Scrutinizing Global Short-Term Medical Outreach

About five years ago, I was among a dozen or so medical and nursing students involved in a short-term medical outreach trip to Honduras. By "short-term medical outreach trip," I mean those brief trips to developing countries taken by medical professionals and often organized by health professional schools in the United States. The idea behind them is that they expose students and faculty to people in developing countries, often for the first time, and bring much-needed care to the countries. The visitors run an acute care clinic or ambulatory surgery center, distribute donated medications, engage in health education, and learn about health care in the developing world.

At the time, I assumed that what I was doing was "ethical" and maybe even commendable. I thought it was altruistic. No doubt many with me shared this belief. But as time passes, the value of what the Hondurans gave me, in moral and educational terms, seems to surpass the value of the acute medical care I helped deliver. I did not intend this; in fact, I thought my participation would help Hondurans much more than it would help me. But if I was wrong, and the benefit went mainly to someone outside the local community, then was the trip fundamentally different from the international AIDS clinical trials that years before received such scrutiny? If so, why did our trip—and others like it—escape the ethical scrutiny applied to clinical research in developing countries?

Not Research?

I wondered at first if my questions were misguided: perhaps global short-term medical outreach is just clinical care, and not "research" at all. From the perspective of those who go on these trips, how best to understand it is less than obvious.¹ Health care personnel from a developed country organize a visit with local contacts in a developing one. The team travels to a community. With them are medical supplies, including medications and educational materials. They stay for a short period and operate something resembling a clinic or surgical center in their home country. Many individuals (though of course not all in need) receive some basic medical care. The team departs. Some time later, the medications and supplies run out (unless another team arrives and brings more). More or less continuing contact exists.

Does this situation describe research or clinical care? If this scenario were research, it might have gone through ethical review by institutional review boards in the developed and developing country. In addition, the researchers would have obtained informed consent (written or oral) from the study participants. If the scenario were a short-term medical outreach trip, neither would have happened. This lack of oversight might not be a problem if short-term outreach is unequivocally good or does not raise any interesting ethical issues. However, once we move beyond the trivial claim that outreach is different from research simply because it is handled differently, interesting ethical issues arise.

Appeals to Benefits

For example, I wondered if the crucial difference between research and clinical practice might lie in outreach's goal. Unlike research, the goal of global short-term medical outreach is not to gain "generalized knowledge" but to provide tangible medical benefits to individuals in the community (a distinction between research and clinical care equally applicable in the United States).

This is probably what many people think when they consider outreach. I thought this, too, before my trip to Honduras. But there are a couple of problems with this view. First, well-designed clinical research often provides medical benefit as well. Second, in outreach, we tend to avoid spelling out exactly what we mean by "benefit."

In fact, we are tempted to act as if any benefit counts ethically in favor of the trip, or that simply intending to provide benefit is enough. Both are too permissive. The former would endorse a short-term medical outreach whose only goal, for example, was to administer ten ibuprofen capsules to each individual in a community (even as we scrutinize a clinical trial that helps sustain a local pharmacy merely because it involves research). The latter is philosophically challenging, and it would...