distress in this case the
29:10program was framed around 4 core
29:12emotions or four FS of frustration,
29:15floundering, futility, and failure.
29:17So here's an example of a valuating a
29:22ethics education program for resonance.
29:25Second example comes from the University
29:27of California at San Francisco.
29:30Here,
29:30following a modified current methodology,
29:32the educators developed simulation training.
29:34These were 10 minute cases involving actors,
29:37and they had them in a few
29:40different case scenarios.
29:41Scope of practice.
29:43Responding to corruption being
29:45privacy in the setting of HIV
29:49and obtaining informed consent,
29:51this evaluation involved 53
29:54participants in 2013 and 14.
29:57Who believed the simulations were effective,
29:59thought they were used.
30:00Colon made them more aware of ethics issues.
30:03They reported that simulation training was
30:05likely more effective than other approaches,
30:08and they perceived interesting Lee that
30:10the scenarios didn't teach right or wrong,
30:13but instead were helping them think
30:16through a process of decision making rather
30:19than teaching one single right answer.
30:22Our third example comes from Yale.
30:25I don't know if Tracy is
30:27on the seminar today,
30:28but want to highlight Yale activities
30:31in this regard because it is one
30:33of the three I think major examples
30:36in the literature.
30:37So in this situation,
30:38a pre post evaluation was done of a 90
30:42minute pace based ethics workshop involved.
30:4482 medical students who undertook
30:46electives at 16 different
30:48international sites from 2012 to 2015.
30:50What did they find?
30:52Well improve self reported outcomes
30:54such as a sense of preparedness and
30:56ability to find ethics domains to find
30:59someone they could contact and so on.
31:01Nearly 2/3 of those who took the
31:03Post Trip survey reported having
31:05actually experienced an ethics
31:07dilemma while they were abroad.
31:09Now, of course,
31:10some of us look at these
31:13data and suggest is 2/3.
31:15The right number of people that
31:17should report having experienced
31:18a dilemma should be higher.
31:20Should it be lower or what do we
31:22really expect that answer to be?
31:24But nevertheless, 2/3 reported,
31:26having experienced in it dilemma.
31:28And finally, after this ethics training,
31:30students felt they were primed
31:33to recognize ethics dilemmas.
31:34So three important examples
31:37there in the literature.
31:39No,
31:39I'm going to share with you
31:41something that we haven't published
31:42about our own evaluation of
31:44ethics and globalhealth.org,
31:45which is a case based series
31:47that I helped develop.
31:49And this is because it's a cautionary tale.
31:52Here are some domains we evaluated in a
31:55pre post format related to this curriculum.
31:59Confidence strategies and knowledge and let's
32:01look closely at these answers pre to post.
32:04You can see participants really
32:06felt an increase in confidence.
32:08I know how to deal with ethical issues
32:11if they arise nearly doubles right?
32:14Pre to post.
32:15Almost everyone feels like they have
32:18confidence in dealing with ethical issues if
32:21they arise during a global health experience.
32:25Look closely below.
32:26Look at the percentage correct on a five
32:30question ethics test that we created.
32:33Ethics tests are forced hard to create and we
32:36can debate what counts as ethics knowledge.
32:39But in any case, in our own evaluation,
32:42no change in knowledge.
32:44So what did our curriculum appear to
32:47do radically increased confidence.
32:49Didn't change knowledge and that caused us
32:52to really stop and think what's the goal?
32:56What exactly are we trying to do?
32:59We expect confidence to decrease
33:01after a simple 10 case curriculum.
33:03And knowledge to increase or
33:05remain unchanged.
33:06What really should be the goal
33:08of our ethics training?
33:09What domains matter?
33:10How do we measure them and
33:12what should we see?
33:14So really cause us to pause and are
33:17thinking about our own case series.
33:20So what are the gaps that I think come
33:23about based on where we are now and
33:26where we are now in ethics training?
33:28Well,
33:28I still think it's true that
33:30limited numbers of trainees have
33:32informed the existing literature,
33:33particularly in light of the many
33:36thousands to go abroad each year.
33:38I think that you probably notice
33:40most of the evaluations involve
33:42self reported or perceived outcomes
33:45rather than hard outcomes.
33:47Do people perceive that they will be
33:49able to manage ethics strategies better?
33:52Do they like the curriculum?
33:54And so on.
33:55These are the types of outcomes
33:57we've seen in the literature.
33:59And as I mentioned there,
34:01at the end there may actually
34:03be some ambivalence about what
34:05we should be seeing as outcomes.
34:07Do we want more or less confidence
34:10as a result of the curricula that we
34:13develop related to short-term global health?
34:16So I would say that at best,
34:17if we took a step back.
34:19And thought about the levels of evidence
34:22of where we are in ethics education,
34:25training.
34:25I think we're pretty low level,
34:27probably around the level of a
34:30case series regarding ethical
34:32challenges in their management.
34:34So although to this point in the
34:36story I do want you to remember,
34:39I think significant progress has been made.
34:42I think there are some significant
34:44questions remaining that we
34:46would would help to address.
34:48And that's where I want to go in
34:51this third and last section is
34:53the future we started in the past.
34:56We said where we are now.
34:58The question is where are we
35:00going in this section?
35:01I want to describe maybe three
35:03challenges for the future of
35:05short-term global health ethics.
35:08Challenge number one.
35:10What counts is success.
35:13At the moment, I think there's actually
35:16little consensus on what would count
35:18as success for ethics evaluation.
35:20Is it ethics knowledge?
35:22How we describe knowledge?
35:24What about attitudes?
35:25What about behaviors do we expect
35:28to see different observed behaviors
35:31among trainees at home or abroad?
35:34Are we trying to teach substantive right
35:37or wrong or moral decision process like
35:40a process of decision making that we
35:43see in The Who Drug Donation program?
35:45Or maybe it's something bigger.
35:47Maybe what we want are actual outcomes
35:50of programs that we'd like to think that
35:53ethics training means that a short term,
35:56global health or a global health
35:59program in general turns out to be
36:02more successful or more effective
36:04at improving global HealthEquity.
36:06Unfortunately, at present,
36:07there's actually little evidence
36:09beyond case reports.
36:11An important individual case examples
36:13that short-term global health actually
36:15results in improved global health.
36:17This is a systematic review
36:20from several years ago,
36:21or in fact,
36:22this was the finding that there
36:24was little evidence that short-term
36:27medical service trips contributed to
36:30longer term global health outcomes.
36:32Again to note.
36:33There are exceptions and we can
36:36all think of programs that have
36:38been highly successful,
36:40but this is of course a systematic review.
36:43It's occurring more at that aggregate level.
36:48Now about 10 years ago there was active
36:50debate in medical ethics and professionalism.
36:53Many of you probably recall
36:55this generally about whether we
36:57should be focusing on behaviors.
36:59Or character or education,
37:00or apprenticeship, is the focus of medical
37:03ethics to promote certain behaviors.
37:04Or is it character? And so on.
37:06This slide I have some articles on
37:08one side of the line that are more
37:11behavioral and on the right side of
37:13the line or some articles pushing back
37:15and saying no medical ethics really is
37:18about character and I think this debate
37:21turns out to be relevant for the way
37:23we think of ethics and global health.
37:26So in some ways,
37:27the classical bioethics approach,
37:29I would say,
37:30can be a little bit behavioral,
37:32and we see this in the weight guidelines.
37:36We see this in the position
37:38paper that I helped Co author,
37:40where we implement or operationalize
37:42these bioethics principles of respect of
37:45beneficent and a justice of both types,
37:47distributive and procedural.
37:48We tend to think of these
37:50as behavioral outcomes,
37:52as what is being done maybe
37:54a little bit about how it's.
37:57Being done,
37:57but certainly around what are risks
38:00and benefits way our benefits
38:02maximized and risk minimize.
38:04Are we obtaining informed consent?
38:06How informed,
38:07understanding and so on sort
38:09of a behavioral approach?
38:11I would suggest to the way
38:14we think through ethics.
38:16This is different than what I
38:18would describe as this alternative,
38:20more character based approach,
38:22and in fact we see this in that publication.
38:25Global health ethics for students by
38:27Pinto and Upshur in within the early
38:29stages of guidelines for short term
38:32global health training and some of
38:34us have started to question this as
38:36well in recent writings of our own.
38:39You can see that the principles
38:41here or I should say the concepts
38:44here are different introspection.
38:46Humility in solidarity and so the
38:48questions that are asked are also different.
38:51Here the question is why am I engaging
38:54in this global health research or
38:57service program versus what am I going to do?
39:00A why question versus a what
39:03question or issue of humility?
39:05What are my own personal and
39:07professional limitations?
39:08And am I exceeding them?
39:11In this particular context.
39:13Or issues of solidarity?
39:15How do my actions demonstrate unity
39:17independent of their tangible impact?
39:19Now I said that some of us have
39:21started to explore what would
39:23it look like to integrate a more
39:26character based approach to the
39:28way we tend to think about ethics,
39:31particularly those of us trained in a
39:33principle based approach to bioethics.
39:36In fact,
39:36we've wondered if these two
39:38approaches may be stronger together.
39:40Do we may?
39:41We may need concepts of introspection,
39:44humility and so on in order to
39:46understand how to apply these basic
39:49bioethics principles in unfamiliar places.
39:51So in other words,
39:53the below concepts may be foundational
39:56to how we interpret the above
39:58principles and let me illustrate.
40:00This with an example.
40:02I mentioned that performing outside the
40:05scope of training is one of the big
40:07issues that trainees of all types
40:10report having experienced abroad,
40:12and I think this example of being
40:14asked to do things outside one scope
40:17illustrates nicely how important humility,
40:19introspection and so on
40:21are to ethical analysis,
40:23particularly when if you look
40:24at those ethics guidelines,
40:26they will say something like this.
40:28It's usually not best to exceed your scope.
40:33You might wonder exactly how
40:35helpful is that as guidance,
40:36but when a principle says what
40:38are the risks and benefits of
40:41me performing outside my scope?
40:43Was the individual aware or informed
40:45of my skills when I did that?
40:48Or am I applying my decision the
40:50same in all circumstances when
40:51the principals say that this
40:53character break based approach says
40:55something different and emphasizes?
40:57Am I being humble in assessing my own skills?
41:01Or the power imbalance is minimized as
41:03a matter of solidarity thinking of us,
41:06not them.
41:07Nor am I the right person to be making
41:10this decision in the 1st place.
41:12My introspectively thinking about
41:14why is it I'm in the situation I am,
41:16and why do I think I should be making
41:19a decision about whether to exceed
41:21my scope of practice abroad or not?
41:23So again, I think these,
41:25but these other concepts.
41:27Introspection,
41:27humility and so on may be fundamental
41:30to the way we should interpret some of
41:34those classic bioethics principles.
41:36They shall not highlight this problem.
41:39This challenge of performing outside
41:41the scope of training abroad I was
41:44part of a group that did a study of
41:46more than 200 global health individuals.
41:49Remember that asterisk?
41:50I said about minimal numbers of
41:52trainees represented in the literature.
41:54Here's a case where one study
41:56nearly doubled that,
41:58but it's in this study more than
42:00200 global health individuals who
42:02were diverse in terms of training.
42:04They were students, residents,
42:06postdocs, and so on.
42:08They recruited by Snowball nearly half.
42:11Reported being asked to do something
42:13outside their scope of practice
42:16and 2/3 actually did it.
42:18What reasons were offered as to why?
42:21Whether it could be a mismatch
42:23with host expectations,
42:24suboptimal supervision,
42:25inadequate preparation was noted.
42:27An absence of alternative options,
42:29and sometimes the perception that
42:31a situation was truly an emergency
42:34and there was no alternative but
42:37to exceed the scope of practice.
42:40Now really interesting Lee trainees
42:42in this sample were twice as likely
42:45to report performing outside their
42:48scope compared to licensed practitioners.
42:51I think we have to interpret this cautiously,
42:54right?
42:54It could be that the issue is
42:57licensed practitioners perceive
42:59their scope to be bigger.
43:01And so less things are going
43:02to fall outside it,
43:03but it did seem like trainees
43:05could be at least more susceptible
43:07to this sort of activity.
43:09This is a phenomenon that was observed
43:11in the study for both clinical and
43:15nonclinical individuals indecisions alike.
43:17So for example,
43:18a public health person or an
43:20education person could perceive
43:23themselves to be making decisions.
43:25They were outside their scope.
43:27Maybe it's not a clinical situation,
43:28but it's a decision that was
43:30beyond the scope of practice.
43:32And then, like I hinted at before,
43:35some of the qualitative findings from
43:38our open ended questions suggested
43:40the potential for lasting distress.
43:42Lasting moral distress after
43:44individuals have performed
43:46outside their scope of practice.
43:52So I talked a little bit about the
43:55challenge of defining success.
43:57Would outcomes matter?
43:58How might we measure them?
43:59How are we thinking about the ethics?
44:02I want to talk about challenge #2,
44:05which is who decides and this is I
44:07think it related ethics question.
44:09Who decides between these
44:11competing conceptions of ethics
44:12or of what matters most when it
44:15comes to outcomes and evaluation?
44:17Here the literature,
44:18but perhaps not all programs.
44:21That's true too infrequently
44:22asked what local priorities are,
44:24but if we look closely at some
44:26of the examples that are in the
44:29literature major just a few,
44:30I think there are some
44:33interesting findings to consider.
44:34So again, here the evidence is sparse,
44:37but I think there's a signal
44:39in the literature that how.
44:41Is just as important as what?
44:43So in a study we did in
44:45the Dominican Republic,
44:47we would ask local community
44:48members what do you like most
44:50about this particular short term,
44:52global health activity and what
44:54was interesting is that the first
44:56responses from individuals was not
44:58always about the tangible benefits.
45:00If you look at these quotes,
45:02I think you can see that the third quote,
45:06because you are friends,
45:07you are treating me all this time.
45:10I'm with you so appealing not.
45:12To the tangible benefits of the program,
45:15not to the medications,
45:17not to the education,
45:19not to the services,
45:20but instead to how those services and
45:23how those activities aren't delivered.
45:26Similarly, in a survey.
45:28Asking host communities what
45:31competency is most important?
45:33For trainees that come from a
45:35high income country to a low and
45:38middle income country to visit you,
45:40what competency matters most?
45:42Look at the ones that come
45:44to the top of the list.
45:46Humility and being respectful
45:47far down the list is the ability
45:49in this case to conduct or
45:51assist in research programs.
45:53So I think if we look here we do
45:56see less emphasis on the tangibles,
45:58but I always say we have to
46:01interpret this cautiously.
46:02We had to be careful because.
46:04Of power imbalances of structural
46:06imbalances that can affect the
46:09way people answer questions
46:11that we shouldn't move too far.
46:13From a focus on real tangible
46:15outcomes and equity focused outcomes,
46:18even if I think these findings are important.
46:24And there's a third challenge.
46:26This is really a methodological
46:27challenge in my mind, and that's the
46:30question of whom should we evaluate?
46:32A recognized need, or the obligation
46:34to evaluate program outcomes,
46:36which is now widely recognized
46:38is really complicated.
46:39In methodological terms by some of
46:41these issues we discussed earlier.
46:43Remember early in the presentation
46:45I said there are these challenges
46:47around what counts as short-term.
46:49What counts as global?
46:50What counts is health.
46:52So there's a lack of consensus
46:54around these key definitions,
46:56and this results in the absence of a
46:58clearly defined population of study.
47:01You need to study.
47:02NGOs, charities, academic centers and so on.
47:05How do we draw boundaries around a
47:09study population in order us for
47:12us to do a rigorous evaluation?
47:14It's also complicated,
47:16oftentimes by lack of funding,
47:18and as I'll describe in a moment,
47:20the pressure to sometimes
47:22localize the global.
47:24So it's not surprising that many
47:26evaluations have tended to be limited
47:29to some of these single offices.
47:31Single site single programs, and so on.
47:33It's not surprising to me that we are
47:36where we are when it comes to evaluation.
47:39Because of these methodological challenges
47:42in finding a population of study.
47:45What do I think about
47:47measuring effectiveness?
47:48These are just some thoughts for discussion,
47:50maybe something we can
47:52talk about more in the Q&A.
47:54I think whatever approach to
47:56measurement of effectiveness we choose,
47:57it should be developmental,
47:59meaning that no one size fits all.
48:02And here it's important to remember
48:05that if we emphasize only successful.
48:08Idealized long-term partnerships.
48:09This will inevitably leave
48:11some places and people out,
48:13and that is itself an issue of justice,
48:17right?
48:17If we demand sustainability from the
48:20outset long-term from the outset,
48:22and so on,
48:23there will be places and people that will
48:27be left out of this particular activity.
48:30I think our approach has to be collaborative,
48:33or more importantly,
48:34decided within by local communities.
48:36I think it needs to be progressive
48:38where we need to emphasize specific
48:40timelines and benchmarks and this is
48:42a bit of a nod to the human rights
48:45contexts and where human rights,
48:47concepts of timelines and benchmarks
48:49really could inform the way we evaluate.
48:51Then Lastly,
48:52evaluation needs to be non exploitative.
48:54We have to avoid benefiting
48:56at others expense.
48:57I want to double click on this concept for
49:01just a moment in a bit of an interlude.
49:06Well sometimes see in the
49:08literature this idea.
49:10The description that have time
49:12abroad can improve knowledge,
49:14skills and attitudes of
49:16trainees as important outcomes,
49:18even leading them to careers
49:21in serving underserved and
49:23marginalized populations at home.
49:25And we might all agree that
49:27similar ethics concepts apply,
49:28but I think this raises far more questions.
49:31Then it does justify short-term
49:33global health questions like these.
49:35Why should we go abroad?
49:38To learn these lessons lessons.
49:40Can or should we learn them
49:42in our own communities?
49:43Or, more provocatively,
49:44is this really a subtle or even
49:47bizarre form of exploitation of
49:50uniquely global communities where
49:53exploitation is this idea of making
49:55use of a situation to gain unfair
49:57advantage for oneself, and I I, really?
50:00You describe it as somewhat bizarre, right?
50:04The idea being that even if underserved
50:07communities are benefiting here,
50:09locali from the types of training
50:12we do globally is that still.
50:15A subtler, bizarre form of exploitation
50:18of a uniquely global community.
50:24So I mentioned before this idea of
50:27rethinking principles or adding even
50:29more character based approaches of
50:31introspection and humility to our more
50:34fundamental bioethics principles, and here.
50:36But here I want to ask another
50:39question that is, is thinking beyond
50:42these principles radical enough?
50:44Remember, I showed this graphic
50:46and I said what's the next step?
50:49In moral progress, if we've gone
50:52from altruism to charity to justice,
50:55what exactly is next?
50:56And here I want to explore the idea
50:59of decolonizing global health,
51:01or decolonization,
51:02as a possible next step with somewhat
51:06radical implications for the way we
51:09think about global health ethics.
51:11So recently there has been a
51:13building movement under this rubric
51:15of decolonizing global health,
51:17and I think we have to ask what would
51:19this mean for short-term global health.
51:22Really exciting, energized movement,
51:24often of students?
51:25If you look at this snapshot from Twitter,
51:28look at the comment underneath
51:30the Twitter handle.
51:31It says we're bored of the Gates
51:34Foundation telling us what to do with it.
51:37Interesting,
51:37cheeky response that only students
51:39probably can get away with.
51:41But it could be an important
51:43concept for us to explore in the
51:46hallmarks of decolonization.
51:47If we go into the decolonization literature,
51:50had to do with things
51:52like self determination,
51:53number one in a political sense.
51:56And then #2 eliminating other structures,
51:58financial structures and so on
52:00that contribute to NEO colonialism.
52:03That is,
52:04colonialism that exists even when an entity,
52:07or when a state is politically independent.
52:11And I think we should ask what would
52:14decolonizing global health mean
52:16for ethics concepts that we see in
52:18some of these ethics guidelines?
52:21Terms like mutual benefit,
52:23sustainability and dare we say,
52:25even those fundamental Western
52:26bioethics principles?
52:27What would it mean to apply
52:30decolonization to some of these concepts?
52:34We should also remember what
52:36decolonization is not.
52:38Decolonizing short-term global
52:39health does have rhetorical appeal,
52:41but we must be clear about what it
52:44means in the rich literature around
52:47decolonization and neocolonialism.
52:49So decolonizing is not, for example,
52:52merely merely political independence.
52:54As I said,
52:55neocolonialism teaches us that
52:57financial and other institutional
53:00structures can matter just as
53:02much as far as control and power.
53:05It's also not about disengagement.
53:06It's not leaving a place where
53:08we created a mess.
53:10We have to still allow for the right kind
53:13of partnerships and engagement to exist.
53:16And of course,
53:17it's not what some described as
53:19fake decolonizing, that is,
53:21restoring ones image without addressing
53:24seriously the structural power imbalances.
53:26Again, that we've often helped create.
53:30So indeed,
53:30if we take this concept seriously,
53:33it might mean rethinking what
53:35our traditional principles mean,
53:36or rethinking them altogether.
53:38Here,
53:38I'm showing you again,
53:40those five consensus principles
53:42from the Lasker Review around
53:44preparation needs and so on.
53:45In the middle is a lens of
53:48decolonizing as a new ethics
53:50lens that we would apply to these
53:53principles and then we have to ask,
53:56does it reshape them?
53:58This preparation mean educating and analyzing
54:01cases with attention to colonialism.
54:04We have to make sure we're eliminating
54:07power and structural imbalances.
54:09Equalized partnerships.
54:09We have to think about sustainability.
54:12Important though,
54:13it is that being separate from
54:15dependence or independence.
54:17What does it mean to promote
54:19local legal standards,
54:20not merely replicate northern ones?
54:23How should evaluation be led
54:25and driven by local media?
54:26So here really I'm asking this as a question.
54:29Again, something we might discuss in the Q&A.
54:32What would it look like?
54:34To take decolonization seriously.
54:35And they use it as a lens to
54:39rethink some of our principles.
54:41Important though they are accepted,
54:43though they are at the present time.
54:47This is just about where I'm going to stop
54:50and again look forward to some discussion.
54:52I'll offer three tentative conclusions.
54:56While much work remains,
54:58I think it's reasonable to suggest.
55:00So we made progress in the policy and
55:02practice of short-term global health
55:04programs over the past 20 years.
55:06Progress that sees this is through
55:09the ethics lens of justice.
55:11I think Secondly,
55:12there's a real need to evaluate
55:14the effectiveness of ethics
55:16training with a critical eye toward
55:18whether we have the ethics right.
55:20And that's again where concepts
55:22of decolonization might come in.
55:24And arguably,
55:25perhaps the eventual goal is to
55:27no longer need short-term global
55:29health activities,
55:30at least not as they are now conceived.
55:35In two additional thoughts.
55:36Medical schools do have a critical
55:39role to play as leaders and they
55:42have to recognize the trickle
55:43down effect of their own policy.
55:46So one thing that just ever colleague
55:48might come to know over the years
55:50is emphasized as a concern about
55:52unintentionally encouraging premed
55:54undergrads to do things that make
55:56their applications stand out globally.
55:59Do we inadvertently reward things
56:02like performing outside the scope of
56:05training only reward applicants who tell us?
56:08Somewhat grandiose stories of things
56:10they've done abroad that arguably they
56:13would never be allowed to do at home.
56:15Another major concern,
56:16but I haven't talked about is the
56:18advent of so called predatory
56:20global health opportunities within
56:22organizations that have variable
56:24financial and charitable efficiencies.
56:26So that concern here being that there
56:29are actually some money makers.
56:31Out there in short term global
56:33health that verge on being predatory
56:35towards students to again give
56:37them these opportunities that may
56:39make their application stand out.
56:41And what's our responsibility in the
56:44medical school environment to correct that?
56:46Let's try to close.
56:48These are just some ethics
56:49education resources.
56:51If anyone wants to learn more about ethics,
56:54education, and short-term global health,
56:55I sure appreciate your time.
56:57And I hope that we have some
57:00time here for discussion,
57:01thanks.
57:13Set of issues around short-term
57:16education and global health.
57:19We certainly want to entertain
57:21questions we have at least 1/2
57:24an hour to to provide questions.
57:27If you will submit your questions to the Q&A,
57:31type them out and we will.
57:35And we will. And I can.
57:39I will read them.
57:40I wanted to take the opportunity to
57:41share their to have the first question
57:43every couple questions already, but.
57:46I'm I'm interested that you you talked
57:50about the possibility that we might
57:53be dealing with forms of exploitation.
57:56And if you phrase that I took it
57:59that you phrased that as a question,
58:02so I want to ask you what can you
58:04unpack that a little further and let
58:07me further ask is it almost isn't
58:10it almost inevitable that there's
58:12going to be some exploitation
58:14in arrangements like this,
58:15where there is all these various
58:18asymmetry's that you've pointed out?
58:21Well, see you know, cheer ladder.
58:24Question about the inevitability of it.
58:27Um? They could seem that way. You know,
58:32there are certainly views out there.
58:35That would suggest, for example,
58:37that if we create an ethics calculus.
58:40Of weighing the good and
58:42the bad of these activities,
58:44that things like magical educational
58:47benefits to our trainees.
58:49Don't count. Or they can't count
58:53because that's exploitation.
58:54They're getting educational
58:56benefit at someone elses expense.
59:00That's one I think extreme view,
59:01and I'm not sure I would actually go
59:04that far to say that they don't count.
59:06But I think we have to be very
59:10careful in how we evaluate.
59:13Those risks and benefits.
59:17To unpack exploitation?
59:18You know the example I gave is this idea
59:24that justifying short-term global health.
59:27On the basis of benefit to underserved
59:31communities locally is could be seen
59:34as a subtle form of exploitation.
59:37Then I don't know what people are.
59:41Not everyone may agree with that.
59:44But it it certainly starts to seem like it.
59:48Um, I think we all hope that,
59:51in an ideal world,
59:52and maybe it's years in the future
59:55that there aren't power imbalances and
59:58things don't come at other peoples.
01:00:00Fences and so on. But it does raise.
01:00:04I think this other question because
01:00:06if we think about exploitation,
01:00:09we think about benefiting at others expense.
01:00:13That requires us to really know
01:00:16what the others expense is.
01:00:18Unfortunately.
01:00:19Those of us who have engaged in
01:00:22these kinds of activities are
01:00:25often in the least best position.
01:00:27To understand what those expenses might be.
01:00:31So when we talk about benefits
01:00:33and burdens really do,
01:00:35short-term activities will often talk,
01:00:37draw analogies from full cost accounting.
01:00:40Right in the nature of we have to really
01:00:43understand what all those potential
01:00:45burdens and expenses might be to even know.
01:00:49Whether or not.
01:00:51There are keruing.
01:00:53And maybe that's the first step.
01:00:56You know, I I,
01:00:57I can say personally,
01:00:58that when I went to Honduras
01:01:00you know now 20 years ago.
01:01:03I probably didn't even see.
01:01:06The burden of the airport transfers.
01:01:10And so on,
01:01:11going back and forth to the site I was
01:01:14in the least best position to see that.
01:01:16And I think until we can understand
01:01:18what those expenses and burns might be,
01:01:20it's hard to even have a
01:01:21conversation about exploitation.
01:01:22I don't know if that answers the question,
01:01:24but those are just some thoughts on it.
01:01:27That's what we wanted.
01:01:30Now let me we we have other questions
01:01:34coming into only from one from one of my
01:01:37colleagues from the Public Health school.
01:01:40Thank you for a wonderful talk.
01:01:43How does the presence or absence
01:01:45of an established long-term
01:01:47partnership between the Hi C&LMIC
01:01:49institutions impact the ethics of
01:01:52short-term global health work?
01:01:54And if you will?
01:01:57Unpaid tell us the meaning
01:01:59of Hi C&LMIC for everyone.
01:02:02Oh sorry,
01:02:02so high income country versus lower middle
01:02:07income country tends to rely on World
01:02:10Bank definitions about Ian and so on.
01:02:14The question about long,
01:02:16long term partnerships.
01:02:18You know it does change.
01:02:20I think the way we we think about the ethics.
01:02:23Most people will say that these
01:02:25longer term partnerships are ideal.
01:02:27We all say, let me let me add this,
01:02:30by the way, when I said that
01:02:31our approach to evaluating the
01:02:33ethics needs to be developmental.
01:02:35I'll also be upfront that this
01:02:36really relies in some respects on
01:02:39my original experience in Honduras.
01:02:43There if you, if I looked only
01:02:45at my experience 20 years ago,
01:02:48that was not a long term partnership.
01:02:51Lot of the activities from
01:02:53the outside probably could be
01:02:55looked at as unsustainable.
01:02:57But that was the start.
01:03:00And overtime because the organizers
01:03:02were committed to longer term
01:03:03sustainable partnerships,
01:03:05it's now grown and developed in
01:03:08such a way that it's entirely run.
01:03:12In Honduras by people in Honduras,
01:03:14in short term groups come in
01:03:16from time to time as part of
01:03:19what we would describe as more
01:03:21mutually beneficial exchange.
01:03:23For a program that really is lead.
01:03:26By people in Honduras.
01:03:28That looks ethically very
01:03:30different than something where
01:03:32a group comes in for two weeks.
01:03:36Does a lot of service activities or
01:03:39clinical care activities and leaves
01:03:41and there's nothing else there.
01:03:43So in a way,
01:03:44I would we want it to be that there
01:03:48is a long term partnership and
01:03:51short-term activities almost become an
01:03:54increasingly small or different part.
01:03:57Of the whole picture.
01:04:00In fact, in that case,
01:04:02go back to the first question.
01:04:04In that case,
01:04:05it may actually be more justifiable that
01:04:08the main benefit there is educational.
01:04:12Because the way that program looks
01:04:14as a whole lot less about quote
01:04:17delivering benefits to the community
01:04:19abroad or benefiting at their expense.
01:04:21So I think it's a great question.
01:04:24Long term sustainable
01:04:25partnerships are often idealized.
01:04:27We shouldn't expect them in all cases.
01:04:29We maybe expect that they
01:04:31grow to that point overtime.
01:04:36Alright, thank you. Another question.
01:04:40How is it possible to quote
01:04:43demonstrate solidarity through
01:04:44global health activities without
01:04:46having a measurable impact?
01:04:47Don't outcomes matter more than
01:04:49both character and actions?
01:04:51Isn't the point of global health
01:04:54activities improving the health of the
01:04:56communities where they are carried out?
01:04:59If these activities do not help,
01:05:01what is the point?
01:05:03Yeah, good. This is a question from someone
01:05:07who who is a hardcore outcomes person.
01:05:10Um? Maybe? I agree.
01:05:14Um, although I probably think
01:05:16that there's still room for both,
01:05:18and if I put on my philosophy hat and came
01:05:21up with a philosophy thought experiment.
01:05:24I would say that we could certainly imagine.
01:05:27A top down program.
01:05:30That's implemented from above.
01:05:33And could be very efficient and
01:05:35heavy handed at achieving an outcome.
01:05:37But it's not been done through a process
01:05:40of decision making that's engaged or
01:05:42involved with the local community
01:05:44where that community is helped define
01:05:47the needs and shapes them overtime and
01:05:49really kind of leaves it on their own.
01:05:53So I still think that some
01:05:56of these process oriented.
01:05:57Outcomes for lack of a better word
01:05:59can really matter, and in fact,
01:06:01if we thought about it,
01:06:03we probably could come up with
01:06:05ways to measure.
01:06:06Sentiments around solidarity.
01:06:09Sentiments around respect.
01:06:12So again, that's that's that's an.
01:06:14I will say that is something we've heard.
01:06:16We've done, you know,
01:06:18research with local communities.
01:06:19They seem also to care about this.
01:06:21Now again,
01:06:22we don't know.
01:06:23I wouldn't go too far in that
01:06:26direction either.
01:06:26But I wouldn't go so far as to say that
01:06:29only these more process or decision
01:06:32process oriented metrics matter.
01:06:34We still want to have the outcomes in mind,
01:06:37but I think.
01:06:39If we listen to people from abroad.
01:06:43And listen to the people that
01:06:45we've talked to.
01:06:46At least they seem to suggest that
01:06:49some of these more character based
01:06:51treatment based process based.
01:06:53Concepts matter just as much to them,
01:06:55and I guess for me I just take
01:06:58that seriously.
01:07:01Before I want to follow up a little bit.
01:07:05By asking I, I think it's admirable
01:07:08that that you and your group have
01:07:12have actually listened to the
01:07:15recipients of some of these programs,
01:07:18and it strikes me that that
01:07:21would should be essential.
01:07:23How regularly does that happen
01:07:25that people actually seek
01:07:27feedback from the communities that
01:07:30they have been engaged with?
01:07:33Yeah, I think it's a great question.
01:07:35It would be hard to make a statement of
01:07:38percentages partly going back to this.
01:07:41Issue that it's such a disk unregulated
01:07:44space of charities and NGOs that it's hard
01:07:47to know exactly what's happening where.
01:07:49I think that there is increasing
01:07:53recognition of the need to do this.
01:07:56So I think it's happening more often.
01:07:59This is a place where I think academic
01:08:02institutions can probably lead.
01:08:03Right, because academic institutions
01:08:05have lead in creating some
01:08:06of these guidance documents,
01:08:08evaluation and understanding the local
01:08:10community are clearly parts of these
01:08:12documents and this is a case where academic
01:08:15programs really can take the lead.
01:08:17So it is happening.
01:08:18I think it's happening more
01:08:20and needs to happen even more.
01:08:25Thank you. Here's another question.
01:08:29I recently had a large grant frozen
01:08:31by Yale because they argue that
01:08:33running a medical training program in
01:08:35East Africa is currently too risky,
01:08:37quote due to covid. At the same time,
01:08:41we're allowing medical training
01:08:42programs in the US to continue.
01:08:44I personally think this is
01:08:46neither fair nor reasonable.
01:08:47Would be interested to hear your thoughts.
01:08:52Right now I don't know the.
01:08:56Yell environment that well but.
01:08:59Yeah, if we abstract from that to
01:09:01the general question, I would say.
01:09:06It's and it is an example of this
01:09:08question of standards, isn't it?
01:09:11You know that the way we think about
01:09:14risk and the way institutions often
01:09:17think about risk as well is not
01:09:20purely based on some objective number.
01:09:23Right that we somehow think that risk is
01:09:26different in one setting versus another,
01:09:28and we're more tolerant of risk in
01:09:30this setting versus another setting,
01:09:32so I don't think I can come out
01:09:35whether it's precisely fair or not,
01:09:37other than to say that I can at
01:09:41least understand that in my view.
01:09:44I don't see risk of a purely
01:09:46objective matter. Yeah.
01:09:49Certainly I see that as a clinician
01:09:52where patients view risk differently.
01:09:54Institutions view risk differently.
01:09:58That said, it's a tough.
01:09:59That is a tough situation.
01:10:02Thank you.
01:10:05Here's another, rather briefer question.
01:10:07Do you have an example of a medical
01:10:11program that comes the closest
01:10:13to being anti colonial? Who?
01:10:21And you can. You can take that
01:10:23question in any direction you like.
01:10:26I I examples you like
01:10:28you know that.
01:10:30I don't know that a perfect example.
01:10:34Comes to mind. But that's partly a
01:10:38reflection of my own limitations in.
01:10:43Not being sure that we really
01:10:46know what anti colonial means.
01:10:49More its implications for ethics.
01:10:53So I think partly my inability or
01:10:56my reluctance to highlight any one
01:10:58program reflects that own uncertainty.
01:11:01In my thinking about what decolonizing.
01:11:05Activities really can or should
01:11:06mean you as part is preparing
01:11:08this and then thinking about
01:11:10decolonizing you know there is a
01:11:12rich literature around decolonization.
01:11:14From the 50s, sixties,
01:11:1670s like and it's a lot to get into
01:11:19and I'm excited to learn more about it.
01:11:22But probably it's that feeling
01:11:24like I only have that tip of the
01:11:26iceberg that prevents me from
01:11:28saying more about that question.
01:11:31Thank you. As it turns out,
01:11:35Tracy Raven is in attendance and she has.
01:11:38She has commented here.
01:11:39Thanks so much for a fantastic talk Matt,
01:11:42I really appreciate the way that
01:11:44you laid out the issues with
01:11:46the evidence based around his
01:11:48predeparture ethics training.
01:11:50I completely agree with your
01:11:51schematic describing the evolution
01:11:53from altruism to charity etc.
01:11:55And I also agree that the decolonization
01:11:58movement is the next step.
01:12:00Harriet my younger mckeary
01:12:02Michelle Berry Ann.
01:12:03I just published a piece in academic
01:12:06medicine last month arguing that
01:12:09the halt in travel due to COVID-19
01:12:11his coincided well with the rise of
01:12:15this new consciousness and gives a
01:12:18great opportunity for educational
01:12:19programs to reevaluate the way that
01:12:22they interact with global partners.
01:12:24Have you seen examples of institutions
01:12:27grappling with these issues
01:12:29over the past year?
01:12:32I, I think it's the truth as well.
01:12:34Thanks for the comments to
01:12:36Tracy and Glad I sorta see you.
01:12:39Glad you saw me like that.
01:12:40I can see you but.
01:12:44I think institutions are grappling with this,
01:12:46and I'll say this this slide in the
01:12:49comments about what decolonizing is not.
01:12:52I think it's also really important.
01:12:55I I always have fears that when
01:13:01concepts become rhetorically appealing.
01:13:05We fail. The scrutinize what they mean,
01:13:09or we pick and choose the
01:13:12parts of it that we like.
01:13:15And so to give a historical example of
01:13:18that in the decolonization literature,
01:13:21there was a very clear concern
01:13:24where when decolonizing meant.
01:13:26Giving political independence.
01:13:28The former colonial states.
01:13:31What actually happened?
01:13:33Was it justified?
01:13:35Colonial powers leaving that state.
01:13:39While continuing to
01:13:40extract natural resources,
01:13:42economic resources,
01:13:43and financial gain now from a former
01:13:47colony over which or for which they
01:13:51had zero responsibility at all.
01:13:54And that was picking and choosing
01:13:56a particular we liked.
01:13:58The part of decolonization that takes
01:14:00us politically out of the state,
01:14:02so long as the financial structures and
01:14:05other parts of the global institutional
01:14:07context allow us to continue to benefit.
01:14:10So I would say that's probably my.
01:14:14Caution about.
01:14:15Decolonizing is for us not to
01:14:18pick and choose just the parts.
01:14:21That we like that if we're really
01:14:23going to take decolonizing seriously,
01:14:26I think it it means scrutinizing
01:14:29every last part.
01:14:31Of our activities and I maybe didn't say
01:14:33it clearly enough in the presentation,
01:14:36but that also includes the ethics principles.
01:14:40That in many ways we have exported
01:14:42Western bioethics principles
01:14:44into places where I'm not quite
01:14:46sure that was the right,
01:14:47or is the right thing to do it maybe?
01:14:52But it may not be.
01:14:53And so I do think institutions are
01:14:55starting to grapple with this.
01:14:56We just have to be careful with
01:14:58the way we apply the concept.
01:15:00It's a great question.
01:15:03Thank you.
01:15:06Now the question so many of
01:15:08your points or comment so many
01:15:10of your points resonate with my
01:15:12experience working on a micro edit.
01:15:14Microcredit project in Kenya.
01:15:15In 2000. I return to the US with
01:15:19many complicated feelings about
01:15:21International Development. Hang on.
01:15:28Such as you describe about
01:15:30the medical missions.
01:15:31You see this research applying
01:15:33in the same way to broader
01:15:35International Development projects
01:15:37there. That's a great question.
01:15:39There are really interesting areas
01:15:41of overlap. Sometimes when I talk
01:15:44to students about short-term global
01:15:46health or to audiences that are less.
01:15:49Maybe less engaged with short term
01:15:51global health then say it clinical.
01:15:54Audience. I will say actually
01:15:56the way we think about short-term
01:15:59global health ethics is a microcosm.
01:16:03Could be seen as a microcosm for
01:16:05global health ethics more broadly.
01:16:07And so these concepts are just examples.
01:16:10This is 1 setting where we have
01:16:12to wrestle with it,
01:16:14but in fact it has intersections and
01:16:17connections to humanitarian ethics.
01:16:19Developmental, a ethics,
01:16:21and oftentimes unfortunately these
01:16:23groups don't talk to each other.
01:16:25It's some extent it could be a criticism,
01:16:29in fact of the short term of that history,
01:16:33I told you of short term global health
01:16:36and development of ethics guidelines.
01:16:38I'm sure there are developmental
01:16:40there aid workers and humanitarian
01:16:43organizations that say.
01:16:45Why did it take short-term global health
01:16:47ethics this long to come to these
01:16:49principles that we've been thinking
01:16:51about in the aid context for decades?
01:16:56As an example, as a concrete example of that,
01:16:58one of the best. Crazy fast,
01:17:01but one of the frameworks that's out there.
01:17:05To help understand exceeding scope of
01:17:08practice and a decision framework for
01:17:10with whether or how it can be justified
01:17:13is actually found from Matthew Hunt,
01:17:16Lisa Schwartz and colleagues
01:17:18in the humanitarian aid world.
01:17:21Where in humanitarian disasters this
01:17:24exact situation often comes up.
01:17:26And so there are ways in which there
01:17:29should be connection between the
01:17:31short term global health context
01:17:33and these other domains,
01:17:35including I would say locally.
01:17:38Right, it is not uncommon for areas in
01:17:41our own communities for us to experience
01:17:44some of these same kinds of issues.
01:17:50Alright, great.
01:17:55Another question. Which should
01:17:58give you some room to two.
01:18:03Two to move. What are your thoughts on the
01:18:06ethics of remote based global health work?
01:18:11So that that's an interesting question too.
01:18:15Yeah, the first thought that comes to mind,
01:18:19of course, is that many remote technologies,
01:18:23AI mobile technologies and so
01:18:26on have have been justified.
01:18:28Buy the potential to leapfrog
01:18:32things like the digital divide.
01:18:35Or leapfrog some of the challenges that
01:18:37we have in delivering global health.
01:18:41Education, health, education and so on.
01:18:44But the question here is a little bit more.
01:18:48I think service directed. Anne.
01:18:52It's probably familiar in my
01:18:54mind is probably a case by case.
01:18:57Sort of. Analysis For that.
01:19:01Certainly some of the same principles
01:19:03about making sure that the remote
01:19:06technology meets a community to find
01:19:09need are still going to apply right?
01:19:12One of the challenges that are
01:19:14one of the ways that challenges
01:19:17in global health can be framed is
01:19:20the idea that we're providing.
01:19:23A type of assistance.
01:19:25Not because it's needed,
01:19:26but because we can provide it.
01:19:30And I think that comes up in the remote
01:19:33global health context too, right?
01:19:35I mean, is it that the community
01:19:38really needs remote phone based
01:19:40diagnosis of diabetic retinopathy?
01:19:41Or is it because we on our
01:19:43gadgets developed a really cool
01:19:45app for diabetic retinopathy
01:19:47and think they should have it?
01:19:49And that's what those are two?
01:19:52Those look very different.
01:19:54Ethically great.
01:19:59And here's a comment from.
01:20:01Tom Duffy your description of how
01:20:03we should behave in these encounters travels
01:20:06in the territory of Virtue and Medicine.
01:20:08Prudence, Justice, Temperance
01:20:10and Fortitude are enchantment
01:20:13with principle based ethics moves
01:20:15such an ethical engagement to the
01:20:18sidelines or even out of the picture.
01:20:21Could you come in?
01:20:23I think that I appreciate the comment and.
01:20:28Yeah, maybe it wasn't.
01:20:30Clear enough, but I I'm hoping to provide.
01:20:34Or at least explore a bit
01:20:36of a corrective to that.
01:20:38With that, that's where I think
01:20:40that some of these. Concepts of.
01:20:44Introspection and humility.
01:20:46And in also in that
01:20:48article is social justice.
01:20:52Do you have a different?
01:20:55A different tenor. And a different
01:20:59impact on the way we think about ethics.
01:21:02Um, and to me it just really is encapsulated
01:21:06in that distinction of the questions between.
01:21:10What is being done? Versus why?
01:21:15Or how? So I I agree with the
01:21:19comment and I'm hoping to think.
01:21:22About how we can.
01:21:24Together promote that kind of a corrective.
01:21:28Certainly plenty of of critics
01:21:31of the principles out there.
01:21:34I know that the authors of the
01:21:36principles think that the principles
01:21:37capture a common morality and we
01:21:38could get into a philosophical
01:21:40discussion about whether or not
01:21:41that you know is or is not the case,
01:21:44but I think I think in the real world
01:21:46there should be space for these other.
01:21:48These other concepts and other principles,
01:21:50so I don't know.
01:21:51I agree with the comment.
01:21:54Thank you.
01:21:57Given global travel restrictions,
01:21:58many global health programs are currently
01:22:01on standby or have been shut down.
01:22:03How and when do you think such programs
01:22:06can resume in a safe and acceptable way?
01:22:08And who will issue guidance on what
01:22:11counts as safe and acceptable?
01:22:14Yeah, this I probably in that as a
01:22:16factor them as a fact of the matter.
01:22:19A lot of these programs.
01:22:21That are institutionally based will
01:22:23be decided based on institutional.
01:22:25Policies and procedures
01:22:26may be informed by you.
01:22:29Know national level CDC type
01:22:31guidance around travel and so on.
01:22:33We certainly talk enough to people
01:22:36in other countries where you know
01:22:39vaccines are just not happening.
01:22:41You know, talk about a big
01:22:44ethics issue right?
01:22:45As much as we want vaccine.
01:22:48For the US, you know we could have a
01:22:50whole conversation about global vaccine
01:22:53distribution and the fairness or unfairness.
01:22:57Of the way the vaccines have been purchased,
01:22:59but certainly talking to some
01:23:00of the global partners we have,
01:23:02there are just no vaccines there.
01:23:04But I suspect that would be a major
01:23:07barrier and a question of fairness
01:23:09when it comes to things like vaccine,
01:23:11passports and so on that
01:23:13institutions won't like.
01:23:15Travelers going to places where
01:23:16there's not been vaccinations,
01:23:18I hesitate to make a prediction,
01:23:20but gosh, it sure seems like.
01:23:23Start imagine some of these programs being
01:23:25back to normal in this calendar year.
01:23:27I don't know whether other folks
01:23:29may think differently, but.
01:23:32Be hard to imagine before the end of 2021.
01:23:36Alright,
01:23:36well let me ask one last question.
01:23:40You have indicated your
01:23:42ambivalence about whether.
01:23:44Western ethics,
01:23:46or our exporting of our ethical
01:23:49principles are Western ethics was
01:23:51a good idea is a good idea I I've
01:23:55learned from Michelle Berry many
01:23:58years ago that it's very different
01:24:00dealing with the community in Africa,
01:24:03for example, where there is that it
01:24:07is understood that the decisions will
01:24:09be made by the Community leaders,
01:24:12The Chieftains and and.
01:24:14Those it's not only in Africa,
01:24:17but in been in a number of of societies.
01:24:21Is that how does one deal with all that?
01:24:29Just to finish up on.
01:24:32Just just a simple question.
01:24:33If yes, yes, yes.
01:24:38There is certainly is room for a correction.
01:24:43And I'll see why I maybe I wouldn't
01:24:46go out like we have to be mindful.
01:24:49I think of the potential to become.
01:24:53Moral relativists right?
01:24:54Most of us don't especially like for me
01:24:58like part of my background and my PhD
01:25:01training in philosophy was in human rights.
01:25:04And so we'd like to think
01:25:06that it's some point.
01:25:07At some level there is a substantive.
01:25:11Moral principle right?
01:25:12And so we don't want to.
01:25:14When we say we decolonize global
01:25:16health ethics, we maybe don't want to
01:25:19go so far as to become relativists.
01:25:23About it on the other hand,
01:25:25back to this notion of a corrective.
01:25:28It certainly seems to me like there is
01:25:31a there is room for correcting that.
01:25:34I'll say I've been sceptical,
01:25:37for example,
01:25:37as a concrete example by the ways in
01:25:40which we have tended to export the
01:25:43Institutional Review Board process,
01:25:45and of course its reliance on Belmont
01:25:48principles for analyzing ethics.
01:25:52Even if we don't go so
01:25:53far as to be relativist,
01:25:55there would be much to gain.
01:25:57From learning about and understanding and
01:26:00thinking through ethics problems differently.
01:26:03Through lenses that are different than.
01:26:06The principles of bioethics
01:26:07or biomedical ethics.
01:26:08As we've learned them,
01:26:10so I guess if I if I had to put
01:26:13my money down, so to speak,
01:26:14I see it as that kind of a corrective as
01:26:17a new way of learning and understanding,
01:26:19only because in the back of my
01:26:21head is this human rights world,
01:26:23and there may be some substantive
01:26:25principles that are so important that
01:26:28we would actually hold on to them.
01:26:31And if I had a whole another hour and a half,
01:26:33I would actually answer your question.
01:26:37Well, we will try to make sure that
01:26:39you get another hour and a half
01:26:42sometime in the not too distant future.
01:26:45Thank you for a superb
01:26:47presentation and and talk.
01:26:49So this is just been most
01:26:51informative an most enjoyable.
01:26:53Thank you again and take care
01:26:55and we do want you to come back.
01:26:59Thank you thank you alright bye bye.