Global Health Ethics

December 02, 2021

December 1, 2021

Tracy Rabin, MD, SM
Rosana Gonzalez-Colaso, PharmD, MPH

Information

ID: 7234
To Cite: DCA Citation Guide

Download Transcript

00:00Let's begin good evening.
00:02Thank you so much for coming.
00:04My name is Mark Metro.
00:05I'm the director of the program
00:07for Biomedical Ethics here at
00:08the Yale School of Medicine,
00:09and we have a wonderful seminar
00:11for you this evening and on
00:14global health ethics by doctors,
00:16Trace Ravine and Rosana Consultants colossal.
00:19But before we get into that,
00:21I want to just kind of give you the
00:23account later probably is going to
00:25go for about 45 minutes or two.
00:27Speakers are going to give a
00:29presentation answer which will be
00:30open to to question and answer.
00:32If you have questions for them,
00:33please put him in the Q and a
00:36portion of the zoom feature and
00:38and I will address the questions
00:39for the 2nd 45 minutes or so.
00:41I moderated a session with our two speakers,
00:44so please put your your questions in Q&A.
00:46I will say that in the in the chat
00:49portion what you'll see pretty soon
00:52entered into the chat is Karen Colbert,
00:54director are excuse me are on medical.
00:57Our manager, program manager chair,
01:00is going to enter the information
01:01that you can text.
01:02In order to get CME credit.
01:05And we've got folks from all over
01:06here from Yale from outside Yale.
01:08Even for our friend Roger Worthington
01:10all over the UK is on the call tonight,
01:12so we were delighted to have an
01:15international audience tonight
01:16for this program.
01:17And I am delighted to present
01:21our two speakers.
01:22Reduce them both at the outset and I
01:24think Tracy is going to speak first.
01:27Sonic and Sally's colosso form D MPH joined
01:30the Yale physician associate program.
01:33They RPA program in 2005 as
01:35faculty in this section of general
01:37internal medicine here at Yale,
01:39she currently serves as a director
01:41of PA Research Education and as
01:43the faculty Director of Workforce
01:45Development and Diversity at the
01:47Equity Research and Innovation Center.
01:49Since 2020, she serves as the associate
01:51director of the POZEN Commonwealth Fund
01:53Fellowship and HealthEquity leadership
01:55at the Yale School of Management.
01:58Her academic interests include health
02:00professional workforce development
02:01to address the needs of marginalized
02:04populations with that vision in mind,
02:05Doctor Gonzalez Kolosso has introduced
02:08international clinical rotations for
02:10PA students by developing partnerships
02:12with several sites in Latin America.
02:14Her interest in global health ethics
02:16curriculum was inspired by the need to
02:19prepare her students for global health
02:20experiences and heavily influenced
02:22by collaborations with Doctor Tracy
02:24Ravine and Doctor Kevin Koch New.
02:26Doctor consults class was a graduate of
02:28the University of Buenos Ares called
02:30the Pharmacy and the Yale School
02:32of Public Health. Welcome, Rosanna.
02:35Tracy Ravine Dr Rubin is an associate
02:39professor of medicine, general,
02:40internal medicine and the director
02:42of Office of Global Health and the
02:44Department of Internal Medicine
02:45at the Yale School of Medicine.
02:47She's also the associate program
02:49director for the local and community
02:51health in the Yale Primary Care
02:53Internal Medicine Residency program.
02:55Since 2011,
02:55she served as the Jelko director
02:57or the Makara Ray University
03:00Yale University collaboration,
03:02a bidirectional medical
03:04educational capacity building.
03:06Collaboration.
03:06Her current areas of interest include
03:09global health workforce education,
03:11the promotion of ethical and equitable,
03:13global health,
03:14academic partnerships,
03:15and ethical challenges related to short term
03:18clinical work and resource limited settings.
03:21Doctor Rubin received her Bachelor
03:22of Arts and Ethics Studies from
03:24the College of William and Mary,
03:25her Master of Science in Immunology
03:28and Infectious Diseases from Harvard,
03:29and as well,
03:30the Public Health Center Dr of Medicine
03:32from the University of Rochester
03:34School of Medicine and Dentistry.
03:36She completed her clinical training in the
03:38Yale Combined Medpeds Residency program,
03:41serving as the Met Police chief,
03:42resident or final year,
03:43and then served as the chief
03:45resident for Global health in the
03:46Department of Internal Medicine.
03:48Prior to joining the faculty,
03:50you know we get.
03:51We were blessed to get wonderful
03:53speakers from all over the country
03:54and beyond all over the world.
03:56Even in these seminars.
03:57But but as you'll see,
03:59we often have the best right here at home,
04:02so I'm very grateful to Doctor Binan Dr
04:04consults colossal for speaking tonight.
04:07So thank you all for coming and
04:08thank you so much to our speakers.
04:10With that I will turn this over
04:13to Doctor Tracy Ravine.
04:15Great,
04:16thank you so much.
04:17Mark for your kind introduction and
04:18I think it was probably I don't know
04:20seven or eight years ago that I first
04:22was talking with you about global health,
04:24clinical ethics and where does
04:26this fit in with respect to some
04:28of the other work that you've been
04:30involved with here at the university.
04:31So it's really exciting for Rosanna
04:33and I to be able to give this
04:34talk to this specific audience.
04:36So thank you for inviting us
04:38to be here tonight.
04:39Let me just share my screen
04:42and we will be off.
04:44Alright. So again,
04:45my name is Tracy Raven and and here with
04:48my colleague Rossana Gonzalez class,
04:50so we're going to be talking about
04:53global health clinical ethics.
04:54So as far as our objectives
04:56for the session today,
04:57they are these three.
04:58We're going to start off by defining and
05:01describing key concepts in global health.
05:03Clinical ethics will describe a bit
05:05about the spectrum of the ethical
05:08issues that clinical students and
05:10trainees have historically faced
05:11when they engage in short term
05:13experiences in global health or Stig.
05:15Is the common abbreviation that
05:17you'll see in the literature.
05:19And then finally,
05:20we'll discuss some potential
05:22dilemmas that trainees may face
05:25during Stig due to the evolving
05:27complexities related to COVID-19.
05:29All right,
05:30so let's start off with our key concepts,
05:31and I think the first for us to
05:33define really is global health.
05:35Just to make sure that we're
05:36all on the same page.
05:37Now,
05:38there is a consensus definition
05:40of global health that was
05:42published in The Lancet in 2009,
05:44which is what most sort of academic
05:46global health centers will
05:47commonly use to center our work.
05:50This was a definition that was
05:52developed by an interdisciplinary
05:54international group of academics
05:57who stated that global health.
05:59Is an area for study, research,
06:00and practice that places a priority on
06:03improving health and achieving equity
06:05in health for all people worldwide.
06:07Global health emphasizes
06:09transnational health issues,
06:10determinants and solutions
06:12involves many disciplines within
06:14and beyond the Health Sciences
06:16and promotes interdisciplinary
06:18collaboration and is a synthesis of
06:20population based prevention with
06:22individual level clinical care,
06:24so the definition goes on to
06:26say that the global in global
06:28health refers to the scope.
06:29Of problems and not their location.
06:31Thus global health can focus
06:33on domestic health disparities
06:35as well as cross border issues.
06:37And this is this is actually very important,
06:38as I, as I say jokingly to our trainees.
06:41Often it turns out that the
06:43United States is on the globe,
06:45and so we have many global health
06:47issues that happen right here at home.
06:48This is not about as a colleague once
06:50accused me of this is not about me
06:52wanting to travel somewhere to do things.
06:54This is these are issues that
06:56actually are fairly universal.
06:58The details.
06:59Maybe slightly different,
07:00but it turns out that that
07:02many of these issues.
07:02Most of these issues are fairly universal,
07:04so that's what we're going to talk about.
07:05That's the global health framework.
07:07We're going to use this evening.
07:10So then the other question is, well,
07:11what is global health clinical ethics means?
07:15And there actually is no
07:16consensus definition for this.
07:18And so as Rosanna and I were trying to
07:20just sort of come up with a a framework
07:22to give to the audience this evening,
07:24this is what we came up with.
07:26Global health clinical ethics
07:27refers to an area of study,
07:29training and advocacy that seeks to
07:32address emerging ethical dilemmas
07:34when health professionals and
07:35learners work in a socio cultural
07:38clinical context that's different.
07:40From their own may have different resources,
07:42but certainly the sociocultural
07:44piece is something that's that's
07:46very important and to give you some
07:48examples of what we're talking about.
07:50So you might think of a medical or
07:53physician associate student rotation
07:55at an international partner site.
07:58You might think of a resident
07:59rotation at a rural domestic site,
08:02or you might think about an
08:04attending physician who participates
08:05in in mission trips,
08:06which is sort of there's a loosely.
08:09It's a big umbrella in terms of what
08:11falls under this idea of mission trips,
08:13and certainly this is health professional,
08:16so this is not something that is
08:19restricted just to physicians.
08:21So this is what we're talking about.
08:24Now,
08:24in terms of applying ethics
08:26frameworks to the types of issues
08:28that people encounter when they
08:30are engaging in work outside of
08:32their typical working environment.
08:34So you know,
08:36I I don't need to explain these
08:38four principles of biomedical
08:39ethics to this audience,
08:40I think everyone is very well versed and
08:43and our trainees all learn that sort of.
08:46These are the four core principles
08:48that should guide us in in navigating
08:51through the challenges that we
08:53encounter in clinical practice.
08:55But there are some criticisms of
08:57how these may not be the most
09:00effective principles to use in
09:02a sort of global health setting,
09:04so the context really matters.
09:07So let me just give you a flavor
09:08of some of these critiques.
09:10So with respect to autonomy,
09:12the question comes up.
09:14You know Ken autonomy mean different
09:16things in different settings,
09:18so if you're working in a place where
09:21the cultural norm is that an individual
09:23may not make health decisions.
09:25For themselves,
09:25there may be another person in the family,
09:28another person in the community,
09:30a group in the community that
09:32helps with those decisions.
09:33What does it mean to then use our
09:36sort of more Western biomedical idea
09:39of what autonomy has come to mean?
09:41How do you implement that?
09:42And then the other question two,
09:44what's the impact of power imbalance
09:46on these discussions?
09:47When we think about somebody making a
09:49decision and sort of having having the
09:52ability to make decisions for themselves,
09:54if I come in.
09:56As a physician from a high income country
10:00with my Yale Insignia on my white coat,
10:03there's a lot of power that I have just by
10:05virtue of being in the room.
10:06So how easy is it for somebody to
10:09truly weigh the merits of risks and
10:11benefits without sort of undue influence
10:14by just the virtue of who I am?
10:16Sort of entering into this conversation?
10:19OK, so that's autonomy.
10:21So then when you think about beneficence
10:23and non maleficence thinking about you
10:25know what are the benefits or harms
10:28to an individual versus the benefits
10:29or harms to a community and this
10:32sort of gets to what is the place?
10:34What is the role of an individual
10:36in a society you know just to give
10:39you an example of something that you
10:41know we will see over and over again
10:43on the clinical wards in Uganda.
10:45You know, I think about a situation
10:46where you may have an adult in
10:48the family who's hospitalized.
10:49With kidney failure and they may
10:52need to start on dialysis or kidney
10:55replacement therapy in order to.
10:58You know either temporarily to heal
10:59or more of as a long term issue.
11:02Well that costs money and it costs
11:04money to do every little piece,
11:07although all the different pieces
11:08of dialysis.
11:09And if it's something that's going
11:11to continue for a long time,
11:12then it's certainly a huge
11:14financial burden for the family.
11:16So if you're thinking about,
11:17you know benefit to the patient.
11:19Well,
11:19maybe this is something they
11:20might need for a short time,
11:22and maybe it's worth the expense to start
11:24doing this treatment so that they can heal,
11:26and then maybe they won't need it anymore.
11:28But maybe coming up with the money
11:30to pay for those costs means that
11:32there are children in the family who
11:35won't go to school for the next six
11:37months because their school fees will
11:38be used to pay for that dialysis,
11:41or worse,
11:41maybe they will have to sell off land.
11:44Maybe they'll have to sell off livestock.
11:46Maybe things will happen that will
11:48infringe upon sort of the economic
11:50sustainability of that family.
11:52In order to do what is good for
11:55that one person.
11:57So just sort of thinking about
11:59where does that person fit into
12:01their context and who is being
12:03harmed and who is being benefited.
12:05Alright,
12:05and then as far as sort of the idea of
12:08justice and so thinking about context.
12:10So when you think about,
12:12you know often we think about
12:14allocation of resources and who has
12:16the right to treatment and things
12:18will just sort of acknowledging that
12:20in different cultural contexts.
12:22There may be different conceptions
12:24of what rights and individual has
12:26and decision making processes about
12:28how resources get allocated may be
12:30very different than the ones that
12:31we are often thinking about here,
12:33so these are some of the challenges
12:36that we run up against when working
12:38in other settings and trying to
12:41apply these principles.
12:42So there is a proposed set of
12:45four principles that colleagues
12:47at the University of Toronto had
12:50written about back in 2009.
12:52Published the wonderful paper in
12:54developing world bioethics and
12:55I wanted to share these four principles
12:58with you because these are the
12:59principles that Rosana and I and others
13:02will teach to the clinical students
13:04and trainees here who are preparing
13:06to go and do global health work.
13:09Global health clinical work.
13:11And ask them to think about using these
13:14four principles as their touchstones when
13:16they're navigating different situations.
13:18So the first is humility and the idea
13:21of recognizing your own limitations so
13:24you find yourself in a new situation.
13:27You may not have all the facts to be able
13:30to be the one who has the correct answer,
13:32or who sort of understands the best
13:34way for a patient to move forward.
13:37And with their clinical care.
13:38So recognizing that your
13:40understanding is limited.
13:42Your role in a setting may be very limited.
13:44You actually may not have, you know,
13:46although you have power by virtue of where
13:49you come from and your education and and
13:51the financial situation that you may have,
13:53you may not be the one who's making
13:55the decision in this situation,
13:56so having humility is key.
14:00The second is introspection and thinking
14:03about you know why are you in this situation?
14:07What's your motive for being in this other
14:09place doing this work in this other place?
14:12And and this isn't to necessarily passed
14:14judgment and say these motives are good,
14:17and these motives are not good,
14:19but it's really more that
14:20people should be self aware.
14:22People should be aware of why they
14:24are going into a situation and their
14:26people may have more than one motives,
14:29and that's that's fine.
14:30But if you find yourself in a sit
14:33in an in a dilemma where you are in
14:36conflict with another provider of local
14:38provider in that place or with the
14:40patient's family thinking about, well.
14:42Why are you there? What are you there to do?
14:45UM can often sort of help us think about.
14:47Well, well, you know how.
14:49How do I want to behave in this situation?
14:51How my gonna navigate?
14:52Who are the people?
14:52I'm going to go to for help?
14:55Solidarity is the third principle
14:57that they propose,
14:59and so the idea that was
15:01similar to introspection,
15:02but the idea that you want to make
15:04sure that your goals for being in
15:06a place have some alignment with
15:08that of the Community,
15:09that you are serving in that place,
15:11or that you're working with in that place.
15:14We talk a lot with,
15:16uh,
15:16we primarily are dealing with learners
15:18who are going to do short term
15:20experiences 4 weeks, six weeks, 12 weeks.
15:24The goal should not be.
15:25I'm going to go to X country or X community.
15:28I'm going to change all of these
15:29things that I don't agree with or
15:31that I think they shouldn't be doing.
15:33That's not an appropriate goal.
15:35Certainly for trainees and anyway,
15:39so enough said about that.
15:39But the the key is thinking about
15:41if you find yourself in conflict
15:44you know are. Are the goals that
15:45you're trying to advocate for?
15:46Are they aligned with that of the
15:48community that you're working with?
15:50And then the last piece is thinking
15:52about social justice and sort of?
15:54What is your role in addressing the
15:57inequities that may exist in that place?
15:59Thinking about, if you find yourself
16:01in a situation of tension or conflict,
16:04trying to get an understanding of what
16:06are the systems levels at level issues at
16:09play and work with your local colleagues,
16:12people who have a much deeper
16:14understanding of the context.
16:15And you do to try to think about.
16:17Well, how do we take this
16:18challenging situation and try to
16:20make something positive out of it?
16:22Sort of trying to address whatever
16:24inequality there may exist.
16:25So when we do our case based
16:28trainings with learners,
16:30these are the four principles
16:31that we have them practice using
16:33as they try to navigate through
16:34these different situations.
16:37Alright, so let me give you a bit
16:39of a flavor of the types of issues
16:42that our learners are dealing with,
16:44because I think some just some.
16:46Some case studies might be helpful
16:48and I'm going to start off actually
16:50with an undergraduate perspective,
16:52so this is not a clinical trainee.
16:54This is from a documentary that that
16:57a couple from Canada put together
17:00called first do no harm and they were
17:04interviewing students who had been who.
17:07At various in various parts of Africa,
17:10who who had gone to do sort of global
17:12health short-term experiences.
17:14And they were interviewing them
17:16about what they were doing.
17:17This clip that I'm going to show
17:19you is short.
17:20This is the story of a young woman
17:22who is a second year college student
17:25in Canada who does not have clinical
17:27training and she has come and been
17:29placed to work in a hospital there.
17:31So let me just play this for you here.
17:35Is
17:36I was in a room.
17:37There were two nurses there.
17:38The Doctor was an agreement
17:40on the ventilator. At the same time, so
17:42two nurses delivered the
17:43other women as women.
17:44There would no doubt were delivered baby.
17:47So I'm unskilled.
17:49But I could support her perineum,
17:51and when the baby comes out I can
17:53cut tie table or even work signed up.
17:55So although I'm not posting person
17:58in Canada, never ever be allowed to do that.
18:00But here when the choice between
18:02like me and no one. There is.
18:05There are different standards because
18:06they have different standards
18:07and watching us right but. Sir.
18:12Great so so this is the type of dilemma,
18:15not this exact one because again,
18:17this is somebody with no clinical
18:19training and so for those folks who may
18:23have done rotations with with OB GYN's.
18:26If you're a physician training for my midwife
18:28colleagues who might be in the audience,
18:31you know you may be hearing this and
18:33you're thinking to yourself, you know,
18:35as a as a student as a medical student.
18:37As a nursing student,
18:38to be left alone in the US to be left
18:41alone with a woman who's delivering.
18:43And be doing the things that
18:45this student is describing.
18:46This is something that would never happen,
18:48right?
18:49There are many different checks
18:50in a system that you would know.
18:52This is not something that would
18:54happen in these days.
18:55Here you have a student who
18:56was put into a situation.
18:58You can see that she's conflicted about it,
19:00but she's rationalizing it because
19:02she's saying there's nobody else here
19:04and so is it better to have nobody,
19:06or is it better to have me?
19:08As part of this, though,
19:09she's not thinking about all of the things
19:11that could have gone wrong in this situation.
19:13All of the things that could have resulted
19:15in devastating consequences to the mother,
19:18to the newborn,
19:19and lasting harm to herself.
19:22Living with the memory of this thing.
19:24So these are these are the types
19:26of things that we sort of asked
19:28our trainees to think about so so
19:31that's sort of an extreme example.
19:33We wanted to try to characterize though the.
19:38Larger scope of the types of
19:40issues that our students here at
19:42Yale were encountering under the
19:45leadership of Bob Rohrbach.
19:46Our medical students have many
19:49opportunities to do global health,
19:52rotations and so together with
19:56three medical students who are
19:57listed here on this paper and
20:00under the umbrella of his office,
20:02we we undertook a series of training.
20:06So every year we do train
20:07predeparture trainings.
20:08For students who are getting ready to go
20:10and do global health clinical rotations
20:12and then we do post return debriefings.
20:14But what we did was survey these
20:16students to try to get a sense of
20:18what types of issues they thought
20:20they were going to encounter.
20:21You know pre our training after our
20:23training and then when they came back
20:25we surveyed them to say you know what
20:27types of issues did you encounter
20:28because we wanted to make sure that we
20:30were preparing students for the types
20:32of things that they would be facing.
20:34So the survey was conducted over
20:36a three year period we surveyed.
20:38There were 82 students who worked at 16
20:41different international sites and as I said,
20:43we surveyed them before and after
20:45our training workshop and then after
20:47they returned from their trips,
20:49about half completed the post trip survey
20:52and when we delved into the results,
20:55we ended up with 60 different
20:57examples of actual dilemmas
20:59that students had encountered.
21:01And then we categorize them into 11 domains,
21:03and so I just want to talk
21:05through these domains with you.
21:07OK, so the first is sort of navigating
21:10situations where you're encountering
21:12different standards of care. You know.
21:15Certainly when you think about levels
21:16of resources that may be available
21:18in one place or not in one place.
21:20This is something that
21:21should easily come to mind.
21:24But when when you are told
21:25you know when you are taught,
21:28you know this is the way to do X and
21:30then you see a patient getting care
21:32and it's done in a very different way.
21:35Some students felt that there was tension.
21:38That they wanted to advocate for
21:39their patients to have the standard
21:41of care that they were aware of,
21:43but that put them into conflict with
21:45the teams that they were working with.
21:48Uhm? So similarly, thinking about,
21:51you know what were the specific
21:52limits of care.
21:53So not necessarily just
21:55witnessing different standards,
21:56but just knowing that care was not even.
21:59It wasn't even possible
22:00to deliver certain things.
22:01There were students who felt themselves
22:03to be conflicted because they found
22:05themselves in situations where
22:06patients they knew that patients
22:07needed certain care and it just was
22:09absolutely not available and they
22:11felt very distressed about how to
22:14navigate this kind of a situation.
22:16Working beyond clinical skills,
22:17I have this in bold because we're
22:19going to talk a little bit more
22:20about this in a bit,
22:21but this is something that comes
22:23up over and over and over again.
22:24Is trainees students,
22:27trainees who you know who have a
22:29certain level of training going
22:31to a place and then being asked to
22:33do things or being felt as if they
22:34are in a situation where they have
22:36to do things as this undergraduate
22:39student in the video was that they
22:41are not trained to do.
22:43There were ethical dilemmas
22:44that students faced that related
22:47to communication barriers,
22:48both due to language barriers with patients,
22:52but also just even communication
22:54with respect to sort of medical terms
22:56and communication with the teams
22:58that they were working with and also
23:00interprofessional issues Ness or
23:02navigating those communication issues.
23:06Personal safety concerns.
23:07So you know this one classic example
23:11would be you know students working at
23:13at the collaboration site in South Africa,
23:17where there has been sort of long
23:19recognized to be multi drug resistant
23:22tuberculosis as well as now extremely
23:24drug resistant tuberculosis.
23:26Our students are trainees,
23:28they go with their own supply of N95 masks.
23:30But what do you do when you're in
23:32a place where the local clinicians
23:34that you're working with?
23:36They don't wear in 95 masks because
23:38they don't have them and so how do
23:41you feel about protecting yourself
23:43when you clearly see that the people
23:45who are working with you are not
23:48able to do so?
23:49There were issues related to
23:51power Dynamics and certainly,
23:53you know hierarchies exist here,
23:54so I'm sure folks can relate to this,
23:56but working in other clinical contexts
23:59where hierarchies may be even more
24:02deeply ingrained than they are here,
24:05students felt that acutely as a source
24:09of ethical dilemma and personal distress.
24:13Issues related to photography.
24:15You know, we know that when we're working
24:17in the clinic and when we're working in
24:19the hospital that it is not OK to just
24:21take out your phone and take a picture of
24:23a patient and send it to people, right?
24:26If you want to take a picture that's going
24:28to get published in an academic journal,
24:31there are ways to do that appropriately
24:32to get consent from a patient.
24:34If it's a question of putting something in
24:36a chart so that other providers will see it,
24:38well, that's a different situation.
24:40But it's not something where you
24:41just take out your phone,
24:43take a picture of a patient,
24:45yet students reported.
24:46Seeing this happen time and time
24:48again and there certainly have been
24:51situations where patient identifying
24:53information patient pictures have ended
24:55up on Facebook have ended up on blogs.
24:58UM, patient coercion.
25:00So situations where students
25:03witnessed sort of a different more.
25:07Some would characterize it as more
25:09paternalistic mode of care provision,
25:11where they felt that patients were
25:14being coerced into doing various things.
25:16Uhm, issues related to burdens on the host.
25:20So thinking about recognizing that when
25:22you have learners who are not from a
25:25certain from your health care system
25:27who now come into a new system to work,
25:29there's a lot that you that those students
25:31don't know about how things function.
25:33And so when you are a busy clinician
25:35trying to get through your day and
25:37now you have a student who's going
25:39to need additional support,
25:41additional learning,
25:42additional education just to navigate,
25:45you know what the team is.
25:46Doing understand what's going on,
25:48that places an additional burden on the host.
25:51And then as far as the last two,
25:53so rotation expectation discrepancies
25:55so students had one understanding
25:57of what would be expected for them,
25:59what roles they would play on the teams,
26:01and then finding that folks who are
26:04supervising them in the other places
26:06did not have those same expectations.
26:08And then the last was feeling pressure to
26:12use personal resources to help patients.
26:14This is where sort of the financial
26:18issue comes into play.
26:20In in the places where we send our
26:23students places where we work,
26:25it is not uncommon for, you know,
26:28providers all know very well the
26:30cost of this test.
26:31This medication in a way that providers
26:33here have no idea because they they
26:35need to be able to tell a patient.
26:38I'm going to prescribe you this
26:39medication or we are going to need
26:41to do this test and it's going to
26:42cost you this amount of money.
26:44And when the patients don't have the money
26:46the situation I talked about earlier,
26:47people will often resort to
26:49extreme measures selling off.
26:50Land various things to to get
26:52the money to do
26:54certain tests or have treatment.
26:56But when you have a student from
26:58a wealthy country who is standing
27:00there as part of the team who may
27:02have that $5 in their pocket or
27:04may have $20 in their pocket and
27:06it doesn't necessarily mean as much
27:08to them as it might to this person.
27:11Students feeling pressured to use those
27:12resources to help their patients,
27:14but then this then leads to a
27:17very leads to a slippery slope in
27:19terms of what then happens.
27:21With future patients. OK.
27:25So I said I was going to come back to this
27:27question of working beyond clinical skills.
27:30So a group of colleagues which included
27:32actually I see someone just raising a hand.
27:35I'm not sure if I'm able to.
27:39Answer a question. Let's see.
27:44Sorry, I'm not sure how I can
27:46answer the question right now,
27:47so I think we'll have to save
27:48it to to the end.
27:49Apologies, Ashley.
27:52So in terms of working beyond clinical
27:54skills as I was starting to say,
27:55this group of colleagues did a survey,
27:58did an international survey looking
28:00at how common is this problem of
28:03people practicing beyond their
28:04scope while working abroad,
28:06and I'd say Mat mat to camp,
28:08who's one of the authors here he
28:09was a speaker who gave a wonderful
28:11talk for this group last year.
28:12So so anyway,
28:13so this was the survey they were
28:15able to get responses from.
28:17223 health professionals and trainees,
28:19some of whom were from employed by
28:22university and some. Who are not?
28:25These individuals represented
28:27a wide array of professions,
28:29and about 50% or about half were asked
28:32at some point to perform outside of
28:35their scope of training when they
28:37were involved in a short term experience.
28:40So that's the number that were asked,
28:42and then of those 61% reported
28:45complying with that request.
28:47Interestingly,
28:48those who were involved who were
28:51encountering these situations,
28:53as trainees were nearly two times.
28:55As likely to comply with requests to
28:58perform outside their scope of training
29:00compared to folks who are fully licensed.
29:03So when you drill down into this and you say,
29:05well, what types of procedures
29:06were people being asked to do?
29:08Well,
29:08this is sort of what the the
29:10main these were the most common,
29:12so ultrasound management of
29:14fractures wound care suturing
29:16an endotracheal intubation,
29:18vaginal delivery and then
29:20neonatal resuscitation.
29:22So you can see there's a bit of a gamut here,
29:24especially when you think about
29:26what's the potential impact on a
29:28patient if you are not trained to
29:29do something and you do it wrong.
29:34But poop, sorry.
29:38We also they also were asked,
29:40sort of, why did you comply?
29:41So these are the types of
29:42procedures that you did well.
29:43Why did you comply with this request when
29:45you knew that you weren't trained to do it?
29:47These were the most common reasons, right?
29:49So there was this mismatch with host
29:52expectations and people wanted to
29:54fulfill the expectations of their hosts.
29:57They felt like there was suboptimal
29:59supervision so that they were in a
30:01place they were asked to do something.
30:02In theory there most someone who might
30:04have been able to supervise them but
30:06not in the way that they were used to.
30:08Uhm, the this this issue of inadequate
30:11preparation to decline a request
30:13to perform outside your scope.
30:15This is something.
30:16This is what we are directly
30:17addressing with our workshops.
30:19You know,
30:19as we as we use our sort of case base
30:23our case studies to help have students.
30:26That practice navigating things,
30:28you know the whole point is to
30:30get them comfortable thinking
30:31about what's the language.
30:32Then I might use to decline an
30:34inappropriate request or something
30:36that might make me uncomfortable.
30:38Who might my resources be that
30:39could help me navigate through the
30:42situation and then also the idea that,
30:44well,
30:44maybe they complied because they didn't
30:46see that there were alternatives.
30:48So like the undergraduate student
30:49in the video,
30:50there's nobody else there,
30:51but maybe the student didn't realize
30:53that two doors down there actually was
30:55a team of nurses who might have been.
30:57Able to come and help out,
30:59it sort of gets to understanding
31:00the context where you're working
31:02and then then emergency situations.
31:04And this comes up all the time when
31:07people are faced with a situation
31:08that seems like an emergency or
31:10is an emergency that emotional
31:12rush this feeling that there's
31:14nobody else that can help.
31:15I need to be the one to do this
31:17because there is nobody else here.
31:18That's a very powerful situation that
31:21certainly can override what somebody
31:22might rationally say they would do
31:25when they're sitting in a classroom.
31:27Importantly though,
31:27and I have this highlighted in red and
31:30the bottom most of the respondents
31:32who did comply with these requests
31:35expressed lasting moral distress,
31:37and I would say that I've been
31:40involved in training students and
31:42residents to doing predeparture
31:43training now for about 11 years and
31:46doing the post return debriefings
31:48and have had a chance to talk with
31:51senior faculty colleagues who have
31:52done global health clinical work
31:54at various points in their career.
31:56And I I would say this.
31:57Is something anecdotally that
31:58comes up time and time again?
32:00Is that thing that they did 20 years
32:03ago that still sticks with them that
32:05they knew they shouldn't have done
32:06that they wish now that they had not
32:08done because there was a bad outcome
32:10and that is something that has
32:12weighed heavily on them since then.
32:14So this is just,
32:14you know,
32:15I think it was when I saw
32:16this come out in the survey.
32:18So this sort of confirms
32:19what I've been hearing from
32:20people over all these years.
32:24But then, then there's the counter arguments
32:26you know from students and trainees.
32:28They say well, but you know,
32:30practicing beyond your scope isn't this sort
32:32of how we're trained in the US at some point.
32:34When you're learning a new skill,
32:35you have to, you know, come outside
32:37your comfort zone and do something
32:39for the first time and there's this,
32:41see one, do one, teach one,
32:43why I would say, you know,
32:44I'm certainly I'm in a medical specialty.
32:46I'm not in a more procedurally based
32:49special team, but in my experience,
32:51what I understand to be the case.
32:53We're sort of getting away from this.
32:54See one. Do one,
32:56teach one and you know now we have you know,
32:59simulation that students and trainees
33:00can sort of practice doing things before
33:03they even see one in the first place.
33:05We we have people do a certain number
33:08of procedures before they're considered
33:10qualified to do them independently.
33:12All of these, sort of.
33:16Safeguards that have been put into place
33:18really for patient safety purposes.
33:20So anyway,
33:20so this is this is one of the
33:22arguments that we will hear that we
33:23have heard from students and trainees,
33:25and then from our supervisors in our
33:28colleagues who are at the host institutions.
33:31You know, I think this is a
33:32really interesting argument.
33:33Well, why do your trainees need this
33:34extra level of supervision when ours?
33:37Don't?
33:37You know, it's it's common for
33:39medical students to graduate.
33:41You know,
33:42in Uganda to graduate medical school do a
33:44year of internship and then they're off.
33:46For two years working in a more remote area,
33:49being the only physician within,
33:52you know,
33:52a pretty large radius where if they
33:54are faced with the need to do a
33:57procedure that they haven't seen before,
33:59they may be looking things up in
34:01textbooks or for calling a friend
34:02or looking things up online to
34:04figure out how to do them.
34:05And that's that's the reality of
34:08practicing in that environment.
34:09But that's not the reality that
34:11we accept for our learners here.
34:13And so thinking about how do you?
34:14How do you navigate this?
34:18Alright, so well, so it's
34:19nice to have some guidance,
34:20so let me talk for a little bit about some
34:23guidance and about predeparture training.
34:27So importantly, guidelines to help
34:29us navigate these situations,
34:32sort of when you're thinking about
34:34academic global health collaborations.
34:36They're relatively new.
34:39The first set of expert consensus
34:41guidelines really only came out in 2010,
34:43and they're called the weight guidelines,
34:45so this was the working group on ethics
34:48guidelines for global health training,
34:50so this also was an international group of
34:53academics who came together to develop these,
34:56and there are pieces of this that
34:58are designed for spending and
35:01hosting institutions to describe
35:02what their responsibilities are.
35:05Then there's pieces relating to the
35:07responsibilities of trainees and then also.
35:09There's a piece that relates to the funders.
35:11Those who sponsor field based
35:13global health training,
35:14what are their responsibilities and really,
35:16this whole idea was to develop a
35:19set of best practices for academic
35:21global health programs.
35:23So just to boil it down into one slide,
35:26you know as far as the sending
35:29and hosting institutions.
35:30And there's there are some specific
35:32responsibilities to find here which
35:34kind of underscore the importance
35:35of working within a partnership,
35:37right?
35:38So the idea that sending and hosting
35:40institutions there should be sort of
35:42faculty responsible on each side who
35:44are discussing expectations of learners
35:46and their responsibilities at the beginning.
35:49And this should be periodically revisited.
35:53The partnership should be considering
35:55local needs and priorities and recognizing
35:57the true costs to all institutions.
35:59So as I was talking about a
36:01little bit earlier,
36:02if you have a tremendous volume
36:04of patients that are being cared
36:06for by individual clinicians that
36:08are working in a space and then
36:11you add in a foreign learner who
36:13needs a fair amount of orientation,
36:15well, let's think about.
36:16Well, how do you offset those costs?
36:19How do you?
36:19How do you try to make up for the fact that
36:22you've now placed an additional burden?
36:23On those clinicians who are already busy.
36:27You also need to have a plan for
36:29effective supervision and mentorship.
36:30Importantly,
36:31this doesn't mean that the supervision
36:33needs to be equivalent to what
36:35the student would have received
36:37at their home institution,
36:38but it needs to be effective within the
36:41confines of what's available at the site.
36:44Additionally,
36:45sending and hosting institutions
36:47should be selecting trainees who
36:49are engaging in this exchange.
36:51The trainees should be folks who
36:53are motivated and adaptable.
36:55While we certainly would love folks,
36:57you know you know all trainees to
36:59be able to have these types of
37:01perspective changing experiences.
37:02That doesn't mean that everybody
37:04is ready to have them at anyone
37:07given point in time.
37:08You really need to think about
37:10flexibility as a very sort of key
37:13characteristic and similarly and and.
37:14Also rather the sending and hosting
37:16institutions are both responsible
37:18for promoting personal safety and
37:20health for the trainees who are going
37:22back and forth now when you look at
37:25the responsibilities that were set
37:26out for trainees.
37:27These are not surprisingly in alignment.
37:30The first is for the trainees to
37:32recognize that their primary purpose for
37:34engaging in this exchange has two parts.
37:37One is global health learning and the
37:41second is appropriately supervised service.
37:43So there is some degree of
37:45service that comes into play.
37:46Uhm, but that said, you know.
37:49And as they often will say to our learners,
37:52you know we are not experts in going
37:54into someone else's health care system
37:56for a six week trip and providing care
37:59and knowing how to navigate that system
38:01the way that we would navigate our own.
38:04So there needs to be a degree of supervision
38:06for the service because you just don't.
38:08You don't know what you don't know in
38:11terms of how to how to navigate a system.
38:14System.
38:16It's also incumbent on the trainees
38:18to recognize and respect divergent
38:20diagnostic and treatment paradigms.
38:22There are going to be differences
38:24that they are going to see.
38:25That doesn't mean that one should spend
38:28their entire time saying well at Yale,
38:30this is how we do it.
38:31And yeah, this is how we do it.
38:32And you know why you do it this way?
38:34Because we do it this way.
38:35Yeah,
38:35you really need to respect the
38:37fact that there are differences
38:39and try to understand why.
38:40And sometimes you know our colleagues
38:42who are just as well read if not more
38:45well read on the medical literature.
38:47As we are,
38:47they have to come up with creative solutions
38:49in order to achieve the same goals.
38:52Because the resources are different.
38:54It's also important for trainees
38:56to communicate with their mentors
38:58and and with their patients.
39:00Certainly if a trainee finds themselves
39:02in in in a situation of conflict or in
39:06an ethical with an ethical dilemma,
39:08we we encourage them in our trainings
39:11to to share that with the mentors they
39:13have local mentors for this purpose to
39:15help them think about how to navigate things.
39:17If we only find out about
39:19issues when they come home,
39:21then damage has been done and.
39:24There's not a lot to do,
39:25but if we can sort of help them
39:27navigate through situations
39:27while there while they're in it,
39:29it's going to be a much more
39:32productive learning experience.
39:33Trainees are also responsible for
39:35demonstrating cultural competency,
39:36so trying to understand the context
39:38and also they have responsibility
39:40for ensuring their own personal
39:42safety and health.
39:43So this is that's the weight guidelines.
39:46Uhm,
39:46professional organizations have a
39:48variety of different types of guidelines
39:51that relate to doing global health,
39:53clinical work,
39:54and this is just a list of some.
39:56I would say that that American
39:59College of Pediatrics,
40:01American American Association of
40:03Pediatrics I mistype, typo on the slide.
40:07They actually have a tremendous set of
40:09of guidance that helps folks navigate
40:12global health clinical situations.
40:14In in 2017,
40:15a group of colleagues did a scoping
40:17review to try to look at sort of.
40:19What's the spectrum of
40:20guidelines that exist and they.
40:22They analyzed a set of 27 guidelines
40:25which included the weight
40:26guidelines and to try to come up
40:28with a set of best practices to
40:30see what these all had in common.
40:32What they noted, though,
40:33was that the majority of the
40:35authors of these guidelines were
40:37from the Global N were from high
40:39income countries and none of
40:41them had a plan for enforcement.
40:42So all of this was.
40:43We suggest that this is.
40:45How you should do these things,
40:46but there were no teeth.
40:46There was no way to make sure
40:49that people were following them.
40:50So you know,
40:51going back to the fact that the majority
40:54of these guidelines were written by
40:56folks from North America from Europe.
40:59Worked with some colleagues over
41:01the last several years to do a
41:03systematic review of low and middle
41:05income country host individual
41:06perspective to try to say well
41:08we need to take the voices of
41:11our hosts and think about well,
41:13what are they telling us about what best
41:15practices should be about global health.
41:17Sort of partnerships,
41:18global health, clinical ethics.
41:21So this came out earlier this
41:23year in academic medicine.
41:24We were able to.
41:26The systematic review looked
41:27at 17 articles and of those.
41:29Articles this included 448
41:32host community voices,
41:34sort of across these papers.
41:3688% of those were folks who are from
41:37low and middle income countries
41:39and the remaining were folks from
41:41high income countries who had been
41:43working in low and middle income countries.
41:46These voices included majority
41:49healthcare professionals,
41:50but there were also folks who
41:51were not in healthier.
41:53There were people who were sort of
41:55community hosts of visitors who were
41:57interviewed as as part of these articles.
42:00To administrators in hospitals,
42:02to talk about their experiences
42:04of having visitors come for short
42:07term global health experiences.
42:09And so we sort of boiled these
42:11hosts perceptions down into four
42:13analytical themes and use this to
42:15come up with a set of best practices.
42:17So in terms of our summary of best
42:20practices for short term experiences.
42:23So these five.
42:24So first that short term
42:27experiences should be couched
42:29within formalized partnerships.
42:30Have bidirectional benefit and
42:32clear learning objectives.
42:34International health, you know.
42:36Previously it was tropical
42:38tropical public health.
42:39You know there is such a legacy of
42:42colonialism that has come with it.
42:44This idea of folks from high income
42:47countries going to less resource setting,
42:49taking data, doing, you know,
42:52doing doing studies,
42:54providing care,
42:55and then leaving without leaving
42:58benefit to do the community that they
43:00were working in without finding you
43:02know in some cases without knowing.
43:04Whether the community wanted them
43:05to be there in the first place.
43:08So when this is sort of part of the
43:10guidance is we want to make sure
43:11that if we are sending trainees
43:13to do short term experiences that
43:15it's within a framework of a
43:18formalized partnership.
43:19The host voices strongly said that
43:22predeparture training should be
43:24mandatory. You would think
43:26that it is mandatory,
43:27but there are still institutions
43:28that are sort of slow to catch
43:30on to this and the feelings were
43:33that predeparture training should
43:34include information about health
43:36care systems about local language
43:38and socio cultural norms about local
43:41standards of care so that people
43:43are not surprised when they first
43:45arrive in a place to see differences,
43:47and about how to navigate ethical.
43:49Challenges. Thirdly,
43:52they were calling for cultural humility
43:54at all levels of the partnership.
43:57So not just saying to the trainees who
43:59are going that we want you to have a
44:01sort of cultural humility approach,
44:03but even goes up to the level of those
44:06faculty and administrators who are
44:08in charge of running partnerships.
44:114th, they strongly suggested that.
44:15There should be collaboration on the
44:17selection of visitors and what the
44:19predeparture training looked like,
44:21so you know certainly you know we
44:23talked about selecting trainees
44:24who might be more flexible to go,
44:26but the feedback from the hosts
44:28who were in these studies was that
44:31we actually want to have a role
44:33in selecting those folks as well.
44:36And then finally that there should
44:38be sort of this constant.
44:40Situation where feedback is being
44:42solicited from both returning visiting
44:45trainees as well as from the hosts
44:47in order to continuously improve the
44:49partnership and sort of thinking
44:51about how do we continue to evolve to
44:53meet changing needs in the host community.
44:57Alright, so I'm going to turn it over
45:00to Rosanna for our last major section.
45:03Thank you Tracy and thank you for a movie.
45:06My slides, UM so I'm Rosanna and it's
45:09a pleasure to be here, and in fact,
45:12it's a pleasure to be here.
45:13Working with Tracy.
45:14This month marks the 10th year
45:16since we started working together.
45:19As we you know,
45:20we're debriefing a group of students
45:22that we're going to or came back from
45:25Uganda when she just joined the faculty.
45:27And so it's my pleasure to walk through
45:30this last section where we would
45:32like to discuss potential dilemmas.
45:34The trainees may face during short term
45:37experiences in global health due to the
45:41evolving complexities related to COVID-19.
45:43Next, while there is much literature
45:46about COVID-19 and what's happening,
45:49we nothing is written to prepare
45:52us for the post COVID context,
45:55but we would like to offer you a
45:57little bit of pre COVID context.
45:59So the.
46:02Steady interest in short term
46:05experiences in global health and much
46:07of we know is from the experiences
46:09of medical students and residents.
46:12Less is known about is known
46:14about other health professionals,
46:16so we are bringing a little bit
46:18of an interprofessional flavor
46:20to put things in context.
46:21So at Matriculation,
46:2367% of medical students expect to
46:25participate in stags during medical school,
46:28continuing into residency,
46:29and early careers.
46:31Not very differently.
46:3260% of PM at regulated students
46:34intend to complete an elective
46:37international rotation,
46:38so my colleagues and I in the PA
46:41program here a lot of these question
46:44during admissions and a little
46:46bit of selection bias because Yale
46:48Precision associate program is one of
46:51the few programs in the country that
46:53offers so many of these electives,
46:56but this is not only it's an elective,
46:58it's a selective process,
47:00so we know already that among those 7067%.
47:03That intend to go only 25% of
47:07medical school graduates participated
47:08in global health experiences in
47:10the period 2016 to 2020.
47:12And this is not because we cannot
47:15meet the demand is because we are
47:17trying to follow those guidelines.
47:20So where are people going?
47:23Well,
47:23we know from a survey of US physicians
47:26who post residency have global health
47:29activities that there is a great
47:32concentration of activities in the global S,
47:36particularly in Africa,
47:37Latin and South America.
47:39And this is great,
47:40because this is a great way to start
47:43developing rotations where we have.
47:45Connections from people in the US and
47:47people who have partnerships abroad.
47:50Now it came March 2020.
47:53Next everything is stopped and I
47:56know exactly what day that was.
47:59March 14th, 2020.
48:00Do you remember where you where?
48:02March 14, 2020?
48:04Well,
48:04I was in an empty plane along with a
48:08few people who had to leave Argentina
48:11before the government government
48:14decided to close the borders to
48:16all foreigners for 17 months.
48:18But that was not that bad.
48:21I was feeling very responsible
48:23for a Yale medical student who
48:25was also in a different city.
48:27They are and who managed to
48:29take the last airplane.
48:31So even many of us are very
48:35risk takers and adventurers.
48:37Nobody really expected this to
48:39happen so quickly and move,
48:41so move us in the following situation next.
48:47This is what the Buenos Aires Airport
48:51looked for all those months with a lot of
48:55airplanes grounded and a very empty airport.
48:58It's a dream for the traveler,
49:00but not if you are grounded
49:02in another country.
49:03So there is a much of interest
49:06in Internet and global or an
49:09International Studies abroad.
49:10There has been a great reduction of studying
49:14abroad in all levels of education, mostly.
49:17For the practical issues that
49:20people cannot go abroad next.
49:23As we are preparing to restart our
49:28short term global cult experiences
49:31and many colleagues here are part
49:34of these meetings to offer very
49:37safe experiences for our trainees.
49:41November 2021.
49:42The last week of November 2021 brought us to.
49:48Alright,
49:48it's starting to closures
49:50and partial closures again,
49:52so this brings us to again,
49:55a situation where we know that this is
49:58going to last for a little bit of time,
50:01and we need to prepare our students in a
50:04way that we were not preparing before.
50:08Next so how is our pre departure curriculum
50:13in going to be in pandemic times?
50:16Well,
50:16we need to recognize that there is
50:18a new context and rapid changing
50:21conditions both locally and globally
50:23and we are not longer going to
50:26rely on past experiences or many
50:28research studies that can show us
50:31anticipated dilemmas that we can have.
50:34We are going to anticipate this right.
50:36We are not just going to train
50:38them on things that happened,
50:40but in things that could happen.
50:41Without much information and we
50:44need to be very strategic about
50:47considering both the abuse of
50:49the trainees and their hosts.
50:51The pandemic broad divisions,
50:53even within our own communities within
50:55our own families within our own society.
50:58So as you can imagine,
51:00the pandemic brings a lot of
51:03these cultural differences,
51:04limited resources, problem,
51:06professional issues,
51:07personal moral dilemmas in into anyone.
51:12Who is traveling to a place that is not
51:14their own and the host expect a lot from us,
51:17especially when they are partners who
51:20we collaborated with for a long time.
51:22They expect that we recognize
51:24that they are also in situations
51:27that are more stringent than the
51:29ones that they were before.
51:32Next so we wonder how will these
51:35themes be affected by COVID-19.
51:38The new context.
51:39What we know from our own
51:41experience here that the COVID-19.
51:43Pandemic made visible structural
51:45differences and other social building
51:47abilities within and across countries.
51:49We had tons of dashboards to show us.
51:52Lots of statistics,
51:53but the statistics are averages,
51:55and don't show really what
51:57happens on the ground.
51:58We expect that at least the following 4
52:01themes are going to be extra exacerbated.
52:05Next differing standards of care,
52:08limited limits to care due to limited
52:11resources issues with burnt on the
52:14host and personal safety concerns.
52:17Another one that we had in the past but
52:19not for such a long term and not changing
52:22so rapidly was travel disruptions and
52:25most importantly, border closures.
52:27Next, so to illustrate these things,
52:30we wanted to show some global
52:33dashboards that we have access to.
52:35So different standards of preventive care.
52:38This is the map of and as of November 21 of
52:42how the level of vaccination is in the world.
52:45Even if you don't want to read
52:48the little letters in this map,
52:50you know by color what region is the
52:53most affected, but you don't know,
52:55although that which is the African region.
52:58Right and where is where we hear
53:00today that we have a new variant
53:03being affected and then lock.
53:04You know, we are locking and we are not
53:07allowing people from Africa to come here.
53:10So what you don't know that there are
53:12lots of places in Latin America that show
53:14that they have good rates of vaccinations,
53:17but some of their vaccinations
53:19are not recognized by WHO?
53:21And for example,
53:23people from certain countries in Latin
53:25America still cannot come to the US
53:27even if they are fully vaccinated.
53:30This put Mick vaccine has been highly
53:33used there in many of those countries
53:36and even fully vaccinated people,
53:39middle class or lower class low
53:42economic class.
53:42People we are only had only access
53:45to that while the upper class was
53:47able to travel to other countries
53:50to get other vaccinations.
53:52So Speaking of solidarity,
53:53I always wonder why didn't we send vaccines
53:56there instead of allowing to vaccinate.
53:59Those who can come here and have this
54:03huge disparity in the way that prevention
54:06preventive care was distributed there next.
54:11It's probably not new to many of
54:15us that there are huge differences
54:17in the resources across different
54:20countries from high level resources.
54:23Country trees to low level resources,
54:25country,
54:26but we bring these idea of exhaust.
54:29Health care systems are after the COVID
54:33pandemic and by showing the number of
54:36hospital beds differences between these
54:39countries with different economic resources.
54:42So we have the hospital
54:44beds per 1000 population.
54:46Examples between low and high
54:49income countries being numbers
54:52that we can hardly read 0.8 to 4.2.
54:55So when we invite our training
54:57so when we invite our trainees.
55:00To go abroad again,
55:01we will have to invite them to reflect.
55:03Also in these statistics the
55:05statistics were bad before they
55:07are not going to be better now and
55:09they will require extra humility.
55:11Extra introspection in extra
55:14solidarity to understand the
55:16conditions of our host sites next.
55:23Extra burden on the host,
55:25you know,
55:25as here we have a health
55:27care workforce that is there.
55:29Doubt we have an extra burden on
55:31the host abroad where we have a
55:34health care workforce shortage
55:36and we burn out in huge numbers
55:39from the economic impact of COVID
55:41pandemic in an already poorly paid
55:45health care workforce in low and
55:48low intermediate income countries
55:50to the number of physicians.
55:53The nurses per capita compared
55:56to the places where we work
56:00and our trainees work next.
56:03Personal safety concerns there are.
56:06There was a scarcity of personal
56:08protective equipment even here
56:09when the pandemic started,
56:10but this is persisting in many
56:14low and middle income country.
56:17Middle income countries and I wanted
56:20to show you these statistics or
56:22this survey that talks about the
56:25availability of disposable face
56:28masks masks at certain institutions
56:30and the N 95 masks and noticed that.
56:36Even across sectors rarely had
56:39access to disposable face masks,
56:42almost 50 percent,
56:4440% of the of the health care
56:48workers and N95 mask,
56:5379.6% had never accessed to N 95 masks,
56:56so the story that Tracy was describing
56:59before about this dilemma of we
57:03sent our trainees with N 95 masks.
57:06In their suitcases and they arrive to
57:08places where even our frontline health
57:10care providers don't have access to that.
57:13This is going to be exacerbated post kovid.
57:17Next and of course we have.
57:22We will continue to have travel
57:25disruptions and border closures.
57:26Hopefully not for a long time,
57:28but we need to be prepared for those.
57:30And there are some calls for taking
57:34opportunities and being using ingenuity
57:36to deal with these disruptions to
57:39create new models of engagement with
57:43low middle income country partners to
57:47have global health education virtually
57:50and enhance those collaborations.
57:53For equal and more balance opportunities
57:56for learners not only in the global north,
57:59but in the global South.
58:02He also called for a shift to global
58:05health opportunities within country.
58:07Tracy has LED some of those rotations
58:10in here at Yale,
58:13and but we also call for the following,
58:16Tracy.
58:18We would like that even in virtual context,
58:21in the domestic context we consider to
58:24apply global health ethics frameworks
58:26to remote or local opportunities.
58:28Technology is not going to make
58:31those dilemmas disappear and we
58:34are sending trainees to domestic
58:37global health rotations without
58:39the similar preparation that we
58:42send them for rotations abroad.
58:45Next
58:49alright, thanks so much Rosanna.
58:51So for our sort of final slide,
58:53sort of what's next for us?
58:55So thinking about how do we move forward?
58:57So Rosanna is highlighted some of
58:58the things that we've been thinking
59:00about with respect to lessons
59:02to take away from COVID-19 I,
59:04I'm imagining that many of
59:05you in the audience, though,
59:07as you hear some of these issues
59:09that our trainees are dealing with in
59:12global health rotations and reflecting
59:14on your experiences of navigating,
59:17especially the early days of
59:19the COVID pandemic.
59:20These global health ethics challenges are
59:23very much relevant here at home as well.
59:26You know, I think you know.
59:28Think about March 2020 April 2020
59:29when there was such a shortage of
59:32personal protective equipment here at
59:34Yale New Haven Hospital when you had
59:36physicians maybe had access to to PPE,
59:39and nurses might have had access
59:40to different PPE.
59:41And then,
59:42how do you think about working
59:44together as a team when you have
59:47these disparities in access?
59:49If if the PPE? Was present at all.
59:52These are the same issues that we're
59:54teaching people to navigate in South Africa,
59:56and so thinking about.
59:57Well,
59:58how do we?
59:58How do we incorporate some of
01:00:00this thinking into into the work
01:00:02that's happening here at home and
01:00:04so that gets to our second point,
01:00:05which is seeking opportunities to
01:00:07teach about engaging these alternate
01:00:09principles to navigate dilemmas.
01:00:11And we've had some sort of preliminary
01:00:13conversations with folks in the
01:00:15different health professional
01:00:16schools about how to do this.
01:00:18And so then finally,
01:00:19just to say that predeparture
01:00:21training and post.
01:00:21Return debriefing at Yale
01:00:23will continue has continued,
01:00:25and as Rosanna was saying,
01:00:27it will evolve to address the new
01:00:29challenges that arise because of COVID-19.
01:00:31But also I think this pause has
01:00:33given us time to reflect about the
01:00:35importance of also incorporating
01:00:37interprofessional perspectives.
01:00:39I think previously we would train sort
01:00:41of the nursing students separately
01:00:42and train the PA students separately
01:00:44in the medical students separately.
01:00:46It's important for everyone to be
01:00:48hearing all of those perspectives,
01:00:49so we've been thinking about how do you
01:00:51do this in a more interprofessional.
01:00:53So with that we will stop and be happy
01:00:57to take questions from the audience.
01:01:00Thank
01:01:00you so much, that was an
01:01:02excellent presentation.
01:01:03Really interesting.
01:01:03I'd invite you folks.
01:01:05I see some questions coming in
01:01:07just to remind everybody if you
01:01:08have questions for the speakers,
01:01:10please just put him in the Q&A
01:01:11portion and I will get to him.
01:01:13I will, however, as moderator,
01:01:15I take the product of the first question,
01:01:17'cause I was intrigued.
01:01:18Retinal get going.
01:01:19It was at any particularly about the
01:01:22alternative principles and I love that idea
01:01:24is that I heard the alternative principles.
01:01:27There was one thing that struck me,
01:01:28which I'll get to in a second.
01:01:29But then there was a quote.
01:01:31Or the other one.
01:01:32Roseanne referred back and she
01:01:34said a proposal to apply global
01:01:36health ethics these frameworks
01:01:37to local opportunities to and.
01:01:40So when I think about those principles,
01:01:41humility and introspection
01:01:43and social justice,
01:01:45these are all things that I think pretty
01:01:49much every American bioethics teacher would.
01:01:52Sign off are absolutely.
01:01:53These are things that that that we teach,
01:01:56but one that interested
01:01:57me most was solidarity,
01:01:58which is to say to try to align align
01:02:00the goals with that of the community.
01:02:02I would say if I don't mean to oversimplify,
01:02:05but I would say that that what
01:02:08we teach here is to align with
01:02:10the goals of the patients,
01:02:12not so much with the Community.
01:02:14So the idea of I think these
01:02:16alternative principles are fascinating.
01:02:17It should be taught in incorporated
01:02:20and internalized,
01:02:20but that one in particular the solidarity.
01:02:23Of basically bringing the goals of
01:02:25the community to a higher level I,
01:02:27I wonder how you feel that would work
01:02:28in a country where very much people
01:02:30feel that it's the goals of the individual,
01:02:32very patient centric approach that we take.
01:02:35And of course that's been
01:02:37challenged appropriately.
01:02:37So during this pandemic,
01:02:39when sometimes the goals of
01:02:41the community had to take an
01:02:43increased spotlight compared to
01:02:44what they were three years ago.
01:02:48Thanks so much Mark.
01:02:49I mean I'll take the first stab and
01:02:51Rosanna if you want to jump in,
01:02:53that would be great too.
01:02:55You know it's such an interesting question
01:02:57and I think I think this question what
01:02:59is what does community mean, right?
01:03:00I mean, I think that's the crux of this,
01:03:02because you can define
01:03:03community in different ways.
01:03:05I think in some situations one might.
01:03:08Think about solidarity in terms of the you
01:03:12know local clinicians that you're going
01:03:14to work with in another place, right?
01:03:16And making sure that you're you know
01:03:18the work that you're doing is in
01:03:20alignment with the goals that they
01:03:22have in caring for their patients
01:03:24within their particular context.
01:03:25But I also think about,
01:03:26you know when you think about
01:03:28patient centered care.
01:03:29There are so many examples of
01:03:30patients that we take care of here
01:03:32that maybe where you don't have sort
01:03:34of cultural alignment between the
01:03:35provider and the patient, right?
01:03:37The patient and their family.
01:03:38They have very different cultural
01:03:41expectations for what will happen
01:03:43in the course of clinical care
01:03:45and and so thinking about.
01:03:47Well, how do you?
01:03:48How do you demonstrate to that
01:03:50patient in that family that that
01:03:51your goals are in alignment,
01:03:53right?
01:03:53I think about solidarity sort
01:03:54of in in that way too.
01:03:56That's sort of a smaller community
01:03:57that one might be thinking about,
01:03:58so I don't think that the word community
01:04:01in in that sort of idea of solidarity.
01:04:04I don't think that it means one thing.
01:04:05I guess that's what I'm trying to say.
01:04:06I think that it can mean many things
01:04:08depending on what the situation is.
01:04:10Yeah,
01:04:11I I echo what Tracy says and
01:04:13also invite reflection about this
01:04:16cross cultural communications
01:04:18between provider and patients.
01:04:20And sometimes it's important
01:04:22to consider that right?
01:04:24So aligning these values and the
01:04:27goals of community may require a
01:04:30little bit more than the one on one.
01:04:33Conversation to rely on that community.
01:04:36To learn more about what that
01:04:38patient needs in conversation
01:04:39with the patient as well, right?
01:04:43Thank you, thanks very much.
01:04:44Let me give you some questions
01:04:46from the audience. Uhm?
01:04:47When hi C send their trainees overseas,
01:04:51the low middle income countries
01:04:52for short periods of time to learn
01:04:55and help post organizations,
01:04:56what do we need to do to avoid the
01:04:59paternalistic attitudes we directly or
01:05:01indirectly project to the Localhost team
01:05:03by coming for short periods of time?
01:05:05Collect data, helped local teams
01:05:07or gain experience and then lead?
01:05:09I have noticed this the fair amount of
01:05:11time over the past 20 years in global
01:05:14health that I've been involved in.
01:05:15What we need to do?
01:05:17Yeah no, I think that's
01:05:18that's that's the meat of it.
01:05:20That's such a great question and you know,
01:05:23I can give you thoughts we can give
01:05:25you thoughts I wouldn't purport
01:05:27to say that I have the answer.
01:05:29I think a lot of it.
01:05:30This sort of gets down to sort of.
01:05:31What is the framework within
01:05:33which these trainees,
01:05:35or or the traveler is having this experience?
01:05:38And there's a wide spectrum.
01:05:41There are institutions our own
01:05:42institution when our global health
01:05:44program and internal medicine.
01:05:46Started 40 years ago was when we first
01:05:49started sending residents abroad and
01:05:52and you know it was not uncommon for
01:05:54a resident to sort of identify a site.
01:05:56Identify a supervisor.
01:05:56Get them to sign off on the form
01:05:59it says you're doing an elective
01:06:00and then go and then come back
01:06:02and then the resident had a great
01:06:04experience and and and then there was
01:06:07nothing left behind to improve or or
01:06:10anything for the host necessarily.
01:06:12They just had had this experience and
01:06:14sometimes there were sort of ripple
01:06:16effects by the attitudes that that
01:06:17individual might have carried with them.
01:06:19So I think overtime what we have done
01:06:21is to shift our focus more towards
01:06:24having our student exchanges in our
01:06:26training exchanges be within the framework.
01:06:29Of a partnership where it's made clear
01:06:31to the trainees to the students that
01:06:34they are not the the be all end all
01:06:37reason for this relationship to be existing.
01:06:39That there is so much more that's
01:06:41happening that they are part of a
01:06:43much larger situation in which you
01:06:45know thinking about the collaboration
01:06:46that I Co direct with my colleague
01:06:49Harriet Mayanja Kizza in Uganda.
01:06:51There's so much other benefits that
01:06:54our institutions are providing to each
01:06:56other that is beyond just one student
01:06:58going to a place and coming back.
01:07:00So I think that that's that's that's
01:07:02one piece because when they come back,
01:07:04invariably trainees and students
01:07:05will reflect upon the fact that
01:07:07they worry that they learned they
01:07:09took away more than they gave.
01:07:11This idea of going to help a lot of folks
01:07:13when they think about why am I going?
01:07:15Well,
01:07:15I'm going to help.
01:07:17Well, if you're going to help,
01:07:18think about what your position
01:07:20to do as far as helping.
01:07:22I mean, I I started doing global health
01:07:25clinical experiences when I was a
01:07:26medical student and struggled with that.
01:07:28And then as a resident and then as faculty.
01:07:30And I still going back as a faculty member
01:07:33who's been working in Uganda now since 2004.
01:07:35Feel like I'm bringing back
01:07:37more than I deliver, right?
01:07:39I think that that you know it's.
01:07:42The humility piece,
01:07:42I think is very important and to openly
01:07:44talk with your colleagues about that.
01:07:46I think that that's that's key,
01:07:48and so I think the framework is important
01:07:51because that's going to keep people
01:07:53centered on what they're there to do
01:07:55and then and why they're there that
01:07:56those are some thoughts that I have,
01:07:58you know, Rosanna, what?
01:07:59What do you want to share?
01:08:00I would like to just focus on
01:08:03their word learning, right?
01:08:04We are sending learners to learn,
01:08:07and initially some of our first rotations
01:08:12started being affiliated with service.
01:08:15Organizations, and so it was even
01:08:18changing the language we need
01:08:20to change the language, right?
01:08:21We were not going to do service,
01:08:23but we were doing.
01:08:24We were going to do a clinical rotation
01:08:27equivalent to rotations that are in EU S.
01:08:30So with that framework we change the
01:08:34narrative you are there to learn from them,
01:08:38not to teach or to help.
01:08:41So I think that helped us.
01:08:43When you think crazy.
01:08:46Yeah it it it. Also you know. It also
01:08:50highlights the point that so much
01:08:52of what your what your teachers
01:08:53tonight is is so relevant.
01:08:54It's just what we do here.
01:08:56I mean it's it's just not a lot.
01:08:57There's not. There were so many
01:08:59there's so much overlap, right?
01:09:00That that mean I think of
01:09:03learning this profession.
01:09:04You know, 40 years ago and
01:09:06where we were sent to various
01:09:08inner city hospitals to learn.
01:09:11And and the humility.
01:09:15The introspection these are things
01:09:17that worked so much emphasized
01:09:19that I think we're that's would
01:09:20serve our students and all of us
01:09:22so well now as we go in there.
01:09:25In particular, this is something
01:09:27that that we you know when our
01:09:30students first arrive at Yale.
01:09:31You know, in their first official
01:09:33lecture on their told though,
01:09:35this is not about them,
01:09:37they are no longer the most important person
01:09:38in the room like they were in college.
01:09:40And you know that this isn't about
01:09:42you and so so so often there's the
01:09:44sense of what am I going to know?
01:09:47What do I get out of this?
01:09:48What are you going to get some training?
01:09:49But but I think what I'm
01:09:51hearing you say words.
01:09:52I'm correct me,
01:09:52if I'm wrong that the students
01:09:54should approach this.
01:09:55The same is when they do
01:09:56a rotation in New Haven.
01:09:58Well, even by accreditation standards,
01:10:00is at least in the PA program is
01:10:02what we need to enforce right?
01:10:04We are sending them to equivalent spaces
01:10:07to learn under supervised conditions.
01:10:10And of course there will be a
01:10:13bidirectional learning right?
01:10:14Because there is always something
01:10:16to learn from students. Even here.
01:10:18I think the difference is when the
01:10:22student goes thinking that they are
01:10:24going to teach it all because what
01:10:26they see is not right and so that.
01:10:29Humility peace is important.
01:10:30They wouldn't do that.
01:10:32Entering an internal medicine
01:10:33rotation in the US.
01:10:35So so right? So it's so to get to a
01:10:37specific point when asked to do something
01:10:40that they're simply not qualified to do,
01:10:42you would have them approach that.
01:10:43Similarly, in the two settings. Yeah.
01:10:47Yeah, I often if they are not
01:10:50prepared to to because of
01:10:52the power dynamics to say no.
01:10:54We always say something that.
01:10:58Nancy Angoff taught me tell
01:11:01them to call me right,
01:11:03or you can blame me right?
01:11:05Sometimes you need to deflect that
01:11:08power dynamics and it happened.
01:11:10We had students who were
01:11:13questioned about using masks
01:11:15wearing preventive medication,
01:11:17so they are going to be challenged
01:11:21and they have to be respectful
01:11:24and humble and and also use
01:11:27strategies to deflect that. Mark,
01:11:30I just want to make another point.
01:11:32You too because you brought up this
01:11:34question about our work here in New Haven.
01:11:35And so I had an opportunity last year
01:11:38working with my colleague Sheila
01:11:39Shenoy to develop what we called
01:11:41a local global health elective.
01:11:43So for our residents who were not
01:11:44able to travel but we're supposed
01:11:46to do global health experiences,
01:11:48we were able to devise sort of a four
01:11:51week elective where they did a deeper
01:11:53dive into the community here in New Haven.
01:11:56Working with different,
01:11:57marginalized and vulnerable populations.
01:11:59Here so working with St Medicine
01:12:01teams you know doing doing a
01:12:04variety of different clinical.
01:12:06And these were third year residents,
01:12:07so they were in their final year.
01:12:10They they've been working in the only
01:12:12Haven hospital for the last three years.
01:12:14Having experiences where they were caring
01:12:17for patients from these communities
01:12:19the entire time and every single one of
01:12:21them at the completion of this experience,
01:12:23in which we asked them to use a global
01:12:25health framework to think about the
01:12:27way they were interacting with these
01:12:29communities and to get out and learn
01:12:31more about the context in which the
01:12:33different individuals were living.
01:12:35Every single one of them.
01:12:36Felt that this was an incredibly
01:12:39transformative and perspective experience.
01:12:41They said,
01:12:42you know,
01:12:42I have taken care of patients who
01:12:44are unhoused who are struggling with,
01:12:45you know,
01:12:46variety of with addiction with a
01:12:48variety of issues for all this time
01:12:50and the perspective that I gained
01:12:51from going out into the community
01:12:53and learning and being open and
01:12:55sort of having the humility to
01:12:57says or teach me about your life.
01:12:59Teach me about how we do medicine when
01:13:02it's St medicine being conducted by
01:13:04a team was transformative for there.
01:13:06For their care and their attitudes,
01:13:09I I mean,
01:13:09I think that it's really interesting.
01:13:10It has to do with the way that we think
01:13:12about how we're interacting with people.
01:13:15And perhaps some of that could be
01:13:18Tracy interacting with people on
01:13:19our turf versus off of our turf.
01:13:21It's it's, it's, and most of what
01:13:23we do is an awful lot easier to do
01:13:25it because we're surrounded by the
01:13:27facility and by our colleagues.
01:13:29You know, in familiar land when we
01:13:31get when we get to an unfamiliar
01:13:33environment and don't have all the
01:13:35backup and support right at our elbows,
01:13:37it's a very different world.
01:13:39Oh, even knew him.
01:13:41This sounds like something I will.
01:13:42We can lean on,
01:13:44will talk about will talk to Jesse Lucy,
01:13:46but I'm wondering how much of this the
01:13:48students are exposed to and perhaps
01:13:50some more wouldn't be a bad thing,
01:13:52but I will tell you certainly
01:13:53in terms of the teaching I do
01:13:55for bioethics for students,
01:13:56I've learned some things tonight,
01:13:57and I, you know,
01:13:58I hope to incorporate some of these
01:14:00things as well into what we teach
01:14:01the students 'cause these are.
01:14:03These are reporting universal concepts.
01:14:05Now I have another question for you.
01:14:06Please,
01:14:06doctor Robin mentioned the lack of teeth
01:14:09for enforcement of the guidelines for.
01:14:11Short term experiences in global health.
01:14:13What enforcement mechanisms
01:14:14would you suggest?
01:14:16That's that's a great
01:14:17question. Thanks for asking that Jack.
01:14:19Uhm, so so it's interesting because I
01:14:23actually had the opportunity in in 2019,
01:14:26I was giving presentations at
01:14:28several conferences where I had the
01:14:30opportunity to sort of convene many
01:14:32focus groups of colleagues who are
01:14:34academics from low and middle income
01:14:36countries to sort of ask this question.
01:14:38Right to say, well,
01:14:39what could we do to try to ensure that
01:14:41these types of standards are put into
01:14:44place for the partnerships when you know?
01:14:46Trainees are going back and forth, you know.
01:14:49Is this something that you would want
01:14:51an international organization to take
01:14:53leadership on to set standards and sort
01:14:55of think about how to put teeth into it?
01:14:57And really,
01:14:58the feedback that I was getting,
01:15:00as you know, part of these discussions
01:15:02was that people wanted local control.
01:15:04They wanted more local control about
01:15:06who was coming in the conditions
01:15:08of the folks that were coming.
01:15:10And you know,
01:15:11as we think about how this the movement
01:15:13to decolonize global health to move
01:15:15away from this sort of colonial.
01:15:17Attitude that folks have historically
01:15:19had towards working with colleagues
01:15:22in low and middle income countries.
01:15:24They think about,
01:15:25you know how many times has an
01:15:27institution accepted to work with
01:15:30a researcher or clinician from a
01:15:32high income country who's coming
01:15:34with an NIH grant to the tune of
01:15:36X number of millions of dollars?
01:15:38And they say, you know,
01:15:39if you let me come and work with you.
01:15:42You know this is the money that
01:15:43will come to your institution.
01:15:44What kind of power does the individual?
01:15:47In that lower middle income country
01:15:50institution have to say you know what
01:15:52I don't like the framework here.
01:15:54You know I'm going to turn
01:15:55this opportunity down, right?
01:15:57So thinking about like, well,
01:15:58how do we empower or happen?
01:16:00Not even in power.
01:16:01But how do we ensure that individuals
01:16:04who are at the host traditionally hosting
01:16:08institutions have the right to say no,
01:16:10you know,
01:16:11these are the trainees you want to send me,
01:16:12but I'm looking over the application
01:16:14and I'm concerned about that one.
01:16:15So I you know,
01:16:16I would like to know more information.
01:16:18These are the. These are the kinds of things.
01:16:20So really it comes to come.
01:16:22What I took away from that was
01:16:24it comes to making sure that that
01:16:26there is more power that's shifted
01:16:28in in the relationship.
01:16:32Yeah, and I would like to add
01:16:34one more thing to that and it
01:16:37related to language competence.
01:16:38So I send students to sites in Latin
01:16:42America and at the beginning we were
01:16:46not testing our students for fluency.
01:16:50Or any type of competency while in order
01:16:53for a foreign student to come here,
01:16:57you have to bring some level of accreditation
01:17:00that you that awful or some other tool.
01:17:05So I convinced my program that we needed
01:17:09to have some standardized tests to evaluate
01:17:13language proficiency in the language that.
01:17:18Of the host country,
01:17:19and that was a request from their
01:17:23partners because it was difficult
01:17:25to teach someone who couldn't.
01:17:29Who couldn't speak but who
01:17:32couldn't understand what was being
01:17:34told was very difficult,
01:17:36so that was something that we we changed
01:17:40and it was part of those guidelines,
01:17:44right?
01:17:44So they didn't want to have a students
01:17:46anymore if they couldn't have a say
01:17:49about their language proficiency.
01:17:52Thank you so a quick
01:17:55announcement from from Karen.
01:17:57Reminders that I think it's both
01:17:59in the chat and the Q&A portion.
01:18:01Information for how you can answer?
01:18:02See me one other comment that
01:18:04learning should be bidirectional and
01:18:06teaching should be bidirectional,
01:18:08which I think is very consistent
01:18:10with what you've got,
01:18:11what you've taught us tonight.
01:18:12Don't watch it.
01:18:13What's your price tonight would you?
01:18:14Would you say that that is spot on?
01:18:17Learning and teaching should
01:18:18both be bidirectional.
01:18:20Absolutely, absolutely well
01:18:22with that alright. And the last,
01:18:24let's see if we would go along with this.
01:18:25The last thing is from our colleague over
01:18:28in the UK who says great presentations.
01:18:30So I think we can go along with that too.
01:18:32And he says thank you and I say thank you.
01:18:35This has been a wonderful evening.
01:18:37Thank you both so much for
01:18:39this for your teaching,
01:18:40our students and the rest of us.
01:18:44I know that that mean I was exposed
01:18:46recently again to your work through
01:18:48the stuff that the global health
01:18:50ethics efforts going on across campus,
01:18:53right and cafes involved in that.
01:18:54And you folks were involved in that,
01:18:56and I've had the pleasure of
01:18:57sitting on some of those meetings,
01:18:58so I look forward to more
01:19:00of that collaboration,
01:19:00and I would encourage folks who are
01:19:03here to think about how they might
01:19:05be able to help in terms of teaching
01:19:06in terms of participating whatever.
01:19:08I think that this is the are working global
01:19:11health both within and outside our borders.
01:19:14What will help us more widely
01:19:16understood now after tonight that
01:19:18work is only going to increase,
01:19:19and rightly so.
01:19:20So I thank you guys so much for tonight
01:19:23and thank you folks for attending.
01:19:25We'll see you in a couple of weeks.
01:19:27You can find the next
01:19:28program etc on the website
01:19:32biomedicalethics@yale.edu Doctor
01:19:33Sandel from a professor Sandel
01:19:35from Harvard is Next up and he has
01:19:37a tough act to follow from Doctor
01:19:38Levine and Toxic and Solace Colossal.
01:19:40Thank you goodnight.