Audrey M Provenzano, Lauren K Graber, Mei Elansary, Kaveh Khoshnood, Asghar Rastegar, Michele Barry. Short-term global health research projects by US medical students: ethical challenges for partnerships. Am J Trop Med Hyg. 2010; 83(2): 211-4.

A chance to train in a low resource setting is a priceless experience for someone who aspires to pursue a career in international health. In recent years the number of US-based medical students undertaking short-term research in low-resource settings has gone up. The paper by Provenzano and others describes specific ethical concerns related to this phenomenon and suggests guidelines medical schools can adopt to ensure that such research is beneficial to both the host and collaborating institutions.

The cost of training medical students in international health research for two to three months, just enough time for them to get used to their research setting, is high. Much of this research does not translate to new scientific knowledge but it does provide opportunities to young medical students to gain experiences that help shape their careers. The authors therefore propose that such opportunities be given to students who possess excellent personal character, exhibit high calibre in academics and research and are highly motivated to work in the field of international health.

The authors use a vignette-based mode of lucidly describing the problems faced by medical students undertaking ethical short-term global health research:

1. Student researchers are not oriented towards the culture and language of their host countries. This makes it difficult for them to collect the data required for their research. The functioning of the health system is affected when already overworked staff must help solve students’ problems.
2. Such research is often based on the priorities of funding organisations, neglecting the needs of the host institution and communities where research is done. Such prioritisation causes experts in the hosting institutions to neglect research that is important for their community.
3. Ethical clearance from the Institutional Review Boards at both the host and the collaborating institutions is usually given after examination of the informed consent process. However, the process of taking consent at the site of data collection can be far from what the researcher envisaged. While collecting data without proper consent is unethical, there is a need to incorporate field requirements into this process.

The authors suggest a list of possible solutions:

1. Such projects must be undertaken within the context of a "highly comprehensive, collaborative, bilateral partnership between the US medical school and the host institution in the destination country."
2. It must be ensured that the research does not overburden the host institution.
3. There must be a longstanding partnership so that the US-based faculty would have lived at, worked at, or at least visited the intended site of research, and therefore is able to advise students on the barriers that may exist at the site of data collection.
4. Medical students should be trained in research methods, research ethics and local cultural requirements before their departure. They should have the help of a research advisor, interpreters and logistical support in order to undertake the research as planned in the host country, and the partnerships must provide for adequate compensation for their contributions.
5. Any comprehensive partnership should provide funding for professionals and students from the hosting institution to rotate at the collaborating institute. Such ventures will build better relationships between the researchers at both institutions.
6. Research in low-resource settings must be in response to the needs of the community. Such research can be achieved if the host institution consults its community and prioritises their needs. The topics in which research is desired can then be given in writing to the collaborating institute, which on its part can facilitate research in these topics by providing funding based on whether the student has chosen a priority topic.
7. A longstanding research partnership allows sustainable capacity building and strengthening of resources at the host institution. Medical students must be encouraged by their institutions to include partners from the host institution in different elements of the research process including authorship.

Commentary

While such efforts exist and have facilitated the development of guidelines for ethical partnerships that are meaningful to both collaborating and host institutions, collaborating institutions in the US will continue to have the bigger slice of the pie until host institutions have a say in funding and selection of topics for research and researchers. Until this happens, research will continue to be dominated by the interests of foundations and agencies with their own pre-conceived ideas about what the problems of the low-resource countries are and how they must be solved.

Student exchange programmes must be based on clear objectives and such students must have a clear idea of what they hope to gain professionally from the programme.

Such initiatives should also create opportunities for young researchers in resource-poor settings and not be driven by local hierarchies which may not necessarily build research capacities in host institutions. Unless there is mutual recognition of the relative advantages and disadvantages of such partnerships, no amount of guidelines will make a difference.