Saturday, September 30, 2017

Breaking the link between colonialism and global medical missions

Rudyard Kipling spoke to the spirit of the age at the turn of the 20th century when he called on newly minted imperial powers to go send your sons to exile to serve your captivesneed. Then, the Western popular imagination was captivated by the myth of the intrepid white civilizer setting off to tame the savage wilds. Unfortunately, this fascination did not die out with the empires it justified. We still see ample evidence of it today, medical volontourismbeing a prime example.
            Healthcare professionals from Europe and North America are traveling in increasing number to developing countries for short-term assignments. The effects of most of these assignments range from the benign to the outright harmful; rarely do they offer real benefit to local communities. Volontourists may arrive poorly equipped to deal with their new cultural, linguistic, and even medical milieu. They can end up providing redundant care that undermines nearby healthcare systems and diverts trained in-country personnel to their activities in an internal brain drain. There is a constant risk that the lions share of the benefits will be reaped by the foreign health workers (and their institutions) who carry back the experience they acquired to their far-flung home countries to decorate their résumés.
            This inequity is a painful reminder of open wounds from a recent colonial past. To the credit of the Western healthcare community, awareness has become firmly established of how problematic medical volontourism can be. Unfortunately, it has yet to devise a solution. The push to professionalize global healthhas hit upon the snag that no one can really agree what the field constitutes. As such, there is no widely-accepted means of weeding out those with a true passion for global health issues from those with only a superficial interest.
            Physician and global health advocate Timothy Laux thinks this role might be played by existing Institutional Review Boards (IRBs). Lauxs case is that, as the only true contender for authority in health science ethics enforcement, IRBs are best-positioned to crack down on medical volontourism.
            Laux acknowledges that, at first glance, IRBs are imperfect candidates for the job. Institutional ethics panels typically confine themselves to review of research proposals and projects in accordance with research-specific regulations and the capacities of the environments they find themselves in. Moreover, theyre frequently overburdened by and understaffed for their workload. Taking the step towards passing ethical judgement on the suitability of individual applicants for volunteer placementsoften clinical in nature and on the other side of the worldwould therefore be massive. But, Laux asks, if not IRBs, who else?
Well, ethics authorities in the regions where volunteers propose to operate for one. Admittedly, this is easier said than done. Knowledge of bioethical principles, let alone the review boards to enforce them, are likely lacking in many of these environments. A possible solution could be to integrate bioethics into existing health institutions, like local Ministries of Health, who are ultimately responsible for permitting short-term medical missions to take place in developing countries. This would be challenging, as it would require buy-infrom those institutions, and the cultivation of a cadre of health and other professionals so that they are in a position to inform ministry decisions. But it is not impossible, and local Ministries of Health have a self-interested motivation in maximizing local benefits from these international volunteer initiatives. Or, to be more realistic, they have an interest to at least be in negotiations with initiatives coming from more powerful countries, to minimize the potential for exploitation.     
            All of this is not to say that IRBs have no place in this discussion. They might still be able to take a lead in assessing the merits of studentsproposed projects, a job more in line with their existing competences. But at the end of the day, the final decision makers should always be the communities who themselves stand to gainor to sufferat the hands of sons sent to exile.

Gaelen Snell 

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Wednesday, September 27, 2017

Trying to look on the bright side of colonialism

There has been a big flap this week about an article published in Third World Quarterly entitled 'The Case for Colonialism' by Bruce Gilley at Portland State University. The controversy seemingly revolves around how the article was published by the journal's editor despite having been rejected by its reviewers, i.e. a violation of the peer review process. But, of course, the complaints are not purely about the process of the paper coming to light: after all, the author is arguing that colonialism was largely a good thing, and we should have more of it. There would be much less political buzz if the journal's editor had, over the objections of reviewers, approved a paper called 'The Case Against Colonialism.'

As for the paper itself, it is something of a train wreck, and there is a strong case for thinking the reviewers (whose reviews are apparently under lock and key) were right. Gilley maps out a series of epistemic virtues (non-biased data and case selection, internal coherence, falsifiability of claims), which he uses to criticize those opposed to colonialism. In the course of building his own argument, however, he violates all of them, and how. You could base a drinking game on how many times he hoists himself on his own petard. Just one example: Gilley claims that colonialism had 'subjective legitimacy' because, he writes, the colonized populations generally approved of colonial powers and governance. His 'data' for this sweeping claim throughout the paper largely comes in the form of journalistic impressions and anecdotal remarks. This is not the worst of it. As others have pointed out, the most damning problem with the article is his relentless cherry-picking of benefits from colonial rule together with a complete disregard for the long-term and widespread damage colonial rule caused or the self-serving and usually racist motivations behind it. It does not take much effort to see the piece, particularly in the current US political climate, as historical revisionism in the service of white supremacy. No doubt defenders of such views will object that academia should be open to 'alternative voices' in the name of the First Amendment. But academic journals have no obligation to be open to crappy papers.

What could have been more interesting, instead of making a case for colonialism, is a critical analysis of the myriad ways former colonies grapple with the legacies of colonialism, since they are typically unable to fully embrace or reject them. Whatever 'benefits' might be attributed to colonialism cannot be disentangled from harms and violations; there are no real concepts to faithfully describe this. Tainted benefits? Abuses with an upside? When you drive the N1 out of Cape Town in South Africa, you are enjoying one of the best highways in Africa. You are also 'enjoying' the fruits of the Apartheid system, built by cheap labor, and as you drive, you can see townships where populations of non-whites were dumped and continue to experience the effects of political oppression. Reading Gilley is like hearing someone say: "Get over it. Don't you see you have a highway? So blind, so ungrateful."

Is there a link here to bioethics? I think so. Bioethics workers in developing countries are in a similarly uncomfortable position of being unable to fully reject assumptions, preoccupations and frameworks originating from the richer countries of the north, but also unable to fully embrace them without losing touch with (and being useful for) their own local context. The decolonization of bioethics in Africa, whose shape is hard to discern, will be a long work in progress.

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