I was first introduced to this mantra in a Zulu village of rural South Africa after college. A Nigerian physician performed a caesarean section in a nonsterile “theater” with reused latex gloves: “Cut; put in your hands; tear; take out baby. Done in 12 minutes. You do the next one.” The request for an undergraduate student to perform surgery raised my ethical concerns about competence, beneficence, and non-malfeasance. I entered medical school with a sharper ethical lens with which to consider research and practice. Through 11 years of training, and now, as a global child/adolescent and adult psychiatrist, the most valuable discipline I have learned is ethics, which in turn has guided my adult learning.
The medical community has developed formal ethical frameworks to guide research and practice, in part as a response to ethical breeches. The Nuremberg Code was the first international framework to standardize clinical trials, developed in response to the Nazi medical experiments in German concentration camps (1). In 1964, the Declaration of Helsinki followed, mandating that the “duty of the physician [is] to promote and safeguard the health of the people” (2). However, this framework was challenged in the 1990s, because of the initiation of HIV/AIDS trials in low-income countries. The International Ethical Guidelines for Biomedical Research Involving Human Subjects was formed to describe how the Declaration could be effectively applied to developing countries (3). Soon after, the emerging controversy regarding the Tuskegee Syphilis Study promoted the development of the Belmont Report, as 400 African American men were denied available treatment for 40 years (4). Guidelines and references have also been discussed for research more specific to vulnerable populations and domains, including child and adult psychiatry (5–7). More recently, ethical recommendations have been discussed for research in low-resource, refugee, and international settings (8–11), and some specific to psychosocial work in disaster and conflict settings (12–16). However, the emerging field of global child psychiatry has no formal ethical framework.
Ethics has long been a formal academic discipline. Discussion began in the mid-1960s of how ethics could be included in medical education (17). This concern for human rights in medical settings reinforced the inclusion of medical ethics curricula in the majority of American medical schools (18). The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) has developed a set of best ethical practice guidelines for field-based global medical training (19).
However, psychiatry is lagging behind medicine in offering global training (20), although global public mental health requires the assistance of academic centers in order to be effective (21). In American medical schools, 11% have formal global health track options for students, and 59% offer elective rotations abroad for residents (22). Students are requesting more global health curricula and experience (23, 24). A systematic review suggests that medical students receiving international health experience are more culturally competent and more likely to choose a primary-care specialty and/or public service career (25). Canadian psychiatry residents who participated in an elective in Ethiopia were reported to learn teaching, clinical, advocacy, collaboration, and leadership skills, with an increased awareness of ethical considerations and benefits from mentoring (26).
A career in global psychiatry, in particular, requires a textured understanding of cultures and belief systems, multidisciplinary learning, frequent reassessing of knowledge gaps, and further training. After working in six postwar countries, I relied on learning through targeted coursework, mentorship, and finding “hands-on” opportunities in global settings. “Global health is more ‘a bunch of problems’ than a discipline,” and, consequently, there are few theories to build a framework upon which to educate practitioners and researchers (27). My work has been guided by an ethical foundation and three guiding principles of adult educational learning theory: self-directed learning, constructivism, and reflection (28).
This concept includes taking personal responsibility for one's own learning, autonomy, and choice (28).
Global health is inherently interdisciplinary (29), with global mental health requiring public health, anthropology, medicine, psychology, and systems-of-care knowledge. In 1999, I lived in KwaZulu/Natal, which, at that time, had the highest prevalence of HIV infection in South Africa (30). Our team distributed condoms, only to have men cut the tips, believing that the government was attempting to suppress the black population. Furthermore, there was a belief that if a man had sex with a virgin (also defined as a child or foreigner), he would be cured of AIDS. Later, as a psychiatry trainee, I listened to villagers in Sierra Leone speak about how former child-soldiers were only accepted to the community after undergoing a traditional body-purification ritual. In Liberia, provinces that housed former child-soldiers reported high rates of seizures (classified under “mental health” in many low-resource countries), perhaps due to traumatic brain injury or somatization. In Ethiopia, patients, complaining of a “burning scalp” and “ringing in the ears,” traveled for 3 hours to the physician, and paid with a live chicken. In Haiti, the plight of fragmented families after the earthquake or those suffering from uncertain loss about the death of a loved one, showed how strongly individual pain extends to family and social networks.
These experiences taught me one main lesson—I needed to develop the expertise and knowledge to ensure nonmaleficence to impoverished communities. As I grew more aware of the political and social impacts on health, the ethical, legal, and medical issues in complex humanitarian emergencies, and the importance of research to answer critical questions, I did not feel I had the expertise to work intimately with those suffering in contexts so foreign to me. In pursuit of appropriate knowledge, I sought additional training through a degree in public health policy; a postdoctoral research fellowship; and certificate trainings in humanitarian response, international mental health research, family therapy, and parent–child psychotherapy.
This concept includes building knowledge on the basis of preexisting knowledge; it posits that the learner actively decides when and how to guide knowledge (26). In global mental health, this approach includes attending to cultural empathy and asymmetries of power to guide our understanding.
Cultural empathy, the ability to connect emotionally with a cultural perspective, and serious anthropological reflection can help guide one's knowledge-base. It is unclear what therapies are effective in global settings, including how or if Western psychotherapeutic knowledge is appropriate or effective in these contexts. There are studies of individual, school-based, and group therapies showing promise for specific subgroups of war-affected youth (31–38). In the context of war, there are often not available formal mental health services (39). As examples, Sierra Leone and Liberia have each endured over decade-long wars infused with horrific human-rights abuses and the conscription of children to become soldiers, messengers, porters, sex-slaves, and cooks for rebel forces (40, 41). Each country has one retired psychiatrist for a country of 4 to 6 million.
Because of the lack of highly-trained mental health professionals, many in low-resource countries use traditional ways of healing that are different from the typical individual-oriented therapies to which Western psychiatrists may be accustomed. Many persons with serious mental health problems visit a traditional healer before seeing a medical professional. Healers are reported to influence mental wounds, because they have a shared belief and understanding of how stress affects the minds and behaviors of youth (42, 43). However, traditional healing should not be romanticized. Although some patients do have less mental distress after encounters with traditional healers, others continue to suffer greatly.
Practice and studies should also be mindful of asymmetries of power inherent in working with those in low-resource countries. I visited an American mental health team that trained Sierra Leonians in cognitive-behavioral therapy (CBT), emphasizing the effects of trauma. Local counselors reported difficulty in describing emotional states, reporting mainly two emotions: “fine” or “bad.” Many non-Western cultures understand distress in terms of disruptions to the social and moral order, with little attention paid to internal emotions (44). When asked how useful CBT was, they took pride in “learning the American model,” although stating that the techniques were culturally foreign and the goals unclear. Living in some of the poorest countries in the world and being dependent on foreign aid, local people may be desperate. Foreigners are viewed as “rich white men”—providers of food and material aid. With this asymmetry in power, local communities may not have the free agency to discuss negative effects or the influence of local beliefs and practices, and may only report what they think the professional wants to hear (15, 45). The asymmetry may also involve local researchers, who compromise their identity and concern for their constituents to be part of a more prestigious and sometimes more lucrative enterprise. One should be socially and culturally responsible when applying existing knowledge, given that sometimes social interventions can have unintended consequences (46).
Formal professional preparation may not solve real-life problems. In response to an unexpected event, one can develop “wisdom” by reflection in action—creatively applying past experiences and reasoning to unfamiliar events while they are occurring, or reflection on action—where thoughtfulness about the event occurs afterward (47). This principle of learning was integral to my education, as I reflect upon the porous boundaries between researcher and clinician in my work in Haiti and Burundi, as well as the feelings of uncertainty and inadequacy inherent in this work.
Reflection in Action: Attend to the Local
For clinician-researchers working in low-resource countries, dire contexts of having few skilled providers and high mental health needs make the dual role differences between physician and researcher more flexible. On January 12, 2010, Haiti experienced a 7.0-Richter Scale earthquake, with an estimated 200,000 deaths and 250,000 collapsed buildings, leaving many individuals homeless overnight. Before the earthquake, the country was ravaged by political coups and widespread gender-based violence (48). One month after the earthquake, the smell of dead bodies lingered in the air, and rubble was strewn throughout, creating a city of gray and white. Women and girls presented with complaints related to rapes in tent camps. Terrified of dilapidated buildings collapsing, people remained homeless, with little access to clean water and food, let alone healthcare.
Often, my role as a clinician overrides that of a researcher to attend to local needs. As part of a research team, I traveled to orphanages and schools, interviewing young people about mental-health concerns. The role of a physician is to help; that of a researcher is to answer a scientific question. Asking about mental health in these settings may reveal serious concerns such as acute suicidal thoughts or the need for child protection in cases of sexual abuse. When asked about trauma, one teen at an orphanage reported she was sexually violated by a gang member after the earthquake and by a male resident 1 month earlier. Since he lived at the orphanage and there were few child-protective systems, she was certain to be violated again. The balance between clinical and research needs shifted, as her clinical needs overtook the research agenda. Each point of contact with youth is potentially a clinical one.
Reflection in Action: Collaboration
Serving the community means not only attending to local needs, but also working with local partners. Complex psychosocial problems require collaborative solutions with local communities. Mutual collaboration can build practical public health and clinical models, leading to sensible care and relevant research studies (48–50).
Burundi, another of the world's poorest countries and a neighbor of Rwanda, emerged from a 12-year genocidal war between Hutus and Tutsis in 2005. Civil strife, human rights abuses, and political instability prevent the provision of basic services. With limited time to collect data, I began interviewing former child-soldiers. After the first interview, I quickly became aware of my similarities to an interrogator, especially when I made the mistake of asking one man whether he was a Hutu or Tutsi. Youth and adults may not have discussed their experiences of traumatic loss, violence, or separations with anyone, let alone a foreigner. I changed my approach to an ethnographic one, and developed a “local ethics board” made up of an ex-combatant and leaders and members of the community, for guidance on priorities, cultural variables, and “next steps.” After these changes, former child-soldiers began sharing experiences of violent murders in the rebellion, and many justified the use of violence as protection against being victimized again, or having a moral or religious responsibility to kill. Soon, I was invited to their homes, spending time with children and families, observing and learning.
Reflection on Action: Tolerate Uncertainty
Upon reflection after each trip, the anxiety and uncertainty about my work grows. Arduous training as a physician and psychiatrist develops a self-created expectation to be an expert in healing. However, my American psychiatric model of understanding and treating cultures falls short of this expectation. Feelings of disappointment are frequent because the task of appreciating the understanding of suffering and healing by truly integrating biological, social, psychological, and cultural factors in these contexts is overwhelming. Inherent in this complex field is the interweaving of poverty, political and social justice, and physical health in mental disorders, along with the lack of resources and local healing practices capable of serving the most severe cases. Because clinical observations can fall outside the existing categories of psychiatric classifications, problems become more difficult to solve by use of a professional knowledge-base. The field then becomes an instructor—teaching how to prioritize needs, existing methods of healing, and the cultural relevance to symptoms and treatment. Through reflection on action in these complex situations, I both use and challenge professional knowledge. The importance of local beliefs and spiritual forces in the causation and healing of mental disturbances is profound. This calls for alternate constructions of understanding and flexible, responsive approaches when current models of understanding are uncertain.
Mental health work in global settings presents multiple ethical challenges, which can guide adult learning principles. Ethical practice requires self-directed learning in order to obtain the expertise to “do no harm.” Constructivism brings one closer to beneficence and autonomy, by attending to asymmetries of power inherent in this work. Reflection both in and on action reinforces the upholding of dignity for communities we are serving, by careful deliberation about our actions and reactions.
There are also security, logistical, and personal challenges inherent in this work. I was isolated by Zulu men in a rural village; our team was held hostage by former child-soldiers in Liberia; and my team was interrogated by rebel police in Burundi. The working conditions are uncomfortable: being alone, with limited access to electricity and water; using mud roads during rainy seasons; having bedbugs and lice from orphanages; and sleeping in a tent on concrete. Moreover, the transition back to America is jarring, with the experience of “reverse culture-shock” and isolation when others do not share one's experiences. Layered on this is the vicarious traumatization familiar to therapists who work with survivors. The stories and experiences are unspeakable, leaving exquisitely humiliating, indelible images in the mind. Quickly, the tie to humanity that likely sparked many of us to become physicians leaves deep feelings of guilt as the longing to return abroad settles in. Despite these difficulties, the formed relationships, new experiences, creative and academic approaches to human rights and healing—all for the purpose of advocating for those who are often unheard—are unsurpassed. Growth through this process, along with the personal and intellectual challenges that keep the mind, heart, and spirit active, keep me in this complex field.
Psychiatrists have much to offer globally. Medical school taught me how to care for patients, and, through them, how to experience suffering on multiple levels: biological, individual, social, and, to some extent, cultural. Psychiatry training taught me skills of active listening, how to construct meanings of narrative, to tolerate affect, build therapeutic alliances, and use multimodal therapeutics to ease suffering. Most important in my training were the fundamentals of effective and ethical practice. I have learned how to tolerate confusion, uncertainty, and vulnerability. We must rely on our personal, professional, and humanitarian ethical compass and rigorous self-observation to be open to lifelong learning on behalf of the people we serve. With deliberate focus on a strong ethical foundation, one can stumble more gracefully along the path forward to advocate compassionately and ease suffering for those in dire need.
I express endless gratitude to Joop de Jong, Roberta Apfel, Carl Feinstein, Ruth O'Hara, Shashank Joshi, and William Greenberg for fostering an internal passion for this work through personal and professional support.