Helping students build strong foundations in ethical global health work

When she was a student at Yale School of Medicine more than a decade ago, Dr. Mei Elansary ’12 conducted a project on the Indonesian island of Borneo. Over several weeks, she interviewed clinic patients about a program that offered more accessible health care in exchange for rainforest protection advocacy.

At the time, Elansary grappled with ethical concerns about her work: Was she taking valuable time away from her on-site mentor? Did the patients she interviewed believe that their participation in her research project was voluntary?

These kinds of concerns were common among her classmates working abroad, says Elansary, now an assistant professor of pediatrics at Boston University School of Medicine. “When we returned, we had each experienced different ethical dilemmas,” she said recently.

When they returned, she and a classmate shared their concerns with faculty members. The feedback soon spawned a series of conversations that would eventually lead to the creation of the Global Health Ethics Program (GHEP). The program, which is now part of the Yale Institute for Global Health, helps students prepare for potential ethical challenges before they conduct research or clinical projects abroad.

“The program teaches students how to recognize what is going on, how to set themselves up for success and avoid challenging ethical situations, and how to identify resources that may help if they do find themselves in those situations,” said Tracy Rabin, associate professor of medicine and co-director of the program.

Many Yale graduate, medical, and nursing students conduct short, 10- to 12-week projects in other countries. Those conducting research are required to carefully consider their project design, make sure they ask good research questions, study previous research so they fully understand the problems they’re exploring, and think through what data to collect and how — just as they would for any research project.

They also have to get approval from Yale’s internal review board (IRB), which ensures proposed projects comply with federal and state regulations, university policy, and ethical standards.

That last part is key, says Kaveh Khoshnood, associate professor of epidemiology at Yale School of Public Health and co-director of the Global Health Ethics Program. “Ethics are central to research projects,” he said. “Students should ask themselves: Why do you even do human subject research? Who is going to benefit? Who is potentially going to be at risk or be harmed by this research? These are big questions.

“And the question behind the program is, how do we prepare students to identify and navigate ethical challenges when pursuing these short-term global health projects?”

Facing challenges abroad

The ethical challenges students face while working abroad can run the gamut, from difficulties navigating relationships at their host institution to misunderstandings about their level of training, from challenges in implementing IRB protocols to distress over their project’s potential impact.

The program aims to use these challenges to prepare students before they ever leave the Yale campus. Students conducting either research or clinical projects attend a pre-departure workshop where they review case studies written by students like Elansary who have returned from projects abroad. During the workshop, students are asked to consider potential challenges they might face and develop strategies to address them. Then, when they return, they reflect on their project, which offers an opportunity to talk about their own experiences and the steps they took to solve problems.

The response from students has been positive. Those who’ve attended the workshops appreciate the opportunity to strategize before leaving, Rabin says.

“Students want to do the right thing,” added Khoshnood. “They want their research to be impactful, be meaningful, and not cause harm.”

In 2017, Rabin and Elansary coauthored a study to formally assess the curriculum, and found that the program is serving its purpose. In most cases the challenges students faced abroad were issues they’d discussed beforehand.

The GHEP team has since made the curriculum available to other universities.

Facing challenges at home

In 2020, the program faced a new kind of challenge when the COVID-19 pandemic hit. Traveling abroad was no longer an option for students, so many pursued local projects instead.

“Everybody agreed that domestic research was important and relevant,” said Khoshnood.

While people sometimes think of “global health” as something that happens “everywhere else,” it actually encompasses every region and every community, Rabin says. “There is plenty of global health work that I engage in domestically and even here in New Haven,” she said.

Some of the issues normally covered in the workshops suddenly became very applicable right here at home, including the lack of personal protective equipment during the early months of the pandemic. Local hospitals didn’t have enough N95 masks for everyone. So while staff members with their own masks were allowed to use them, there were occasions when they were the only person on their team with a mask, working side-by-side with others who weren’t protected in the same way.

“The same issues that we prepare folks to deal with in resource-limited settings outside of New Haven were coming up here,” said Rabin. “People started to realize that these issues of ethics that relate to global health are very much applicable to our setting.”

Many aspects of working during the pandemic were familiar to those with experience with global health, says Rabin. She and other global health educators recently discussed how clinicians with global health experience felt more prepared to handle difficult pandemic situations. Highlighting the value of these experiences might encourage more support for global health education, she says.

Meanwhile, as old problems surfaced in new settings, new challenges arose as well. Some researchers shifted to conducting projects abroad remotely. And ethical issues particular to that type of work became apparent.

Joe Williams ’22 M.P.H. led a research project on the ethical challenges of remote research. He interviewed students in the United States who conducted remote global health research in 2021 and 2022 and found some common themes. “We found that in-country research partners are really important, as is having active mentors,” he said. “Also, according to the students we interviewed, training for this work could be improved.”

His interviews also highlighted how remote research brought new benefits and new challenges, including lower costs and unreliable technology, respectively. Williams recalled one student who shared concerns about conducting remote interviews in the studio apartment she shared with her partner. Confidentiality was important, so she would do interviews in her bathroom so as not to risk being overheard.

The program’s workshops now include case studies on the ethical challenges of remote research, written by Williams and based on the interviews he conducted. Given the lack of scholarship in this area, this work is a first step in filling an important gap, said Khoshnood, who was Williams’ mentor for the study.

Working in this field has been particularly interesting in this moment, Khoshnood added, as people see issues around global health ethics play out in real time.

“Global health ethics are now more urgent than ever,” he said. “And I hope the world agrees with that.”