HEC Forum

, Volume 23, Issue 1, pp 43–56

Bioethics Training in Uganda: Report on Research and Clinical Ethics Workshops

Authors

    • Clinical Ethics ServiceUniversity Hospitals Case Medical Center
  • Christian Simon
    • Program in Bioethics and HumanitiesUniversity of Iowa
  • Frederick Nelson Nakwagala
    • Mulago Hospital
  • Rebecca D. Pentz
    • Emory School of Medicine
Article

DOI: 10.1007/s10730-010-9144-3

Cite this article as:
Griggins, C., Simon, C., Nakwagala, F.N. et al. HEC Forum (2011) 23: 43. doi:10.1007/s10730-010-9144-3
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Abstract

This essay describes and critically evaluates a co-operative educational program to train Ugandan health care workers in bioethics. It describes one “bottom-up” effort, a week-long intensive workshop in bioethics provided by the authors to health care professionals in a developing country—Uganda. We will describe the background and circumstances that led to the organization of the workshop, and review its planning, design, curriculum, and outcome. We will focus especially on measures taken to make the workshop relevant for the audience of Ugandan professionals, and describe lessons learned after two presentations of the workshop. Finally, we will discuss the strengths and weaknesses of such a format, and its potential value in raising bioethical expertise in developing countries.

Keywords

AIDSInternational bioethicsUganda bioethicsAbortionAccess to healthcareBiomedical research

Introduction

The volume of biomedical research being conducted in resource-poor countries has been steadily increasing, partially in response to the AIDS crisis in Africa and Asia, but also because of an ever-growing need for populations willing to participate in clinical trials of all kinds. Research is being sponsored not only by academic centers and non-government organizations (NGOs) from wealthy countries, but increasingly by the for-profit sector (primarily pharmaceutical companies). Whenever multinational research involves collaboration between a wealthy sponsoring country and a resource-poor host country, however, there is great potential for exploitation and harm. The reasons for this circumstance lie in the host countries’ poverty and desperation for medical treatments, their lack of medico-legal systems to serve as watchdogs on powerful foreign entities conducting the research, and their lack of expertise with ethical issues which govern research (Macklin 2004; Simon et al. 2007; Benatar 2002). Also, fundamental differences in moral theory and sense of interpersonal relationships may make those in traditional cultures vulnerable to exploitation. Numerous regulations, laws, and standards have been written in an attempt to protect human subjects from harm, dating back to the Nuremberg Code and Declaration of Helsinki, but these are only as effective as the ethics review committees who are charged with interpreting them and utilizing them to monitor research.

One response to the problem of exploitation by powerful researchers has been to focus on capacity building within the resource-poor countries—raising local professionals’ level of ethical expertise so that they can provide their own analysis and management of proposed research protocols. Although host countries have local ethics review boards, which must approve all research to be conducted within their borders, these boards operate at varying levels of sophistication. There is concern about their effectiveness in “pushing back” when powerful sponsors’ ethics consultants have already approved research protocols. It is assumed that if a larger core of professionals were sufficiently trained in medical and research ethics, they could better articulate their country’s morals and values, and more effectively protect their populations from harmful or exploitative research studies. Increased expertise in bioethics could strengthen resource-poor countries’ positions when negotiating with foreign sponsors, companies, and NGOs desiring to conduct research in their communities, hospitals, and clinics.

Another reason for raising the level of bioethical expertise in resource-poor countries is the widespread availability, often for the first time, of treatments for infectious diseases like HIV. As these countries gain access to HIV treatments, facility with “implementation ethics” (Rennie & Behets 2006) becomes necessary. The implementation of treatment protocols raises significant ethical challenges with regard to screening for the virus and fair distribution of treatment resources.

Capacity building in resource-poor countries can be accomplished in a number of ways. One model, used by the NIH-sponsored Fogarty International Program, offers training grants to bring select individuals to developed nations to study bioethics in established centers and academic programs. Often structured assistance is available as these trainees return to their countries to serve on ethics review boards, assume leadership positions in research and health care, or set up educational programs of their own.

An alternative model of capacity building focuses on targeting larger groups of students and professionals in the developing country, providing briefer, less intense training but reaching a larger number of individuals. This “bottom-up” approach has been utilized by a number of academic research programs and NGOs, including Family Health International (http://www.fhi.org).

Both approaches—providing formal bioethics education in Western academic centers, or less intense training to a larger group in the host country—pose similar challenges. First, there is a danger of the “Western experts” (even with the best of intentions) imposing their own ethical viewpoint upon trainees whose culture may have quite different values, customs, and moral theories (Metz 2007). Second, the vast economic disparity between Western countries and those in the developing world results in widely different health care resources and systems, with widely differing problems. Western bioethicists, less familiar with the problems of extreme poverty, grossly underfunded health care systems, and full-blown epidemics of infectious disease, may lack the frame of reference that would most resonate with resource-poor professionals.

Finally, offering bioethics training to select health care workers or researchers may be relatively ineffective in bringing about real change for patients and research participants in resource-poor countries. As Ashcroft (2005) has suggested, such limited efforts may be simply a “moral fig leaf covering the structural violence in countries in transition” (p. 229). In other words, this type of education in bioethics may be simply misguided, serving only to appease Western audiences, and failing to address the true ethical problems facing health care and research professionals in developing countries.

This paper describes one “bottom-up” effort, a week-long intensive workshop in bioethics provided by the authors to health care professionals in a developing country—Uganda. We will describe the background and circumstances that led to the organization of the workshop, and review its planning, design, curriculum, and outcome. We will focus especially on measures taken to make the workshop relevant for the audience of Ugandan professionals, and describe lessons learned after two presentations of the workshop. Finally, we will discuss the strengths and weaknesses of such a format, and its potential value in raising bioethical expertise in developing countries.

Workshop Context

Uganda, an independent nation in eastern, sub-Saharan Africa, has a population of 32 million. A former British colony, it has had a relatively stable government since 1986 and enjoys friendly relations with the United States. The country is quite poor (ranked 149 out of 171 countries in per capita income) with 87% of Ugandans living in rural areas and surviving on subsistence agriculture. The literacy rate is 69%, and public education has only recently become mandatory through the 6th grade. English is the official language, although there are approximately 43 different ethnic groups within the borders of Uganda, many of whom speak their own language.

In 2007, Uganda had one physician for every 10,000 people. The national health care budget is just over $135 per person.

Like most sub-Saharan countries, Uganda has experienced HIV/AIDS in epidemic proportions. Some 132,500 new cases of HIV were reported in 2005; and in 2007, 940,000 adults were known to be living with AIDS. The average life expectancy is now 48 years (46 for males; 51 for females) (http://www.who.int/gho/countries/uga.pdf). There are 1,200,000 children orphaned as a result of AIDS living in Uganda. The health care system struggles to deal with the epidemic (as well as the related epidemic of TB); 50–70% of hospital admissions are AIDS-related.

Uganda, however, differs from most other sub-Saharan countries in that ever since the identification of the first AIDS case in 1982, it has been acclaimed as the African nation that has taken the most open and aggressive public health approach to dealing with the epidemic. As early as 1987, President Museveni urged Ugandans to become aware of the virus that causes AIDS and protect themselves from its transmission. This open stance by the government, with widespread public education in the media, is believed to be responsible for what is known as the “Ugandan miracle”—the reduction of the HIV infection rate from a high of 25% (at antenatal sentinel sites) to the current national rate of 5.4%.

Given its stability, well-established medical schools, and friendly stance towards the US, Uganda is the site of numerous Western-sponsored research efforts. Recently, Uganda has received large amounts of aid from the US government (through the President’s Emergency Plan for AIDS relief) to provide HIV treatment to the population.

Like many African countries, Uganda is in transition from a traditional, rural and tribal-based society to a modernized, urban society. As a result, a majority of Ugandans seek treatment from both Western (modern) medicine and traditional healers when they become ill. The Western health care system can be described as two-tiered, with wealthier, insured Ugandans receiving care from private clinics and hospitals, and the majority treated in a system of government-funded hospitals and clinics.

The bioethics workshop described here was first requested by a well-established, NIH-funded, HIV and TB research program based in Kampala, the capital of Uganda. The program, a collaborative effort between an American university and a Ugandan institution, has been in existence for nearly 20 years, and is currently conducting numerous clinical trials related to TB and HIV. The goal was to provide a service to the local professionals by offering a yearly workshop in research ethics. The Ugandan partners would be responsible for designing the educational effort and would choose the site each year.

Designing the Workshop

A major concern of the workshop organizers was that the educational offering not be inappropriately dominated by Western ideology, and that the structure and content be accessible and relevant to the Ugandan participants. To this end, all aspects of planning and execution were the result of close collaboration between the American and Ugandan partners. Several key decisions promoted the “Ugandanization” of the workshop.

Ugandan Leadership

The first of these decisions determined that the Ugandans should take the lead in designing the format, recruiting faculty, and selecting participants for the training. A 5 day, intensive workshop format was determined to be the most practical for the targeted audience of Ugandan health care professionals, who could be released from work duties for that length of time. The workshop would be repeated once each year. Because most of Uganda’s ethics expertise is concentrated in the capital, it was decided that the workshops would be offered in the second largest city, where less formal ethics training has been offered. Participants would not be charged a fee to attend, nor would they receive any payment for their participation.

The Ugandan planners extended invitations to the first workshop to senior health care providers (physicians, nurses, pharmacists) in the local hospital, as well as to faculty and administrators in the local medical and nursing schools, and to individuals serving on research ethics committees (equivalent to American Institutional Review Boards). Because of favorable response to the first offering of the workshop, a number of professionals expressed interest in the second offering, and participants were selected from a pool of applicants. The selection process resulted in a more senior, established group of professionals in the first workshop, and a significantly younger group, more junior in their careers, in the second. No research ethics committee members were included in the second workshop. Attendance at each workshop was limited to 40.

International Faculty

Planners determined that an equal number of Ugandan and American faculty should be recruited. Ugandan faculty included a physician who had earned a Master’s degree in bioethics in the U.S. through the Fogarty International Program. The American faculty, recruited from academic and hospital bioethics departments, came from a variety of academic backgrounds, including medical anthropology, clinical psychology, and philosophy. Local guest lecturers were included in both workshops.

Incorporating Clinical and Research Ethics into the Curriculum

Perhaps the most important decision made by the Ugandans planners was that the curriculum should include both research ethics and clinical ethics. This decision was based on the recognition that biomedical research in Uganda, as in many developing countries, is inextricably intertwined with the delivery of medical care. Public hospitals and NGO-sponsored clinics often deliver treatment as part of research protocols, and professionals and patients alike have difficulty discriminating between research and clinical care. Aware that most front line health care workers encounter patients who are enrolled in clinical studies, the planners realized that all Ugandan clinicians should be conversant in both research and clinical ethics in order to recognize the differences between them, and the difference in the ethical guidelines that govern each. They also realized that frontline health care workers who understand the ethical requirements of research are in an excellent position to note and report any unethical practices. Because of this dual focus, faculty experienced in both research and clinical ethics were recruited.

Designing a Relevant Curriculum

Although the American faculty was charged with planning the curriculum, the Ugandans made suggestions of desirable topics and made final alterations to the drafted plan. A list of topics covered in the curriculum is presented in Appendix 1.

A unique feature of the workshop was the faculty’s high level of commitment to making the curriculum relevant to the Ugandan situation and culture. Multiple steps were taken to realize this commitment. American faculty familiar with African culture and the Ugandan health care system were recruited. Prior to the first workshop, they visited Ugandan hospitals and clinics in order to observe conditions and current initiatives such as the recently-inaugurated nationwide “Routine Counseling and Testing” program. They observed physician–patient interactions and interviewed physicians, nurses, administrators, and faculty members in order to learn of the typical ethical dilemmas faced by health care workers and researchers.

Because the hallmark teaching tool in bioethics is the case example, relevance was further enhanced by the commitment to use only cases gathered from the Ugandan experience in the workshop curriculum. Cases were gathered not only from pre-workshop observations and interviews, but also from participants at the beginning of each workshop. Participants were asked anonymously to submit descriptions of ethical dilemmas that they had encountered themselves, or observed in their work. Approximately 30 case examples were collected on the first day of each workshop and used throughout the week. A variety of both clinical and research dilemmas were submitted (see Table 1 for examples) and are presented in full in Appendix 2.
Table 1

Examples of Ugandan Ethical Dilemmas

1. “We always have prisoners being brought into hospital for further management by doctors. But oftimes there may be no drugs and then patients are required to buy their own drugs; yet they may not easily access their relatives for help. So the patients are left helpless.”

2. “My problem—why I came to hospital—is the abdominal problem which needs operation. (1) Why should I be asked to take an HIV test? (2) I have agreed and it’s positive. Now you are asking for CD4 count—and it’s low. Now you say the plan is: you can’t operate because the CD4 is low. Why deny me treatment? Doctor’s explanation: ‘The prognosis may become worse’”

3. “Unconscious patient tested for HIV (for diagnostic purpose) and found positive. On improving, patient was counseled for testing and he refused completely. How would you disclose the results, as it was done without his consent? His wife (8 months pregnant) consented and was counseled for testing and she was negative.”

4. “Breakdown during study—child: You are in the middle of an interview with an HIV orphan whose caretakers have consented to the study and he has also accepted to participate. He is 9 years old. All of a sudden he starts crying after questions concerning his late parents. He continues to cry without hope of ending soon. Do you go on with the interview? Do you stop? What can you do?”

5. “Fair Benefits: In a study of a contagious disease, only a few members in a home are eligible. They are enrolled, and they receive free full medical care and follow up. Along the way, other members of the family succumb to the disease/infection but still cannot be enrolled on the study. Is it fair for only some members to get free medical care? Shouldn’t the uninfected members of the family be given free prophylactic care?”

6. “Abortion: Just recently I had a patient who was HIV+ and had an unwanted pregnancy. She really wanted to have an abortion. She called me specifically (I am her physician) to advise her. Personally, I value my religious beliefs and practices and they are against abortion. Abortion is illegal in this country but people do it anyway. So I couldn’t tell her that. She badly needed my advice and I became speechless. How could I have handled her?”

Another pedagogical exercise was employed in each workshop, in part to deepen American faculty’s understanding of Ugandan culture, but also to focus participants’ attention on aspects of their culture that impact health care and participation in research. Small groups were asked to reflect upon Ugandan values and beliefs regarding a specific health-related topic, such as sexuality, birth control, substance abuse, or death. Topics with key observations are listed in Appendix 3.

Participants were also asked to focus on ethnic differences that might affect health care and participation in research. An exercise of this type is essential when teaching bioethics in an African nation like Uganda, which consists of 43 different ethnic groups—most of which have their own language, values, and traditions. Rivalries, prejudices, and misunderstandings exist among these groups, and impact physician–patient relationships, participation in research, and health care delivery. At least five Ugandan ethnic groups were represented among the workshop participants, and they appreciated an opportunity to talk in a formal and somewhat academic way about the ethnic differences and tensions between themselves and their patients.

Several changes were made after the first workshop to further customize the curriculum to the participants’ experiences and needs. Small group projects were assigned during the second workshop, to be completed by the end of the week. The topics were gleaned from participants’ own work experiences or research ideas, and are listed in Appendix 4. Presentation of the projects to the larger group on the last day of the workshop enabled faculty to assess the participants’ learning and skills acquisition. Also during the second workshop, a condensed version of a research protocol originating in the US, which had been implemented in Uganda several years previously, was distributed with the Principle Investigator’s permission, and a mock ethics review committee meeting was staged to illustrate the review process.

Finally, in order to heighten relevance, the faculty made a commitment to be flexible and responsive to the particular interests of the workshop participants. The curriculum was not only rewritten based on Ugandan faculty’s input, but was revised nightly based on feedback from participants.

Lectures were presented in Power Point format, although a high level of interaction and discussion were encouraged throughout the workshops. Unfortunately, because access to computers and the internet is expensive and inconsistent, course materials and readings could not be distributed electronically. Instead, they were printed in the US prior to the workshop, shipped to Uganda, and distributed during the workshop.

Excellent attendance was maintained throughout the workshops, which is somewhat unusual for the Ugandan setting. Verbal and written feedback provided at the conclusion of the workshops was extremely positive. Participants reported that the content was relevant and applicable to their daily work. A number of participants felt that their careers would be enhanced by their participation, and at least one reported later that he had been promoted to a new position in part because of his attendance at the workshop.

Lessons Learned

Providing Bioethics Education to Frontline Health Care Workers in a Host Country is an Effective and Efficient Use of Resources

Directing ethics education towards frontline health care workers makes sense for a number of reasons. Participants in both workshops reported that they regularly encountered ethical dilemmas in their clinical work, and most had directly observed irregularities related to research participation. These frontline workers knew Ugandan patients well—their cultural tendency towards passivity, their lack of education, and their tradition of paternalism. They understood how easily patients, because of their great trust in physicians, could be manipulated and even deceived. Workshop participants were also aware of the Ugandan ethics review boards, which are seen as the protectors of human research subjects. They reported dysfunction in the system, including favoritism, nepotism, corruption, and review board “shopping” when protocols are rejected. These perspectives supported the organizers’ assumption that educating frontline health care workers can enhance the level of monitoring and oversight, and provide valuable assistance to PIs, research teams, and even ethics review boards.

The appropriateness of educating frontline workers was also supported by their high level of motivation and engagement in the workshops and their willingness to disseminate the information to others. Verbal and written feedback indicated that the content was highly relevant to their work, and almost all participants demonstrated an excellent level of understanding and facility with ethical analysis by the end of the week. A number of participants shared formal and informal plans to educate others at their place of employment or in their educational programs following the workshop. At least one graduate from the first workshop returned as a “guest lecturer” for the second, and played a pivotal role in several discussions.

Careful Attention Should be Paid to Participant Selection and Group Dynamics During Ethics Training in Diverse Societies

Ethical discourse, or moral deliberation, is based on dialogue. It is rooted in the belief that each and every stakeholder has a uniquely valuable point of view, and that open discussion among stakeholders is essential to finding the optimal resolution to an ethical dilemma. This process of open dialogue between individuals of different ages, sexes, professions, levels of power, and social standing may be novel, challenging, and even upsetting for individuals from hierarchical societies such as those in Africa. Faculty learned that when teaching ethics in Uganda and possibly elsewhere in Africa, great care must be taken to facilitate open dialogue while simultaneously respecting the local culture. Faculty can accomplish this first by modeling cooperation between individuals of different sexes and professional disciplines. They can structure discussions in such a way that local elders and traditional leaders are honored, but participation by all is expected. They can also continually and explicitly point out the unique contribution of both sexes and all professional disciplines.

In observing the group dynamics in the two offerings of the workshop, it appeared that females, nurses, and younger professionals in the first workshop were inhibited by the presence of males, physicians, or “elders.” The females (most of whom were nurses) rarely contributed to group discussions except when specifically encouraged by the faculty, or when required by the structured exercises. In contrast, participants in the second workshop, who were generally younger, more junior in professional standing, and less bound by traditional gender and professional roles, adapted more easily to open discussion. They were able to establish fluid dialogue among themselves, even when disagreement was evident. Modeling a free exchange of ideas appeared to be more successful when the majority of faculty was female rather than male, and when different disciplines (not just physicians) were represented.

An International Team of Faculty, Collaborating on Design and Presentation of an Ethics Workshop can be Highly Effective, and may be Preferable to Local Faculty Alone

Concern about cultural imperialism might suggest that Western faculty should play a less active role in the design and presentation of an ethics workshop in a developing country. However, the authors’ experience suggests that an equal sharing between an international faculty is extremely valuable.

Throughout the workshops, constant comparisons of American and Ugandan culture were made by faculty. Rather than inhibiting the Ugandans, this continual juxtaposition of the two cultures seemed to help them see their own cultural values and beliefs more clearly. Hearing how Americans viewed an issue forced the participants to articulate what the Ugandan stance might be with regard to that same issue. The value of this cross-cultural discussion was such that, following the second workshop, the Ugandan organizers stipulated that American faculty should be involved in all future workshops, even if their own faculty should become sufficiently skilled to teach the workshops alone.

The multicultural nature of the faculty was key in provoking discussions that might not have occurred, or certainly would not have developed in the same way if only Ugandan faculty had been teaching. A prime example was the intense discussions that took place during the second workshop regarding homosexuality. The timing of the second workshop coincided with a sudden public discourse on homosexuality in Uganda, triggered by a lesbian couple who had very publicly “come out” and accused numerous individuals—including their physicians—of discriminating against them. Ugandan culture and religious teaching strongly condemn homosexual activity and the Ugandan participants and faculty were almost unanimous in supporting this view. The American faculty’s perception of homosexuality as a human rights issue was challenging to the Ugandans, and faculty purposely returned to the issue throughout the week. The issue had implications not only for ethical clinical practice, but also for fair inclusion of all individuals in clinical research. While no agreement was reached, the quality and depth of the discussion most certainly would not have been the same had the American faculty not been present. The ongoing discussion demonstrated to the group that respectful dialogue can occur between thoughtful individuals with strongly differing opinions.

Conclusion

With the increase in multinational research involving subjects from resource-poor countries, the need for oversight and protection of vulnerable participants is greater than ever before. Regulations and standards that effectively address the power differential and economic disparity between researchers and desperate populations are constantly being re-evaluated and refined. But equally as important are thoughtful critics and effective ethics review boards—in both the sponsoring and host countries—who will be vigilant in upholding those standards. Therefore, raising the level of ethics expertise in resource-poor countries is vital if they are to do their part in strengthening ethics review committees, making their own voices heard, and “pushing back” in a meaningful way against potentially harmful research.

One way to raise the level of ethics expertise in developing countries is to expose front line health care workers to ethics education through brief training workshops, and in this paper, we have described our experience in offering such a workshop. After reflection, we believe that this experience has implications for the larger task of ethics capacity building in developing nations.

Overall, the experience suggests that a brief (1 week) intensive program for frontline health care workers is feasible, effective, and an efficient use of resources. Financially, the costs are minimal and can be easily included in the budget of multinational research organizations. The format is workable, as participants can be granted a leave from work and/or educational activities for this length of time without undue burden. The logistics of setting up such a workshop are facilitated if there is an ongoing collaborative relationship between the researcher’s institution and the host country; an existing infrastructure greatly reduces the practical problems of communication between geographically-separated faculty and the staging of the workshop itself. However, even without a well-established infrastructure, researchers working with host countries could offer ethics training to those carrying out research protocols as well as frontline workers in the host institution.

We believe that the format described here is effective in accomplishing several goals. Recruiting frontline health care workers makes sense because they bring to the workshop a fairly astute awareness of the ethical problems that arise in local clinics and in research. With their experience as health care providers, they are able to reach a high level of sophistication and skill in a 1 week training session. In 40 hours, they are able to gain an appreciation for the similarities and differences between clinical treatment and research, and a solid understanding of the ethical principles that govern each of these endeavors. By the end of the workshop, participants can apply their learning to resolve ethical problems in their own clinics, and are capable of educating others about basic ethical issues.

Our experience suggests that a small team of faculty, but one diverse in gender, academic discipline, and cultural background, can be highly effective in educating professionals in a traditional culture. A diverse faculty can demonstrate the process of moral deliberation, which may be novel and even uncomfortable for professionals more familiar with a hierarchical or paternalistic approach to decision-making. A faculty made up of nurses, physicians, philosophers, and other professionals can underscore the value of hearing different opinions and different voices: women’s voices, nurses’ voices, minorities’ voices, and voices from completely different cultures. Participants can experience open discussion of controversial and provocative issues that might not ordinarily be discussed in their culture.

Obviously, there are many shortcomings to a brief educational model such as described here. Time limitations restrict the number of topics that can be addressed, and the depth in which they can be discussed. However, 40 hours of training in bioethics is more than is offered to most health care workers, even in resource-rich countries. A judicious use of time, exclusive focus on topics relevant to the host country, and provision of supplementary reading materials are clearly necessary, especially when both research and clinical ethics must be presented. Our experience has also taught us that sufficient time must be allowed for discussion of post-workshop implementation if participants are expected to train others or apply their new skills in their work. Building networks to support post-workshop communication is also important.

A second criticism of an ethics workshop for frontline workers is that awareness of ethical problems is being sharpened in individuals who must then return to environments that lack mechanisms for addressing these problems. Participants reported an increased ability to analyze ethical dilemmas, consider options, and recommend solutions. However, they expressed frustration that they had no real power to carry out those solutions or affect change. Participants who observed irregularities in research or in the functioning of ethics review committees not only feared retribution for speaking up, but usually could not even identify individuals or groups to whom they could make such reports. Clinical dilemmas sparked the same frustration. Participants reported great moral distress when they had to “ration at the bedside” or watch vulnerable patients like prisoners, or patients without families be denied treatment. They wished for hospital policies that would address these problems and relieve them of this burden. Obviously, making organizational change is well beyond the scope of the faculty and most of the participants in a workshop format. Educational efforts of this type clearly have to be part of a larger strategy that focuses on administrative and organizational change. Otherwise workshops of the type described here can indeed be considered window-dressing, or “moral fig leafs.”

A third problem is common to any educational effort offered by a Western faculty to a developing country audience. Presenting Western moral theories, or even “mid-level” principles such as beneficence, nonmaleficence, autonomy, and justice, may be inappropriate or even disrespectful of a developing country’s own moral framework. For example, authors such as Metz (2007, 2010) have described an “African moral theory” based on principles such as harmony, communality, and solidarity. While there are certainly commonalities between Western and African ethics, African principles may lead Ugandan physicians or researchers to very different conclusions or actions from their American colleagues. (This was quite obvious when workshop discussions turned to the topic of duty to warn partners and family of a patient’s HIV infection). It is important that the faculty from the host country be well-versed in their own moral tradition and be able to “translate” or compare and contrast their principles with those presented by the Westerners.

A final problem is that much of Western academic bioethics is, simply put, irrelevant to resource-poor countries. One of the authors (F.N.), a Ugandan faculty member educated in the United States through a Fogarty International training grant, expressed his frustration by saying to his American colleagues: “yours is a bioethics unconstrained by poverty.” What he meant, of course, was that much of Western bioethics is pre-occupied with problems that are totally irrelevant in impoverished countries: issues surrounding esoteric, cutting-edge technologies, physician-assisted suicide, and futile treatments at the beginning or end of life. Well aware of this circumstance, faculty excluded these topics from the curriculum.

However, what the resource-poor audience needed was expertise in the ethics of poverty, resource distribution, epidemics, gender inequality, government corruption, and wartime casualties—the areas in which Western bioethicists are the weakest, and to which bioethics as a discipline has devoted the least amount of research and scholarship. Participants needed to analyze the ethics of colonialism, the ways it has shaped the African psyche, and how it impacts relationships with foreign researchers today. They needed to discuss how ethics can respond to government corruption, and what professionals’ responsibility is when all the funds for patient meals have been “diverted” and there is no food in the hospital for 3 days. Granted, these problems, which fall under Paul Farmer’s label of structural violence (Farmer 2005), are not being totally ignored. They are being studied by a subgroup of internationally-oriented bioethicists. However, as a discipline, bioethics is still woefully unsophisticated in these areas.

It is naïve to think that any one type of intervention can impact global health care, or meet even a single country’s needs for ethics education. The question is whether a workshop such as the one described here can be an effective part of a larger strategy to raise ethical expertise in a resource-poor country. We believe that it can be, provided that the educational effort is responsive to the country’s realities and needs, focuses on both clinical and research ethics, and teaches skills that can be applied by participants in their environments. Finally, the training should be repeated often enough and long enough in one geographic area so as to “saturate” the area’s pool of health care workers. A critical mass of frontline workers conversant with basic research and clinical ethics can be a key factor in protecting human participants in research by keeping ethics review boards aware of problems and promoting ethical practices in health care systems.

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© Springer Science+Business Media B.V. 2010