Health Equity for Everyone, Everywhere

On April 25, Dr. Judith van de Kamp from UGlobe's flagship initiative Global Health, participated in the launch ceremony of the Department of Bioethics and Health Humanities at UMC Utrecht.

Her talk provided an ideal opportunity to learn more about Ethical Guidance for International Clinical Electives, so we sat down for a brief interview.

UMC Utrecht WHO Collaborating Centre for Bioethics

Dr. Judith van de Kamp represents the Global Network of WHO Collaborating Centres for Bioethics. The UMC Utrecht WHO Collaborating Centre for Bioethics, directed by Prof. Dr. Hans van Delden and Dr. Rieke van der Graaf, is a significant driving force behind this initiative.

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Equity in global health is about participation. It's about equal opportunities, also for students and medical personnel to develop professionally and share knowledge. By setting up International Clinical Electives within the context of strong and fair partnerships, reciprocity is created. This is crucial for sustainable and equitable medical education, and it is directly related to inclusive care, everywhere.

What is the importance of ethical guidance in this matter?

In the past 20 years, it has become increasingly popular for medical students in universities in high-income countries (HICs) to perform clinical electives in low- and middle-income countries (LMICs). It is a way for students to broaden their horizon, gain clinical exposure and knowledge on tropical diseases and health systems, while at the same time gaining intercultural competences and language skills. There is also increasing attention for the risks of LMIC clinical electives, if students are not adequately prepared for medical work in the specific cultural and socio-economic contexts. For instance, practicing outside scope of training (POST) may hinder the building of relationships with local staff and students. Moreover, electives are often unidirectional, with students from HICs traveling to LMICs and not vice versa.

So ethical guidance is important because 'traditional' International Clinical Electives (ICEs) are no longer an option. At UMC Utrecht, we are redesigning our international electives program, and were interested in knowing how other medical schools are moving towards reciprocal international electives, especially in the contemporary context of emerging social and climate justice movements. Therefore, we decided to systematically review the literature from the five past years on ethical principles for medical students and their medical schools in HICs for clinical electives in LMICs.

Could you tell us more about your (preliminary) findings?

From the systematic review of 24 articles from the last 5 years, it appears that there are 5 important themes:

1) Humility;
2) Reflection and transformative learning;
3) Local embeddedness;
4) Equitable partnerships;
5) Student health and well-being.

Within these themes, roles are distinguished for the various medical institutions (sending and hosting students), the staff, and the students who will do internships. Within these themes, there are sometimes conflicting ideas on who should do what. For instance, related to the theme of local embeddedness, authors of several articles call for HIC faculty staff accompanying their students for supervision, in order to reduce the burden on local staff in the LMIC host hospitals. There are other articles, whose authors question whether that is the right thing to do, based on a lack of knowledge on the impact of HIC faculty staff’s presence locally, and based on the principle of participation (of host staff in this case) and justice.

So the themes offer guidance in the sense of providing information on WHAT is important, and WHY, but more research is needed in order to translate this into specific guidelines.

What is the value of these findings for equitable International Clinical Electives?

I think the findings provide us with a sense of direction on how to move towards equitable and future-proof International Clinical Electives; through the establishment of ‘equitable partnerships'. Within these partnerships, active efforts are made to create internship opportunities, reduce risks, and increase benefits for all diverse stakeholders, based on principles of sustainability and reciprocity.

It is striking to see, though, that the findings also show that the academic literature on international clinical electives is still very much HIC-based, with first and last authors of 92% of the included articles affiliated to institutions in High-Income Countries, and authors of 0% of the included articles coming solely from LMICs. This focus on a HIC pose – to use Seye Abimbola’s concept from his article on foreign gaze and pose, stemming from epistemic injustice in academic global health – is showing us important gaps in academic literature on the topic.

It emphasizes the importance of acknowledging the unequal power dynamics that permeate the landscape of academic global health and global health education. We can only work towards equitable International Clinical Electives when all institutions and people involved are able to join the conversation.