2017 AM: Executive Session: Short-Term Global Health Travel: Good Intentions, Murky Ethics,

2017 AM: Executive Session: Short-Term Global Health Travel: Good Intentions, Murky Ethics,

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Hi. Everyone thank you very much for coming this, is the. Panel that's the executive session for. A, short term volunteer, short, term global. Health travel. Good. Intentions murky ethics and, how anthropology, matters and I wanted to first just, say. That we're actually recording this. Session as well as a, session that we had on Thursday, which were designed to be put together and pitched, as an executive session and. We, had designed it to be back-to-back. Where the first part was going to be about the. Empirical. Evidence that we have, that. Looks at some of the murky ethics or things of concern in terms of different types of short-term, global health travel, this was short-term medical missions. International. Volunteering in health care settings international. Medical electives and so, that. Was actually a recorded, session and which should be going up on the triple A's YouTube channel relatively. Soon and. Then this side of it which, got the executive session status, was really about trying to bring together really. Conscientious. Anthropologically. Informed. Practitioners. Who've, really thought about ways, to be, doing, this, kind of global health travel, in ways that are. Much. More sensitive to the murky ethics and, more on the day-to-day basis thinking about how. Do we consciously. Conscientiously. Engage, and. So I wanted, to first just thank Olga Steen Fuentes who, was the, the. Designer, for this year's, theme on anthropology matters, and worked very well with us to try to set up this executive session and, also, the executive committee for the consideration, because it's a topic that as, educators. And, practitioners we. Come across a lot of people trying to figure out how do we create, spaces. Of engagement, across global health travel, and. Training, and this kind of thing that will actually follow, ethical. Guidelines and be truly meaningful for all parties, involved. So. Just a little bit on the Thursday panel and it included. Data. From Tanzania that was my own on international, volunteering, and healthcare settings from, Botswana, on, medical, electives, and then, to pieces on Guatemala by nichole who's here, and Katelyn who's sort of close to the end and. Those. Were on more, short term medical missions on the way that patients were trying to engage with foreigners. Who are coming to provide health care services and, all of that brought, up a lot of really. Problematic, ethics, in terms of the way that people are engaging and so this was really about hating, that part of the Anthropology, matters. Call. To, actually, look at solutions, as well or models, that that have some promise that we could potentially collectively, think with so. I'm going to invite. Nicole. Berry, to come up and talk a little bit about our format for today's roundtable. Thanks. Noel so. What. We are going to do for the roundtable, is first I am going to introduce our, long table of participants. Noel, introduced, herself and we do have two. Other participants beside, myself from the panel who won't, be talking as much but will be engaging in conversation, so. One, of them is Claire, Wendland who's associate, professor and professor or, associate, chair and professor in the Department of Anthropology and, professor, in obstetrics and gynaecology at the university of madison.

With University of wisconsin-madison, and then. Also Kaitlin, Baird who is a PhD candidate, from the department of anthropology at, the University of Florida who's seated, at the end and. So what I'm gonna do is I will briefly, introduce our, roundtable, position, participants. Who, are our anthropologically. Informed, practitioners. And then, I'm going to turn, it over to them and they're each going to give a brief around, five minute three to five minute introduction to. Talk a little bit about their work and then, we'll bring it back together and we have a couple focal questions, just. To get conversation, going among, our different panelists and once we, get that going then we're gonna go to the floor and open, up, to. The floor to take questions from you and hopefully be able to stimulate our discussion, more so. I wanted, to introduce you first of all at the very end we have David citroen and David. Is a medical anthropologist trained. In global public health who's, worked in since 2001. His. Early experiences, a met as a medical, volunteers, coordinating, medical camps led him to critically reexamine, the ethics and limitations, of model Asst models, of ephemeral health care David. Is an affiliate instructor, in the Department of Anthropology and, global health and co-directs, the Nepal studies initiative in the Jackson School of International Studies, at the University of Washington. David. Is also the director for impact, director. Of impact, for possible, an organization. That partners with the Government of Nepal to strengthen, public sector healthcare delivery. Systems. Next. We have dil flurry a so. Jill is an associate, professor of anthropology in, the associate, dean of the Honors College at the University of Texas at San Antonio, she's. A cultural and medical anthropologist. Who works on issues of healthcare, inequalities, in, the us-mexico. Border lands, northern Mexico, and south-central Texas, Jill.

Was Responsible, for implementing, a short term Spanish and clinical immersion program, for pre health professional. Or profession. Undergraduate. Students from UTSA. With, Monterey Tech University and. The Mexican Social Security Institute in Guadalajara, Jalisco. Mexico and, then. We have Rafael. Frankfurter so Rafi. Was an executive director of the well body alliance from, 2012. To 2015, and, the, well body alliance is a healthcare organization in eastern sierra leone operating, a medical center community health worker program and health system strengthening work integrated. With the Ministry of Health well. Body was at the frontlines of the Ebola crisis, and Rafi was the acting director and designer for the Ebola community, health worker systems, linked to a network of remote Ebola care centers across the early own as well, as oversaw, the integration, of partners in health into their programming and he, is currently pursuing pursuing. An MD PhD in anthropology at, the University of California, San Francisco and. Finally. We have Saskia. Bunchy and Saskia. Is a Guatemalan, physician, with an mph, in community and behavioral health, and she, works in rural southwest, of Guatemala, for fun salud Guatemala, which is a foundation, that focuses on primary, health services, and health promotion and the, foundation, hosts, medical, residents, physician's, assistants, Public Health and pharmacy students from from, abroad for month-long rotations. So. I will turn it off to you over. To you maybe we could start at the end with David and we'll work our way back. Okay. Well, first I wanted to start, by thanking Noel, and Nicole for organizing, this, roundtable. And and, the panel which unfortunately I wasn't able to attend on Thursday but I. Look, forward to seeing it on. The youtubes, because. I think it's an. Incredibly, important topic and I kind of love having this conversation so I'm really excited to be our stuff so thanks for organizing this panel I think it's great. So. I, just, had a few, kind, of ideas or comments I want to share based on. My. Experience. Kind, of being. A medical volunteer. So to speak and or helping to organize these short-term medical clinics in Nepal.

Early, On, when. I beat was first becoming a graduate student in anthropology and. Some. Of the kind of ethical. Challenges. And dilemmas that I've seen kind of permeate. This growing phenomenon, and talk, about some of the potential long-term consequences. Of short-term. Forms. Of ephemeral, care I, think. The first point I wanted to kind. Of highlight was, I. Mean from an anthropological perspective, I think one thing we, are well-positioned. And, kind of trained to focus in on as identifying. Inequalities. And I think they're, kind, of remains, a, very, strong thread. Of inequality, that exists, in these kinds of global health engagements, and opportunities, and, tremendous. Asymmetry, and the. Opportunities. And benefits as. Susan, Erickson and Claire Wendelin have written about in, an. Article called exclusionary, practices you. Know as you see the kind of explosion of global, health travel. Global, health electives, rotations. You. Might expect to see something called a get, one send one kind of approach. Where you know there's a one-for-one exchange but, that is rarely the case. Recently. For example we had a nurse. And Nepali nurse that I work with at the organization, who received a fully funded. Month. Academic. Training program, to a reputable. University in the United States and, helped. Crowdfund the remaining part of what, she needed to go travel there after kind of you, know she had been given paid time off by the organization, and we tried to support her in every way summarily. Rejected, twice by the US Embassy for her visa to come to the United States no, explanation, and you know several hundred dollars kind, of not, to mention the time gone down the drains so I, think, one. One thing we really need to do is try and push our own universities. Or institutions and, organizations, to really try and struggle for equity. Of opportunities, as a prerequisite, for kind, of engaging in global health opportunities. One. University. That does this particularly well I think in. One example is the UCSF, heal, Fellowship, which. Heal, stands for health equity action and leadership and I really, try and promote, the kind of mutual. Opportunities. For for, people for example, getting. To come to the United States getting. To be involved in fully funded master's programs, and UK. And in the United States so they're, really trying to remedy this kind of inequality of opportunities. And benefits including. Social capital which is also a major part of what these global health engagements, bring. Another. Point I wanted to highlight was this idea of regulations. And kind of. The. Importance, and global health engagements. And, short-term. Travel. Opportunities. That. Often. Skirt around councils. Or governing bodies in quote-unquote. Host countries I see this all the time in Nepal for example it, is actually illegal to engage. In any direct health care delivery on. A tourist, visa if, you come to Nepal which, is primarily, how most, students. And providers. Come. To Nepal because getting a non tourist visa or work visa is incredibly, difficult and takes months and months so most people actually do skirt, around that. Skirt. Around that that registration, process, and. I. Think one way that. We can help safeguard against. These. Maybe, misinformed, or ill-prepared opportunities. From from the United States side of things for example is to have. I are bees potentially, play a role here and evaluating, the appropriateness, of these opportunities just, like they do with research. We, might be able to. Envision. That. They evaluate, these proposals to go engage in global health travel, on a similar kind of criteria or, you, know a number of points that they look to evaluate the the appropriateness of this you could think about is, there, a partnership in place. Are. They able, to speak the language or is there a plan in place to to. Be able to communicate with the places that with people in, the places they're heading they have funding set up are. They, culturally, humble, as opposed to the phrase culturally, competent I like cultural humility versus, competency, and, are, they duplicating, efforts are they proposing something that is already going on and then maybe the IRB can kind of help link up these opportunities, and efforts so they're not, duplicating. The efforts of other folks and duplicating. Efforts of the. Local. Government. Public health and service delivery efforts. And. I think maybe it's it could, be time to to, talk about a medical volunteer or a global health travel code of conduct similar, to what we've seen with the NGO code of conduct that organizations. Like Health Alliance international. Have. Started, to write and the, first, author of that code of conduct was a medical anthropologist who's, been working in implementation, science and global health for quite a while so really helping, to kind of drive that, there are principals, and tenants in place to strengthen strengthen.

Public, Sector. Health care delivery systems as opposed to skirting, them or undermining, which I think is sometimes the, unintended consequence, of some of these opportunities. And. Then I think one, of the other. Things. That anthropologists, can bring to. Looking at these opportunities is, some. Of the long-term research that can follow from them kind of looking at the traces and after lives of these engagements what, happens when people leave both, in the. Host country you know what happens after the, medical. Student. The you, know the volunteer. Goes back and. Kind of looking, at what unfolds, there both in terms of the disruption, of healthcare delivery efforts or, for. Example if what I often see with surgical camps are there any post-operative, complications, and really, looking at the outcomes but also kind of some of this and political lives, of medicines and how they circulate, after, people, bring them there, and. Then. I think I. Don't know how much time I've probably taken more than three minutes but I'll, end, with maybe two. Kind of phrases, that I like to think about in terms of if, there are two lessons to kind of inject into the these opportunities what, might they be I think one is this rethinking. Of the idea of better than nothing something. I hear very regularly, from. People who go to Nepal to engage in these trips sighs you, know I know, they're just public health students or I know you, know we might not have saved lies but it's better than nothing and I think really pushing back against this idea that nothing. Is what people are kind of presenting up to it really does kind of quite a symbolic. Violence too already you know the the real, efforts to deliver. Public. Health and health care delivery in countries, and, the last one is in. All ways possible try, not to medicalize, poverty, and, I think a lot of these opportunities end, up really. Seeing, intervention. As kind of what, they should be doing they're the kind of biomedical, ization of these global health opportunities. Technology. Is ideology, and. Really. Trying to figure out if if, we are going to go and engage in these what, how, can we become involved in, struggles. Around. Social justice and. Projects. That lead to improved. Health outcomes that we know for example and, pull self-determine sources of food clean drinking water education, for girls and women you know things that might not be as hot, in the global health travel scene, such. As like a health, or em health are seeing a lot of this. Happening, with medical, volunteers but trying. To kind of take a step back and get back to the basics and engage, in some of these broader struggles for social justice and, the last one I guess I'd leave it with is that sorry. Global. Health starts at home so I think a lot of the students who come and ask us and they say well.

You've. Successfully bummed, me out and now I'm rethinking if I should go abroad and this opportunity, and, I, think you know one thing that we can kind. Of coach and steer students, who are increasingly coming to us to ask how to do this right you. Know global health does start at home and far, often we go abroad to help people, who we would so readily ignore right back homes so I think kind of the reframing, of the idea of global, health could, be a good story point so sorry, I took more time. So. I would also like to start by thanking Nicola, Noel um I, think. I'm probably, the only one that is mostly a clinician, and then, a public health specialist, with an anthropological, background, so I think I can speak more from. Experience, of what I see on a daily basis by working with residents and doctors, that come from the United States or students that come from the United States on a daily basis, um the, place where I work and is in the rural south west of what they might love which is a place that is very interesting. Because it's a very migrant population, and so there's not really a sense of community and so most of the time even. Myself. As a physician. In with them and uh from the city I have to approach it from the fact that I'm an outsider and that's something that most, physicians even, in the country don't realize is that as. A position, of a physician you're coming, at it as an outsider as well and, when I first worked started, working at the foundation where I work at I. Found. It interesting that we were asking, medical residents and students to rate their rotation, so, that was the first thing that we asked, them was or asked them to rate the rotation, as. An experience, and we were never really asking, the patients what they thought about the services, so, one of the first things that we implement, it was very medical. Oriented, we started looking at rhe consultations. Or revisits, or follow-up visits to see if that had an effect between doctors, but, obviously that wasn't really what we had to get out we had to start interviewing. Patients, to actually understand, what they were feeling from, being treated by both outsiders, who. Were physicians from what omona and also Outsiders that were physicians and students from the United States and what we really got to was the fact that we, didn't really know the community as a whole as well and so we started, doing a little bit of different. Changes as. One of the things that we started doing was the first week that doctors, or people, start rotating through our clinic. They're. Not allowed to start, in the clinic they must go into the communities first and so we, have a community outreach project, program and so one. Of the things that we started was if we want anybody, to come close to appreciating, or understanding, the differences we had to start with something, that was visible and so things, that you could see we're visibly different in the communities a story I like telling. Was I had, a resident, pediatric, resident telling a family that. Their. Child shouldn't be doing Co sleeping with them which, was obviously something, that in the United States is given, as part of the anticipatory. Guidance to pediatric, patients but, that was something that in the community we were in was something that was completely irrational. To me recommending. There's, another one that I like to explain too is a pediatrician, was trying to tell a family member that little, kids shouldn't, have bracelets. With beads on them because they can chew it and you, know but. That was an amulet against, my day oh ho and so that was on there but, those are very different things one is a very visible understanding. That there's, a home with one bed and everybody, sleeps in that bed and the other one is an understanding, of a culturally, bound syndrome, which is not available and if we want to get at, explaining. Something, like that to somebody who's only in the country for a month we have to start by the visible differences and so that was one of the things that we started was go. Out in the community see the homes with our nurses and. That's I think one of the benefits that we have is that our clinic is fully staffed by Guatemalan, nurses that are local and even, us as physicians that, are come, from more urban places are constantly, learning from the nurses and approaching that as a learning experience from the fact that we are, outsiders, as well because we come from more urban settings. Helps. Us a lot but mostly the fact that we have an, overwhelming, amount of local. Nurses, that come from the communities and are constantly, teaching us, so. I think one of the important, things and. Engaging. Local, physicians. In the process of medical tourism is important because it's, a rolling process for them as well. Making. Local health professionals, responsible and involving, them because, most of the time even as health professionals we come from.

A Very narrow, view that, any, help, or any medicine that comes from the outside is better and I can say that for myself it took me a long time because. Most of our training, you. Know comes from medical. Journals from the United States and books that are written in the United States and so most the time we're approaching that that that is the best medicine, and, the best and the only medicine and so you have to understand that all the doctors and health professionals in. The country, are being trained that way as well. So. I think this for me specifically. Is more a learning opportunity from, everything that you guys are saying that comes from a very different perspective but I think informs a lot of the decisions, that, I think most of us should be doing as local, practitioners. Involved in travel because. It's a learning experience not only for us but for if, you want to make. The experiences, not the experiences that make. Professionals. Visiting us do. A better job for, our patients, then we have to be informed as well. So. This is my Triple A debut so I actually wrote something that I will read. Autobiographical. But I, thought. It might be helpful if I give a bit more background of my own trajectory in this field as it has shaped my perspectives, on how we might think of global health tourism as an opportunity, to model, how ethnographic. Engagement, and the doing of global health can be profoundly, interdependent. At. This point I feel somehow, like a grateful, but deeply ambivalent product, of global health tourism myself. Entered. College vaguely interested, in medicine culture, the intersection, of the two Paul Farmer, and service in. My freshman year I became a part of a pilot project run, by Schwab, Beale in which, small groups of students from multiple social and natural science disciplines, were funded to conduct immersive, research alongside, local, global health NGOs throughout the developing world over, the summers and then, reconvened, throughout the year for critical discussion, reading and writing to think more broadly about, the intersections, of ethnography, critical. And anthropological theory, global health and the burgeoning interest in the field on campus I, was. Linked with a small NGO called well body Alliance in rural Eastern Sierra Leone my. Job that summer was to spend each day with people who had been maimed during the Civil War resettled. By Norwegian. NGO and to quote amputee, camps and then largely abandoned, after that. The. Amputees now faced widespread hunger and destitute poverty, and I had been tasked with trying. To make culturally, valid a PTSD, questionnaire. So that the NGO could potentially, begin prescribing, anti-anxiety, medications. With, an anthropology. Postdoc. I remember. Well a first interview when a woman shrugged her hands up and swept them around beckoning, us to look at her crumbling toilet children, with bloated stomachs her small subsistence subsistence. Garden and said our problems, are on your desk now I felt. Lost implicated. Shocked appalled, humbled, and confused, but, also motivated, to develop these relationships more substantively and think about how I might maybe help. Over. That summer we were increasingly, pressured, by the American, doctors running the organization to find turn our findings into a medical program and. I found myself increasingly, confronting. The limits of medicine or clinical intervention, within, such a brutal socio-economic. Context, as I. Became more deeply aware of the profound complexity, of the amputees condition, and what an appropriate intervention. Could possibly look like I also, found a certain intellectual energy along, with my peers that summer and cobbling together in crafting points of critique to push back on the reductive tendencies, of the American humanitarian, clinicians, there I bring.

This Up because I think this energy and my continued commitment to anthropology, and global health work came out of this initial volunteer, experience, and is also a possible, response to the question that came up on Thursday, so. How can we think about differentiating. Criticism. And cynicism. Over. The following three years as I returned to Sierra Leone each summer to continue service projects, for the organization, and engage in ethnographic explorations. Broadly. Surrounding the ways in which patients, healers and health workers interact, and make do amidst fleeting but promising sites of humanitarian, care in tandem. With my wrestling with thinkers like. Wendland. In particular, Petrina Redfield. In. And outside of my anthropology classes, I, found. Myself drawn to an ethnographic orientation. That was not necessarily, instrumental. But was one. Of trying to understand, while, doing, reflecting. On the ethics and politics in which I was entangled myself, and of privileges, in which my immersive experience, shall travel could bring into view the limits and problematic assumptions, inherent to global health practice, while, also maintaining a, commitment, to enacting an agenda, of global health equity this. Is an anthropology, that could open up creative, possibilities, for thinking about caregiving, beyond the technocratic logics, as much of global Public Health Theory skills. And orientations, that deeply influenced my subsequent work during the Ebola outbreak. After. College I became the executive director, for the organization, the strengthen ties with Partners in Health and establish short term volunteer, relationships, with a number of medical schools across the u.s. by. 2014, we were one of the major community, health organizations, in Sierra Leone. One. Position I took as a director, was that in developing and staffing our international, volunteer programs we could privilege both the concrete skills and services volunteers, could provide hmm. Whether. They would quote add value, as public health monks like to say but. Also recognize, that there is value inherent, in facilitating, the type of critical ethnographic, engagement, our volunteer, program offered. In shaping undergraduates, medical, students and residents to, be more complex thinkers and global health practitioners, and I'm. Happy to speak more concretely about how we selected volunteers, to operate our program supervise. Them etc I. Was. In Sierra Leone when the first Ebola cases, spread to the country and subsequently worked with Sierra Leone and colleagues to design and manage Ebola, community health worker systems attached, to remote Ebola, care centers that. Might be more attentive to communities devastated, by the disease. Reflecting. On at all I obviously, know I feel like I've transcended the uncomfortable, optics logics, ethics and politics implicated, in global health work and my own desire to work in this field but. It was certainly through my undergraduate anthropology. Education, and global health field work that I learned to feel comfortable wrestling, with them in real time voicing. Them and envisioning. What could constitute a more people centered politically, engaged copal health practice in this, case oriented, towards the Ebola response.

So. I'm left wondering after, the set of papers on Thursday morning what. If anything is substantively different between my trajectory and that of one of the global health tourists, that were described, and also. How fundamentally. Does ethnographic. Travel in global health tourism differ. I've. Personally, observed and managed 50 to 70 short-term clinicians, and I've seen inappropriate, behavior Savior complexes, simplistic worldviews reaffirmed, I've. Fired, a number of them but. I've also seen how these stints can bring into view the profound messiness, of real global health work and the need to attend to the complexity, of individual, patients and public health management in. The limits of humanitarian, medicine and resolving complex, fundamentally, political in structural disparities, in addition. To saving real lives. For, one thing we, might consider how context, matters in the region in which I work there were two doctors for 600,000. People clinical. Volunteers, in that sense we're not really displacing, local health workers in the same way as some of the papers that we. Heard and I'd, argue they actually constitute, the system, that patients navigate and have their own ways of critiquing, and theorizing and making do through fractured sites of medical care and chronic illness that endures and, I think of this as sort, of what you mentioned as the shadows, that linger after. Humanitarian. Volunteers leave. Second. I think these programs even. When only six weeks long can be structured in a way that productively, bridges critical pedagogy and insights from social science is to shape but not necessarily, burden engagement, and, finally. A point I'd like to bring up and I only truly came to appreciate as I found myself thrust, into it Ebola management, spheres is, the pervasive consequences. Of the utterly a political, and technocratic orientation. And epistemology, so, inherent, too, much of global health practice, this. Is what I spent my intellectual, energy and time countering, during the outbreak not just American, humanitarian. Cowboys though there was that - the. Irony it seems as that Global Health Travel, can either reify, this reductive worldview or challenge it and I wonder how we might think about further, reclaiming, the short-term, health trip as an opportunity, for training in ethnographic, sensitivity.

In The limits of humanitarian, logics of care. I'm. Gonna echo my thanks I'm, thrilled, to be here and I'm already learning a lot so. What I'd like to talk about is a study, abroad abroad program, in Guadalajara, Mexico, that. I co-lead, year, before last and. It definitely can be categorized. As clinical, tourism, / Clare's definition, we, were a small group of eight, women undergraduate, students in two faculty and, we, spent four weeks in Guadalajara, working with the medical school at, instituto. Tecnológico de. Su do estudios. Superiores the, Monterey or Tec de Monterrey and, their affiliated teaching hospital which was part of the Mexican Institute of social service the. First week we spent in Guadalajara, was intensive, medical Spanish training, coursework. In cross-cultural, ethics, that I taught or my co-lead. Taught and clinical. Skills, training, taught by the faculty, at the medical school at Monterrey Tech the. Last three weeks included. Clinical interning, at the teaching hospital so Monday through Thursday. Five hours a day we. Went to the hospital where, students worked with nurse teams with physician, oversight delivering, primary, care well woman care and, emergency, care our. Students worked alongside. Mexican. Medical students who were the same age and that's because in Mexico you start medical school right out of high school so our students. Are pre health medical, pre. Health profession, students, they, were working with Mexican. Medical students, I should, also note that Mexico. Works off an apprenticeship, model and, so, they put their students, immediately into, either. Teaching hospitals, or clinics if not, the first semester and then, definitely by the beginning of the second year so, the you know 19, 20 years old after. Clinical interning each day we returned in the afternoon to the Monterrey Tec campus where, we had our seminar in medical anthropology, where. We, targeted, topics. Of American and Mexican healthcare, systems and inequalities. Humanitarianism. And, medical ethics we, it was largely a structural, competency, model plus little med anthro because these were students that were coming from public health either. The EPI track or a community health model med, social medical anthropology, biology psychology, and, every. Clinic day students, wrote an academic, reflective, analytical, essay. That connected, course concepts, to observations, and, interpretations. Of the clinic experience which were then peer reviewed by at least one other student and then they received feedback from myself, at. The end of each week they, had then tied together all of their reflective. Essays into a synthetic critique. Each Friday, we spent the day in clinical, skills training, at the Medical School which I mentioned, were taught by their faculty so. Two things struck me about, our experience, compared, to what I've read about in the clinical tourism, lecturer so, barring from Claire and also, Julie Livingston our students, moral maps were different, than other, clinical, tourists, groups. Largely. Because of our students relationship, to Mexico and also, our University's, relationship. With Mexican universities, and federal agencies these. Moral maps were deeply connected to the Crono types Pripet see Betsy brought on Thursday, the students narratives about what they were doing where and why and we, saw these change through their academic essays over, the four weeks we were there the. Second, thing that struck me was that despite our somewhat, unique positioning.

Similar. Ethical, issues. Arose, nonetheless that, let, me get to our first point our position a letís our. Programming, was more in line with medicines. Recommendations. For global Ms T's and, structural. Comment competency, metod curricula. Institutionally. Though it's really important to note that UTSA. Does not have a medical school and, our students were undergrads, UTSA. Is also an HSI, or an Hispanic serving institution. With, over 40% first-gen, in college the, overwhelming, majority of, whom's, who. Their parents are from Mexico and. Are UTSA Guadalajara students, were all first gen half, were heritage Spanish speakers and half had family in Mexico that they regularly visited, as their. Instructor I'm from the us-mexico, border lands, did my dissertation work, in Mexico have collaborated, with Mexican, anthropologist. And work with Mexican, immigrant communities, and my research in the borderlands, now. At an institutional, level UTSA. Has an MoU a Memorandum, of Understanding, with Monterrey Tec we do have faculty and student, exchanges and, finally. UTSA, houses, a new higher level partnership, between knesset. The federal research funding, organization, in Mexico, we can think of it as similar to NSF and the University, of Texas System, so. Our moral maps then were implicated in complex, experience. Near pasts, and places. That perhaps. Are not as commonly represented in, the clinical tourism, literature and those. Moral, maps really, shape the students responses, to the common common, ethical challenges. That of course did arise, including. Being asked to perform clinical. Work they were entirely. Untrained. For and. Or working, in situations, that were already scarce, in time, resources. Expertise. And. Materials, thank. You. Okay. Thanks, so much for, that introduction I wanted, to say we did have one of our panelists, from Thursday or last one joining us this is Betsy beretta so, I was gonna start this off just with a continuation, I feel like Raffy is the one who touched on it most, directly, but. I wanted to take up and, hope everybody would comment on this, topic that came up at the end of Thursday's, panel, about. The value, of critique, and in forming a reforming global health travel. It seems particularly pertinent because anthropology. Is a critical discipline, that's predicated on unpacking. And interrogating, ideas and practices that, are frequently, taken for granted or, not questioned, in other disciplines yet. Critique is often interpreted outside, of anthropology, as negative, or obstructionist, to action and so. I'm hoping. People can talk to that point and. Maybe you guys do find that it's negative or obstructionist. To action too so. I hope you're kidding talk, to is critique useful in your practice how is it useful and if it is why is it useful. Any. Of you, I'll. Start okay okay but. I'll be brief. I. Think, with respect to what I'm doing so my other hat is the associate dean of our Honors College where, 85%. Of them are from the College of Sciences, and engineering, overwhelmingly, pre-health profession, pre-med students and I'm sure everybody has similar. Demographics, in their honors colleges, and. Many, of those students, want to go on clinical. Tourism. Trips and we have some that are most entirely unsupervised, and so, the way in which I see anthropology, critique informing. Practice is that anthropologist. And related. Social scientists, have to get involved in these they need to be the faculty leads they need to be their faculty sponsors, they, need to be in the forefront of their pedagogical discussions. We, also I also think that the, critiques, that we. Have heard about global health travel, are very similar to the critiques about service learning when you're working with in in your cities in your communities, with, anthropology. Coursework as well and. So I think there's a broader discussion that, can be had a cross. Disciplines, at each University in terms of how we structure. Community-based. Pedagogy, --hz which is in in large part what I see this to be I. Also. Agree, that the. Value, of anthropological critique, in what we do is very very, important, and. I will, say that as a physician, and somebody that's working in the field I understand, how.

If. You're, not used to critique and especially in Latin America where we don't take or like taking critique that easily, it, can seem very negative. It's. Very consumed. Very offensive to begin with but when. We, looked at our patient interviews we realized that most of the time patients, didn't recon salt or didn't come back for follow-up visits, it wasn't monetary, it wasn't the fact that it have transport, it wasn't any of the barriers that we normally assume, people. Have we, talked about barriers to access to health and it wasn't anything related. To that is was the fact that they didn't, feel understood, by. Their physician, and that's something that as clinicians, as providers. We really can't understand. If we don't have that anthropological. Critique to what we're doing and so, that became very very apparent when we interviewed, patients, that. Our assumption. Of what the barriers were we're definitely not the ones that, patients, had. Thanks. Yeah I think. Yes. I think the critique is always a I. Can. Say from, experience having walked into electric electra halls of. Providers. Clinicians. Doctors as a non clinician, you're, often not very, welcome they often kind of see our. Ethnographic. And, yets or details, as you, know interesting. Or quaint, but. Not necessarily, enough, to drive kind, of the changing of policy or approaches, but. But. Kind, of as you. Know as you were just saying I think some, of the broader questions, that we can ask about outcomes, about these kinds of interactions help, kind of elucidate. You. Know those unintended consequences. Of these engagements or short-term short-term. Trips, I. Can, think of several from from Nepal or even just how anthropological. Kind. Of you. Know the upstream thinking, that I think we're trained to do can often help. Identify. You. Know ways. Where people can kind of meet in the middle everything, from you, know you're talking about the amulet that had you know significance, I remember there, was one health, clinic that was set up in Nepal, and there were pediatricians.

From Austria who kept trying to get young, children to take albendazole, tablets, warm tablets very useful but. The color during. That month, of the pill happened to be inauspicious it, was as simple as that none of the parents would provide their children with this this pill because it was red they, had a generic, tablet in the back it was you. Know different color and they brought it out and all of a sudden you know children were were being given this I'm hesitant, to use that as an example because I don't want to say we. Should be using kind of or anthropological insight, to overcome, cultural barriers, in order to deliver care I think this is where the cultural competency, kind of runs a ground as opposed to humility, the. Idea that culture is something you need to understand, kind. Of you, know, shift. A little bit and then you can overcome, it in order to deliver good healthcare but I think kind of the the pulling back. And trying to understand flirt you know plural approaches, to healing the idea that you, know I think, there's a lot of conflation, of health and healthcare often, in the. Global health short-term. Mission engagements, so kind, of trying to understand that even. Outside these clinics or people, presenting, to to. You during your medical treks or whatever the model is kind. Of that that is just one. Node. In the kind of complex, you, know patterns, of resort that people are attending, to to try and seek healing some kind of helping, differentiate, between some of these categories like, healing. Treating. Curing, because I think they are very different so hopefully. I think there's room for anthropological insight, in there as well. Yeah. I think. As. I mentioned in the, thing I just read I've always, found the close integration of, critique and practice. Like, profoundly, energizing. Experience. Intellectually. Personally, professionally, the. Way that they can be dialectical, and. So, I was reflecting on that after the, panel. On Thursday, and I one, thing that I think is. Important. Potentially, although I'd be curious and hearing everyone's response is kind of. Separating. As the object, of critique, the, politics, and structures in which actual humanitarian. Practice, takes. Form. From. The, underlying, sense, of humanism that is inspiring, an, unprecedented, number of undergraduates medical, students and residents. Doctors. To want, to help in the world and, part. Of that I think is reckoning. With the. The. Real, effects. That Paul, farmers. Political. Consciousness, kind, of entering, with some sort of mainstream global, health. Discourse. On campuses, like. A political consciousness that somehow, situates. Our. Relative, privilege as deeply. Entangled with. The. Poverty, in much of the world. You. Can't you know what. That engenders, and, so. That would be my initial response is kind of how, can we, disentangle. Have, the the, desire to do good in the world to, engage, and resolve, suffering, on the part of of, students, and medical practitioners, from the very, complicated. Ways. In which such. Humanitarian, activities take form and since, the kind of engaging. An exciting way in which ethnographic. Empiricism, brings, into view the. The messiness. Of how that works. I. Mean. I don't know if anybody wants to respond to that I mean now that you're talking about this traffic it's hoping, maybe you could go back. Both. You and Jill have experiences. Of doing, some sort of curricular development. And. I guess Saskia, did you have you guys done curricular development then afterward so maybe, we. Can hear a little bit about what, what, that looks like in terms of. Some. Sort of structured guided approach to, reflection. In places where you feel, and. I don't know if you know somebody used the word structural competence so I don't know and. Then I you know I'm hearing Rafi say yes we need to be aware of the structural issues and barriers so is it just unpacking those sorts of issues that are gonna be the focus of the curriculum are those those sorts of successful, approaches or what is it that you guys have. Found as being instructive, or limiting in terms of coming up with these curricula. Around, global health practice. So. I can talk a bit more concretely, about the volunteer program that, we that. We ran if that would be helpful so. So. As, part of our application process, for, medical students, and, residents. Who. Were interested in volunteering with us in Sierra Leone we, would first do an interview an initial screen and then our main application was. A set of two, or three really. Complicated, ethical quandaries. With. No right answer like really the murky ethics of global health, you. Know well, I can give some examples if people, would be interested but and see what their responses, and how they think through it and, and.

In. General we were what, we were looking to avoid as people who were kind of overly. Dogmatic and, political in their responses, versus people who were able to wade. Through uncomfortable. Ethics in a way that seemed somehow, sensitive, and complicated. To us, when. People came out and worked with us in Sierra Leone there, if. They were clinical volunteers, there would be kind of four components, to the experience, the first would be service. To the organization, and. That often involved, direct clinical care within the district, hospital as well as, the. Oh sorry actually before I say that part of our orientation was. A pretty substantial set, of readings some, of windlance some, of some. Other critical humanitarian. Pieces. Different things that various. Theses that undergraduates, who, had worked in this. Region. Had written on complicated. Cultural. Social historical, context, so what we really primed, people with, the type of critical. Thinking that we were expecting, them to perform. In their work so, then when they got to Sierra Leone. You, know there were there were kind of four components, there was. Service for the organization as I mentioned or direct clinical care there. Was. Training. And partnership, with, local. Clinicians. We. Had a couple long-term partnerships, that introduced, whole, new services, like ultrasound. To. The, public health system which was incredible. And we would require everyone. To have. An immersive community. Experience. With some regularity that usually, involved going out with community health workers and seeing the. Socio-economic. Conditions, in, which patients lived and this was where I really, saw some productive. And generative, synthesis. Of thinking, about where. What. The limits are of clinical. Practice and in a context, like this and. Then. Finally we, all live together and we would have nightly, discussions, and continued. Reading and engaging questions about. Structure. Versus agency, what. We're doing, and prop how we're processing. You. Know the various, theory, and and. Readings. That we had they had done before and during the experience. So that. Was how we kind of thought, about. Producing. A program that would kind of whet. Critical, pedagogy with. The object, the goal of of producing. Complex, nuanced, global health thinkers with, the. Actual service that they could provide. Um. What we did for as, part of our curriculum when we have residents, or, students come over so we did two things one was work. With the social, determinants, of health and the other ones capacity-building, so the first one is we did you know what I had mentioned before the. First week was spent in the field with their community health workers or community nurses visiting. Homes they do home visits with pregnant women and with.

Children As part of our programs and so the residents, could watch and see and so there's, always a discussion about what they saw and how those determined, health and how they had to modify most. Of the education or the you know plans that they gave the treatment plans to patients based on what they saw but. I think the most important, element was, a part where we had, residents, come and we. Took their knowledge in capacity-building, and so we took residents. And we, created lists of subjects that our nurses felt they needed training on and these are community nurses training with Amala and also our local physicians. Things that we thought we were lacking in and probably, the residents from the United States had just been trained in. Especially. Pediatrics so something that was very good for example we had nurses take. Pictures in the field of dermatological, concerns. That they had the patients came with and so there. Was many times, then. We created a curriculum based on what the nurses needed and the, nurses were taught how. To treat these things from home and this was something that we use the volunteers, to teach, the. Nurses a different, subject that we might have not dominated, or might have not been expert, in and so we, use the residents back for capacity, building and things that locals, identified, as. Concerns. Or that. They lack knowledge in. So. I'm gonna talk about what I didn't like about my curriculum. So. The academic reflective, writing daily and weekly at that was did, work. The. Cross-cultural, ethics and humanitarianism, and that anthro content was good but way too late it. Needed to happen earlier and since. That time I've, learned more, about these, study. Abroad and study await horses, and pedagogy x' where you connect it with a semester, on campus and. You, also do community based experience, you're learning that's similar to what you will be doing abroad so it makes it connections, with your own community, and it, also allows the students, to have time to digest and understand, what's, going on and how it's going on the, same thing happened that I would say the same thing about our clinical skills component it. Needed to happen before the students got there and so. If I in. Fact it I put the the program, on hiatus for a little while to. Try and figure out how to address these because. We. Had the right components, but we had them in the wrong order I think. The other thing that really struck. Me when I was down there is that we were doing a full ethnographic. Immersion, experience, we were living into Medical School campus. We were participating, with the medical students we were being taught by their faculty, but. We didn't get the patient perspective and, that's because, of course in Mexico, as in the United States there are huge, power differentials, between the doctors and the patients, particularly. In the eeap's, situation. And also less. So but still there between the nurses and the patients and the patient's, point of view wasn't being solicited. As. Far as we could tell with. Respect to how the medical students were doing at. All and and, I don't know how to introduce that I know I don't want to say hey by the way can I think I think going out and visiting the community is an excellent idea if they already do it if I go now and ask them to do it that's just more, time that they don't have even. If there is compensation, for it. And it's and it's staff that we're taking away from an already understaffed, Hospital, so. So I'm not sure how, to bring that in unless it already exists, and again it may, in some degree or form that we didn't see and. Then we weren't privy to but it's certainly something I would change in the future. So. Um, I, kind, of wear two hats I. You. Know do, research, looking.

At The effects of global. Health travel, in health facilities in Tanzania and, in. The case of the research that I've done it's not the prettiest picture but. I'm also leading. A program myself or, have done for several years it's also on hiatus for some of the common. Issues Jill deals with but, to. Get at that sort of combination. Of critical pedagogy, with, with, reciprocity. And practice I think, what. We did in in, Tanzania, was actually quite great. And. It required, a lot of resources, to affect. Well, but. You. Know I think anthropologists. Are in a very unique place to be able to do something meaningful in. This realm so in my case I'd, been working doing, research in the, Tanzanian healthcare system for several years I had, very good connections, to people in particular parts of the country, and. So I was able to. Navigate. Partnerships. With, Tanzanian. Entities that would enable us a space, to be able to develop a program and, then, I told, my university, that I wasn't going to do a study abroad program looking. At in this case it was going to be community-based. Health research, on topics that local, community leaders had decided they wanted to learn about, more or better I. Said, I wouldn't do it to my university, unless they made, spaces, for for undergraduates, from, the University, of Dar aslam so. They, funded. The. Tanzanian. Students, to come and I found that the best. Matchup, in terms of the type of training they had was actually the. Medical sociology program. In the Department of Sociology and, anthropology at, the University of Dar Salaam they, were very happy to work with us on that and, also. There, was sort of some low-hanging fruit in that the, conception. That I had had was let's. Get these. Students. Outside of, what I was seeing with the volunteers, which was doing interventions. On patients, that were well. Beyond the standards of adequate. Care. Because they didn't know what they would doing and actually move them into doing something that at versus, benign in a very good. Experience. In terms of meaningful. Collaboration across, differences, and at best may give the, local governments, and local health, care workers some information, they could use, to improve their own. Understanding. Of the community that they're serving or improve their own practice. And so. The. Low-hanging fruit was that the medical sociology students. Had actually had a qualitative. Methods class during. Their curriculum, and my, plan on the Northwestern University side was to provide. A qualitative. Research methods class also where, we talked about ethics, of community health. Research and you know just thinking about more, critically, understanding. Power. Differentials. Across, different things so the, northwestern, students who went on the program were required to take a methods class with me or my colleague Peter Locke at Northwestern, and then they. Went through a rigorous process of, interviewing, to, ensure, that they had. A sense of the messiness of context. And we're really going, to go into it with much less of this. Very. Static, view of poverty's the same everywhere and much more about understanding. Nuances. Of context, and being humble about that and wanting to collaborate across differences, and then, we left it to the University of Dar Salaam to select the students that they wanted to have come.

Along So they had their own criteria and selection process and. Then they actually were, put, into teams of one. Or two northwestern, students to every. Tanzanian. Student and they would come up with I. Would give them the topics based on the topics that were selected by community, leaders where we were working and then, they, would put together a proposal, design, and I help them improve those and understand how it would map onto that context, and then, over the following several, weeks they would do it together the northwestern, students also had language. Training program in Swahili. Swahili. Is one of these languages you can actually pick up quite quickly it's a relatively straightforward. Thing, you can learn standard. Greetings and how to have a conversation with people in about a week if you've got a good teacher. And so they were actually, pretty proficient, language. Wise at least with conversations. Within, the first two or three weeks of the program. And over all the things that I would change I would definitely you, I mean I think one of the challenges with. Doing. These, kinds of programs is the amount of time and toll it can take on the, people that are trying. To coordinate all. Of that it's something that's so familiar to you and the students it's their first experience and, you, know with the Tanzanian, students as well trying. To get them to feel, at home to, engage with these foreigners that were coming in with whom they were living on a day-to-day basis, was, a challenge. Often. The Tanzanians, underestimated. The quality of their own training which was often far superior to, the training we were able to provide at Northwestern, because ours. Is interdisciplinary training. But. It was hard to get the students, to sort of own their own expertise. And their own training and. Take their take their spot as an equal in those partnerships, even when the students they were working with from. Northwestern, we're really asking them to -, you, know what do you think about that oh yeah it's good you know always without, a lot, of critical feedback so even, I think the best-laid. Programs. That really work on reciprocity, and equity. Often. That's hard to achieve from. The different players coming involved, and a lot of times, students. If you're working with students, from the hosting community as well it, can be challenging for them to find their place and I haven't quite figured out how. To how. To work through that because there's a lot of interesting, hierarchies, there as well where you never question it a professor, at in Tanzania, you you, know there's there's dynamics, of you always respect your elders you always respect guests, and it, was hard for them to sort of get, comfortable so I never quite figured out how to navigate that either. But. It did, it was something that everyone got a lot out of and I'm gonna get off my soapbox now. So. We, have, about, 45 minutes left and I had said we were gonna also, open it up to questions so.

I Have more questions but let's see if there's, anybody, who. Is among our audience, participants, we'd like to ask a question and if, you would I would ask that you go to one of the microphones so that everybody, is able to hear. Yes. Thank. You so much for this panel, I have, actually, and. Now I'm wondering. Why in the world I ever did this but a group of students, came. Up to me and said we're, gonna go on this medical. Global. Health brigades we're gonna go on this global health brigades thing we've, we've already got got. The the wheels turning. Do. You want to be our faculty, advisor and I was like. Okay. So, I. I. Guess, so. I have no I'm, a medical anthropologist but, I've never done something like this before and, I've navigated my, own complex. Relationships. And my own research. And stuff but, these. Are health. Science, students, pharmacy physical, therapy occupational therapy students, and I, and what, I understand, is there's a pretty robust, infrastructure. With, global, medical brigades but I was just wondering if like any. Of you had any experience, with this organization. If, you could give me any pointers. Unfortunately. Their. Their curriculum, is such that they won't really be able to I'm teaching a global health class in the fall but none of them will be able to take it. So. I'm, gonna do like a quick and dirty cultural. Humility seminar. They're, gonna go to Nicaragua. Let's. Talk about some. Some. Literature. But. Any advice you could, give would be would be wonderful. One. Just very short piece, that I recommend, and maybe you've read it and then I'll pass it on but there's a great it's, not an article but it's been put in print it was a speech given by Yvonne Ilic in, 1968. So incredibly, prescient it's. Called to hell with good intentions, I like, to read it every few, months and it's a beautiful piece and it was if. You don't know about Yvonne village she's amazing. And this piece is really really. Great and it is one of those ones where at the end it's pretty short and you know students are just like but. It really, encourages.

To Kind of willfully, give up the. Privilege, we have to go and kind of spread our benevolence. Around the around, the world yeah. I. Think I think it's really important for students to understand, even, before they get there that their perceptions, coming in can actually influence. The, organization, that, they're going to so. It. It, becomes a case of sometimes if students go in expecting to see a certain kind of person and. Those. Students are bringing money into that organization, then. It becomes a sort of donor driven chaos that, can change, programming. And actually. Make sure that ensure. That some people don't have access to care so. Um I, think that's an important. Thing to start thinking about before you ever put boots on the ground. So, probably. The two texts that I would recommend, for thinking. About that seriously, and I think they're appropriate for an undergraduate audience, would be Mark Schiller's killing with kindness of, course and Vincent. Adams markets. Of sorrow and laborers of faith. If. I can jump on that Vince and Adam tips. Excuse. Me if I can jump on the Vince and Adam tip I've. Been sand Adams tips sorry that's hard to say uh ask. A. Text as a recommendation, for, a question to ask them and that is what. What. Are the metrics, that, they implicitly. Think. Would. Be useful. In. Assessing. What. It is that they think they are doing. Right. So. You. Know at least in my own research there's, a lot of. There's. A lot of attention paid to how close did you get to somebody's, body right. What, kind of body was it what kind of illness was, it right I, think in her in her discussion. On Thursday. Claire wetland gave us her undergrads. Ranking. Of sort. Of the most the, most suffering body you can touches, the was it the samal deworming the Somali orphans, right. Okay, right so so, these, are things I think it's really worth trying, to. Helping. Them try to make explicit, to themselves. Before. They go right, would, it be enough, to watch, somebody, do, physiotherapy. Or pharmacy. In a, really different place, right. Would, that somehow feel like they lost out right. And why what. Are they losing right. Because. I mean, at least for. Yeah, I might do my research in Botswana, and and, was, looking at a program where where, medical advanced, medical students were coming through on on sort of six to eight week rotations, and one, of the things that made them very anxious, was a sense that they might somehow, lose out on something. That they needed to get. Right. And they weren't always entirely, sure, what that thing, was but. It made them anxious and their anxiety. I think, contributed, to a, phenomenon. We've all seen which is people overstepping, their, clinical training in ways. That approach injury. I'm. Just gonna step in here as well because I've got a lot of sensitivity, about I, mean. As faculty members that if you do any kind of teaching and medical anthropology, or global health you're often asked to do that kind of service. As the faculty, advisor. And, a, lot of that in my experience anyway some. Student, groups are much more willing, to come to you and and and. Have you help them think through these things and others are and. I think I want, to be really sensitive to the structures, that inform. How. Students, are thinking about those experiences right, because. It's it gets very easy. Through. The criticism, for students to feel like they're being attacked and that's, not. Really. Where we're, going to get them to think a little bit more critically, about what's happening, and. When you always get a flattened. Understanding. Because, of all of the advertising. And the discourses, that are so familiar about. Places. That we tend to other in, our media, and our. Daily. Conversations. And the issues of white supremacy, that are sort, of seem, to trickle through a lot of things in our big part of our discourse right now I found. Our students really don't want to engage in that or not really trying to figure out how to do it right. But. One of the there's, there's two major barriers one is that an organization. That. Is a national organization, that has these student, chapters, the. Presumption, that a lot of my students have is that the, chapters, done all the research so, I can plug and play and.

What. I can tell you about, this, is there. Tends to be on the part of the of, these now, I'm not speaking about my, research, is on private. For-profit. Volunteer. Placement organizations, but the. Organization, you mentioned in several others are of a slightly different type because there's partially, student-run, but there's a national, sort. Of office that helps direct things right and so, in those cases a lot of times they're saying, okay here's what the needs are in this plac

2018-01-25 17:39

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