Outlaws: Is it essential for medical volunteers to have their credentials formally recognized by the host country?

April 9, 2018 | Christopher Dainton

Should it be mandatory for clinicians to be credentialed by the Ministry of Health in the country they visit?

It’s the question I quietly lobbed out to a group of medical residents during a recent MacGlobal talk concerning the complicated ethics of international relief work. I explained that it was one of the most contentious items of the original thirty we proposed to our best practices discussion panel. In the end, eighteen practices found agreement. Host country licencing was not one of them.

“That’s contentious?” interjected one resident. Indeed, it is not contentious at all – in academic global health circles anyway. At the Canadian Conference for Global Health , it was the first question asked following my presentation of the 18 approved elements. Where is appropriate licencing on the list, an audience member challenged. At the time, I agreed with him wholeheartedly that it was an important omission.

After all: how was this even controversial?

CUGH Jessica Evert credentials
A virtual consensus among global health academics

Based on comments from one contingent within our panel, this was a “no brainer”. As we waited for attendees to start trickling into a session at the Consortium of Universities for Global Health, one global health heavyweight mused: “What would happen if a Haitian doctor flew to America and started providing medical care without a licence? There are lots of uninsured people in Los Angeles.”

The implication was clear. Well-intentioned or not, he would be arrested and thrown in jail.

It was similarly uncontroversial in the standing-room-only crowd of academics who then packed the room to discuss controversies around the current practices of medical volunteers. Moreover, in a separate telephone conversation, one prominent global health expert on the CUGH panel called the majority of international programs “frankly illegal”. It is undeniably true in the sense that they operate outside the authority and approval of any local government body.

Clinic in Honduras credentials
Whose voices matter?

But other voices emerged both within and outside of our panel. Many argued that host country credentialing was not a patient centred outcome. One program administrator was particularly passionate in arguing against the need for licencing in the Global South:

“Not everything that is ethical is legal, and not everything legal is ethical. That type of thinking would have kept my grandmother at the back of the bus for a lot longer than she needed to be.”

“Are you saying that unless we defer our program to the approval of this indifferent, corrupt, bureaucratically inefficient, systematically racist central government that hasn’t shown the slightest interest in these marginalized people – well, then it would be unethical to carry out our program?”

She continued:

“These are governments that routinely score near the bottom on international corruption indices. So to say that there’s no difference between an American doctor practicing in Guatemala without a specific licence, and a Guatemalan doctor practicing in the US without a licence is not an accurate comparison. To say that this rubber stamp from a faceless bureaucrat in the capital is more important than real, face-to-face community partnership is a little bit rich.”

PerĂº Carabamba credentials
What do local stakeholders think?

In January, I brought the same best practices survey south to Latin America, expecting that host stakeholders would come down strongly on the side of licencing. I was wrong.

From Peru to the Dominican Republic, there was skepticism that governments truly had the interests of their most marginalised citizens at heart. Increasingly, there is a push to integrate host perspectives into frameworks for best practice. That is definitely a good thing. But what happens when local stakeholders don’t neatly deliver the prepackaged answers that we’re expecting?

As Dr. Lorena Lopez phrased it:

“It all comes down to if locals care or not. It will make everything take more time than it should. I guess they should try to understand that even when they are trying to do things in the best way possible, like in a really formal way, that there are differences in culture.”

What did the MacGlobal medical residents think?

Back to my MacGlobal talk.

Before contaminating them with my own feelings on the matter, the residents discussed clinician credentialing in small groups. Unprompted, three out of the four groups came out against making it a mandatory requirement for volunteer groups. Many of their justifications arose from their personal experiences navigating complex bureaucracies. Meanwhile, others voiced concerns about undermining an already fragile public system.

It’s yet another front in the complicated debate over volunteering ethics. Whose voices should drive the discussion forward?




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