Short-term humanitarian medical volunteerism has grown significantly among both clinicians and trainees over the past several years. Increasingly, both volunteers and their respective institutions have faced important challenges in regard to medical ethics and professional codes that should not be overlooked. We explore these potential concerns and their risk factors in three categories: ethical responsibilities in patient care, professional responsibility to communities and populations, and institutional responsibilities towards trainees. We discuss factors increasing the risk of harm to patients and communities, including inadequate preparation, the use of advanced technology and the translation of Western medicine, issues with clinical epidemiology and test utility, difficulties with the principles of justice and clinical justice, the lack of population-based medicine, sociopolitical effects of foreign aid, volunteer stress management, and need for sufficient trainee supervision. We review existing resources and offer suggestions for future skill-based training, organisational responsibilities, and ethical preparation.
- Clinical Ethics
- Applied and Professional Ethics
- Education for Health Care Professionals
- Public Health Ethics
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- Clinical Ethics
- Applied and Professional Ethics
- Education for Health Care Professionals
- Public Health Ethics
‘The longer one's engagement in humanitarian work, the greater one's appreciation of … the potential to do harm …’.1 Several decades ago, healthcare practitioners (HCPs) interested in international health would obtain training in public health and tropical medicine, then sign up to be deployed abroad with a non-governmental organisation (NGO) to provide humanitarian medical services.2 In essence, they would make this service their career, becoming experts at practicing in low-resource settings (LRSs).i
In recent years, however, short-term medical volunteerism3 has grown as another form of international medical service, especially after disasters, such as the tsunami in Southeast Asia, Hurricane Katrina and the Haiti earthquake, but also for non-emergent humanitarian causes, such as regular healthcare in LRSs, treatment of chronic epidemics and targeted treatment of specific neglected diseases. HCPs typically continue to hold clinical practices in their native countries, and travel to international sites for days to weeks over vacation time, or employer-approved time off to provide medical services.4–11 Volunteers may serve as part of a finite mission or in short-term assistance as part of an ongoing organisational presence. With interest in global health growing internationally, HCPs are increasingly coming in teams including healthcare students and sometimes undergraduate students, hoping to learn and assist either through volunteerism or through more structured service learning.12–21 Service projects are often organised by academic or non-academic medical centres or members of their faculty,6 ,22 religious or community groups, or an ever-growing number of NGOs. There are many considerations when providing international medical aid, and oversight of any of them is potentially problematic. A range of professional and ethical concerns are raised for patients, communities, sociopolitical systems and healthcare systems when volunteers without proper preparation or long-term experience lack understanding of contextual, technical and logistic aspects of working in humanitarian and LRSs, intentions to join a core of experienced volunteers, and plans to integrate short-term efforts into long-term sustainable solutions.1 ,21–22 Even with good intentions, it is important to remain cognisant that our actions have consequences, and that thorough preparation and investment are needed.
In this manuscript, we explore potential professional and ethical concerns in three categories, namely, our ethical duties in patient care related to the principles of non-maleficence and justice, our professional responsibilities to communities and populations, and institutional responsibilities towards trainees. We will briefly review existing resources for technical training, discuss considerations for humanitarian situations broadly, including emergent and non-emergent humanitarian situations, and finally offer potential recommendations for future programmes. Though a wide variety of health personnel provide services in international health, this paper focuses on those providing direct medical care in such settings.
Professional and ethical considerations for patients and communities
The need for adequate preparation and local collaboration
Many supporting organisations offer short-term volunteers some basic predeparture educational materials, such as about health concerns for volunteers and local culture.23 ,24 However, there is a wide range of issues requiring consideration, training and preparation, and short-term medical volunteers may not be aware of the breadth of these topics or of potential consequences if any are neglected. For instance, it is important to be knowledgeable about local disease epidemiology, medical conditions, healthcare systems and cultural and sociopolitical considerations.
Without the same preparation and experience in global health as career medical humanitarians, short-term volunteers may lack appropriate knowledge and clinical and technical skills relevant to international and low-resource medicine, and may benefit from more comprehensive training. Without adequate preparation and training, volunteers may risk causing additional harm to patients and their communities through misdiagnoses, inappropriate treatments and ineffective use of resources.7 ,25–27
Long-term relationships are also important for effective and sustainable delivery of quality patient care. Without long-term investment, short-term medical volunteers may lack prior relationships with local healthcare systems in their intended destination, or plans to continue care there in the future. For instance, while some organisations with long-term relationships in Haiti continued to serve after the 2010 earthquake,28 many medical teams with no previous experience in humanitarian settings or low-resource medicine were deployed to provide important medical services in the immediate aftermath, and did not maintain long-term assistance, leaving Haitian HCPs ill-prepared to deal with long-term follow-up care and infrastructure rebuilding.29 While immediate assistance is required in many disaster situations, and a pre-existing relationship may not be expected, leaving without providing long-term assistance may remove accountability for poor healthcare outcomes from short-term volunteers and can place significant burden on local healthcare systems to provide follow-up care.27
In the setting of non-disaster humanitarian medical aid, though short-term volunteer teams may return to one location repeatedly, long-term relationships and consistency of medical services are also important to effectively serve local communities. Without collaboration with local healthcare systems and governments, foreign aid can take pressure off of local systems to improve healthcare. Local residents may also view the care provided by foreign HCPs as superior, potentially creating distrust or non-reliance on local healthcare systems.1 ,5 ,30 Furthermore, providing medical and surgical services, medications, or medical devices that are locally unavailable or with which local providers are unfamiliar, may create complications that local healthcare systems are unable to manage.
Advanced technology, practice-based medicine, and translating Western medical practice
With increasingly advanced diagnostic technology and extensive diagnostic and therapeutic support systems becoming the norm in Western medicine, practitioners are becoming reliant on these technologies.31 ,32 Consequently, they are becoming less adept at the art of clinical diagnosis and less skilled in interpreting test results independently. However, the high cost, lack of availability and the need for supporting infrastructure are often limiting factors in LRSs.33 Volunteers may be unaware of the lack of supplies or ancillary services, or may be unfamiliar with resource-appropriate techniques, and might attempt to provide care consistent with Western standards of systemic support that are inappropriate for LRSs.27 When tests are sporadically available, Western practitioners sometimes use them disproportionately, often to rule out different conditions with which they lack clinical experience, consuming resources in an already resource-poor setting.17 ,34 Furthermore, some medications and supplies, such as laboratory reagents, disinfectants and diagnostic tests, might become unsafe or ineffective under the extreme environmental conditions, lack of controlled laboratory conditions and power outages that occur in some LRSs.35 HCPs must educate themselves about the requirements for medications and supplies before bringing or using them in LRSs without supporting laboratory or pharmacy systems.
With advances in medical knowledge and technology over recent decades, medical providers have become increasingly specialised, and the scope of residency training has, accordingly, narrowed in Western countries.36–38 The proper functioning of Western medicine relies on a robust referral system that connects a wide range of super-specialists across multiple institutions for diagnosis and treatment recommendations outside one's field. Efforts to provide Western-style care sometime fail in LRSs, which might function on basics. For instance, several surgeons in Haiti after the earthquake felt that the Haitian facilities ‘could not nearly accommodate our equipment nor our expertise …’.39 In these settings, volunteers often need to perform other duties and skills outside the scope of their normal practice, for instance, monitoring supply availability and efficacy, or preparing and interpreting blood and urine smears.5 ,22 ,40 HCPs lacking skills in practice-based medicine in such settings may have significant difficulty providing effective medical care in LRSs.
Differences in clinical epidemiology and test utility
Diagnostic probabilities, such as pretest probability and positive and negative predictive values, might differ for each symptomatic complaint, physical exam finding, or ancillary test result depending on many factors, including geographic setting (tropical, developing, etc), population characteristics (such as race, behaviour, culture, disease prevalence), and environmental setting (ie, postdisaster). Local epidemiology could change after a disaster due to changed living conditions and epidemic outbreak.41 ,42 Short-term humanitarian medical volunteers who are trained in settings with different disease epidemiology, pretest probabilities and clinical presentations of diseases may not have been well educated about local risk factors, exposures and disease incidence and prevalence, which are often compounded by a lack of primary care and preventative medicine.43 For instance, volunteers may need to educate themselves about local customs regarding pasteurisation, food preparation and storage, dietary and sanitary habits, systems for water treatment and sanitation, use of available vaccinations, clinical presentations of vaccine-preventable diseases, common antibiotic sensitivities and resistance among bacterial and parasitic infections, and the presentation and treatment of diseases, such as tuberculosis, malaria, tropical and vector-borne infections, locally endemic diseases and common diseases among displaced populations. Furthermore, many ancillary tests were developed and validated under different environmental conditions and on populations with different characteristics and disease prevalence, possibly changing the test sensitivity and specificity, and limiting the diagnostic utility. Results might need to be interpreted with respect to shifted predictive values and diagnostic likelihood, for which many humanitarian medical volunteers have limited training or experience.
Principles of justice and clinical justice
Justice, the fourth bioethical principle, is based on fairness and equity, but can have multiple and controversial meanings.44 ,45 Clinical justice includes concepts that guide our decisions about the distribution and allocation of medical resources, such as urgency, need, efficacy and equality, and argues against resource allocation based on comparative judgement of patients’ worthiness.46 Distributive justice,44 the fair distribution of scarce resources, can be especially difficult to uphold when triaging patients or resources in LRSs due to differing opinions of fairness and equality. For instance, members of some communities may prefer to utilise more resources and deliver more aggressive care to an important community figure or an older adult over a child, given a higher child mortality rate, a greater significance of elders as leaders, and the potential for immediate, rather than delayed, contribution to the community.47 Given that many short-term medical volunteers working in LRSs are from settings with relatively abundant resources, and that some may have never worked in a LRS domestically, they might struggle with making triage decisions based on patient, community or healthcare system preferences or resources, and can experience intense emotions when needing to withhold or ration treatment.9 ,47–49 Additionally, it can be very difficult to withhold treatment from patients who would have different likelihoods of survival in developed settings with more resources,50 such as a 60-year-old with a myocardial infarction, a teenager with extensive burns, or survivors of head injury, gunshot wound and poly-trauma. These decisions are always morally challenging, but they may be compounded by cultural preferences in sharp contrast with their own social norms,47 or pressure from distressed citizens attempting to use their position on the social hierarchy to obtain resources. Practitioners need to be aware and constantly considerate of dilemmas in clinical and social justice when serving in humanitarian settings.51
Greater consideration is also needed by medical volunteers to a broader social justice and human rights concept, that those with fewer resources have a right to assistance and protection, and that care should be provided as our duty as global citizens, rather than as an act of charity.42 ,52–54 When humanitarian medical aid is viewed only as an act of charity, it might be acceptable to send any HCP who is available, interested and has time and funding to travel abroad, because otherwise patients would be ‘worse off’. However, this approach risks exploiting the vulnerability of populations in need, establishing power-imbalanced patient–provider relationships, removing pressure from local governments, and creating distrust of local healthcare systems.1 ,3 ,10 ,30 ,53 ,55 ,56 Though Western standards of care may not be appropriate or attainable, the highest quality of care should be strived for. Providing care as an act of charity validates providing lower standards of care, which disrespects the dignity of patients and discounts their equality as fellow humans.53
Broader public health and population-based medicine approaches
Outbreaks of diseases, such as malaria, leptospirosis, measles and cholera often occur after disasters, due to stagnant water, lack of sanitation and change in living conditions. Epidemics significantly drain resources, but are often easily detectable and manageable with proper public health interventions. However, LRSs often lack capable systems for public health surveillance, emergency response and hospital safety control. Thus, especially after a disaster, but also in non-emergent situations, individual HCPs may need to play the role of a public health officer and be able to participate in and or direct population-based measures such as mass vaccination or other prophylaxis; health education and information campaigning; promotion of sanitation, proper medical and non-medical waste disposal, and water treatment; and early outbreak prevention, detection, investigation and containment.22 ,57 Humanitarian organisations or groups may need to establish systems for quality control, staff supervision and local surveillance of epidemiology. Many public health topics are not routinely taught in standard Western medical education, and for those with only short-term investment in international health, many do not pursue advanced training in public health or health administration. Thus, many HCPs on short-term humanitarian projects may lack the understanding, let alone the skills and practical knowledge, to implement these systems and interventions, contributing to resource wasting and potentially poorer patient care.40
Sociopolitical effects of foreign humanitarian aid
Humanitarian medical aid can affect the communities served in harmful ways as well. For instance, foreign aid can be manipulated as a political tool when medical aid is recruited preferentially to one side in a civil conflict. Potential dissonance with communities can be created by one's own social, moral and political values in areas, such as style of dress, relationships with colleagues, and hierarchy within social or health systems.1 There may be additional ethical considerations in some situations, such as the indication for community consent in addition to individual patient consent.51 ,58 HCPs with less international experience may be unaware of sociopolitical consequences, and relationships with communities may become strained in the short or long term, limiting the delivery of effective patient care and local collaboration. Measures to educate HCPs about local culture, political, historical and demographic context, and social factors can help to avoid conflict and maintain relationships.
Organisational and institutional responsibilities
Volunteer preparation and stress management:
Volunteers are exposed to extreme working conditions, higher morbidity and mortality, and ethically challenging life-saving decisions on a daily basis which contributes to potential emotional burden.48 ,57 Burn-out, depression and substance abuse are very high among humanitarian workers, with between 15% and 33% having reported depression, anxiety, exhaustion or post-traumatic stress disorder symptoms upon return.59–62 Short-term volunteers may be less prepared for the hardship of working in LRSs, and may be more vulnerable to stress responses in difficult ethical situations.22 However, some of these effects could be minimised if the volunteer has been informed before departure about potential cases they may encounter, choices they may have to make, and the possible cumulative emotional burden.14 ,48 ,50 ,63 Training in stress management, clarification of expectations and debriefing upon return have been used to reduce stress by some groups,64 ,65 but many academic institutions and international organisations that support short-term volunteers do not offer these provisions.59–66 Only about half of 17 surveyed major humanitarian aid organisations provided formal debriefing for their volunteers.59 Lack of adequate organisational support indirectly affects patient beneficence by allowing stressed clinicians to continue to serve in LRSs, possibly making more emotionally driven choices and potentially contributing to drop-out of medical volunteers.
Predeparture training and onsite supervision for trainees
With growing demand for global health experiences, but an insufficient number of academic international opportunities, healthcare students are seeking out these experiences independently, but often without adequate support and preparation.6 ,13 ,14 ,16 ,19 ,33 ,40 ,63 ,67–69 For instance, 27.5% of graduating American and Canadian medical students had participated in an international health elective as of 2006,12 but only a small percentage of medical schools provide training in global health topics.70 Among Canadian medical schools, 75% did not provide, or require, predeparture training, and 44% allowed students to arrange experiences abroad without faculty supervision or support.18
While important for learning global health skills, students often practise clinical skills while on international experiences,14 ,16 but this can be stressful for trainees and potentially place patients at increased risk without sufficient training or supervision. Teaching and leadership is expected from healthcare faculty, but they themselves may lack the expertise in humanitarian situations or in low-resource medicine to be able to provide adequate support and training.10 ,16 ,20 ,71 Organisations sometimes accept student participation without ensuring that they have the institutional resources and manpower to provide adequate supervision, without clarifying expectations that the trainee and organisation have for each other, and without interviewing trainees to assess their decision-making capacity and understanding of their own professional boundaries.14 ,16 ,63 Thus, students may attempt to practise medicine beyond their expertise or their home standards, or may provide medical care with minimal supervision.5 ,14 ,16 ,25 ,39 ,63 ,72 This can lead to significant misunderstanding, a stressful working situation, and ultimately provision of ineffective or potentially harmful medical care.14 ,33 ,63 Furthermore, insufficient student preparation and supervision places additional strain on the already resource-constrained organisations that host them.14 ,20 ,33 ,71
Multiple professional and ethical dilemmas face individuals and organisations providing services in humanitarian and global health settings.1 ,47 These dilemmas are perhaps more prominent and have larger implications with short-term volunteer-based programmes, and when trainees are participating. Ethical discussions often become very philosophical, but there is a significant need for a practical, realistic and effective approach. Little comprehensive and collaborative effort to address potential ethical and professional issues, and to create a global framework for guidance, coordination, monitoring and evaluation exist.73
The few existing educational resources for international and low-resource medicine face many barriers to their proper, practical and widespread use. Sometimes these resources are only available to those affiliated with the host organisation, such as the intensive courses produced for volunteers with Medicins san Frontiers and the International Federation of Red Cross and Red Crescent Societies,65 ,74 or are inadequately advertised or distributed, such as materials designed by some NGOs or academic institutions. Furthermore, these resources are usually designed for certified clinicians rather than trainees, and are usually not comprehensive in scope, focusing on topics such as volunteer safety, recommended vaccinations, programme specifications, travel and malpractice insurance and local culture.10 ,22 ,43 ,75–78 Handbooks containing more practical knowledge have been produced by NGOs formed to address the need for education and ethical standards in humanitarian aid, such as those by the Sphere project and Humanitarian Accountability Partnership International,30 ,41–43 ,79 but these often lack discussion of professionalism and medical ethics. Major organisations offer a few resources, such as a manual by WHO, a few publications endorsed by the American Medical Association, and an epidemiology course by the US Center for Disease Control,80–81 but there is insufficient development of educational resources, promotion of these resources to humanitarian and academic institutions, and support of preparatory education as an important issue by major national and international organisations.73 Many medical schools and residency programmes are starting to incorporate global health lectures into their regular curricula or as part of an elective track, and public health programmes routinely offer courses on topics, such as epidemiology, biostatistics and outbreak investigation,6 ,73 ,82–85 however, the cost, location or time needed for these courses may be prohibitive to HCPs planning to provide short-term services. Informal training courses through online lecture databases have been established,86–89 but require a capable internet connection, may demand background knowledge, and lack skills training.
More broadly, the lack of collaboration between NGOs and academic institutions has limited the spread and scope of existing resources. NGOs usually have more experience in the education and practice of low-resource medicine and in cooperation with local governments and healthcare systems,57 but academic institutions publish the majority of global health literature.73 Comprehensive technical training is beyond the scope of an individual NGO or academic institution, and increased effective communication, collaboration and resource sharing between these groups is needed to develop comprehensive and realistic training about clinical decision making, ethical challenges and skills needed in LRSs that can be incorporated into medical school or residency curricula. We propose the following suggestions to build a practical framework for greater professionalism and ethical consideration in global health volunteership.
Practical and skill-based training
Humanitarian medical volunteers should be trained in necessary skills for LRSs that are outside the scope of a typical daily Western medical practice, such as using microscopy, lumbar punctures, ultrasound, running a trauma protocol, complicated deliveries and the use of rudimentary chest-tube water seals.40 HCPs should have training in regard to different local standards of care, epidemiology, healthcare systems, environmental requirements for medications and laboratory tests and cultural competencies. In addition to case presentations and discussion sessions,22 hands-on simulations should be designed to gain expertise in practice-based medicine, including clinical decision making, efficiency and the art of ‘ruling in’ rather than ‘ruling out’ diagnoses. Established relationships between Western medical centres and supporting organisations for international medical volunteering can facilitate learning and direct supervision by expert faculty. Ideally, training should be incorporated longitudinally into medical education and residency programmes, and trainees should be encouraged to participate in supervised electives or projects abroad or in domestic LRSs, such as Indian reservations, inner-city clinics or medical services for immigrants and refugees.83 Written educational materials should be provided supplementary to in-person teaching.40 Development of standardised and centralised educational resources applicable to different levels and types of HCPs will allow for more comprehensive and consistent training in low-resource medicine. For those who have completed their training, an intensive course could be organised collaboratively by the international global health community as a standard source for HCPs to fill existing gaps in training. The curriculum should be developed by expert panels from major national or international medical societies, humanitarian NGOs and academic institutions participating in global health programmes, and potential venues include annual conferences, a seminar or workshop series, or Continuing Medical Education courses. More thorough global health training for HCPs will decrease the risk of patient harm in LRSs, decrease negative effects on communities, and promote a global health workforce to offer more sustainable humanitarian care.
Organisations and academic institutions have a noble duty to either train their staff or to ensure that they have necessary skills and knowledge when departing for humanitarian medical services. Candidate volunteers should be thoroughly interviewed to assess the provider's knowledge, past experiences, preparation for ethical challenges, expectations for the organisation, motivations, moral character, awareness and acceptance of their professional limitations, response to stress, and interest in long-term global health work.7 ,10 ,68 Ultimately, organisations are responsible for monitoring and evaluating healthcare provided, giving feedback to their medical volunteers, providing stress management training and services, creating systems to assure quality in patient care, and collaborating with existing governmental and non-governmental agencies in the host country.5 ,10 ,11 ,22 ,47 ,90 Medical trainees should only be accepted onto an international project if the hosting group can ensure that they will have adequate ability to meaningfully supervise trainees during tasks especially in direct patient care. To deliver more effective and efficient service, academic institutions and other global health organisations should communicate more openly, share resources and coordinate their work in a specific area, combine their strengths and collaborate to develop standardised educational resources and a supportive global health community.
Ethical challenges should be addressed at three levels. First, HCPs should receive briefing, debriefing and in-field organisational support for ethical challenges, including open discussion, case-based ethical preparation and teaching about burn-out and stress-management strategies.10 ,63 ,66 These measures will help to create a well trained and supported medical task force that is more likely to continue providing quality medical aid in low-resource areas in the future.66 Additionally, academic institutions and organisations should convey in detail their expectations for volunteers, available resources for stress and morally difficult cases, and procedures of communication when challenges do arise.10 ,22 ,66 Second, HCPs and trainees should be held accountable to the same ethical and professional standards in LRSs as in their home institutions, and thereafter to the standards of local providers and trainees.5 Additionally, confidentiality in regard to private patient information, consent for information sharing and photography (especially in the era of social media), and approval by community ethics groups for research or service activities are important concerns and need to be reinforced. There may be situations in which it is appropriate for trainees to provide care beyond their home country standards, but which is superior to that which is otherwise available, is desired by patients, and is equal to the standard for the same level of host country trainees. Most importantly, HCPs, and especially trainees, should remain aware of their limitations, seek consultation as necessary and gain patient approval before providing care. Third, standardised guidelines about how best to prepare volunteers and to detect and address ethical and professional challenges should be developed by an expert panel for the broader global health community.5 ,11 ,68
General guidelines in how to practically approach clinical ethical dilemmas, considering sets of principles, duties and concepts in medical ethics have been proposed.91 Frameworks have also been proposed to help make difficult decisions in humanitarian settings30 ,47 ,92–94 based on different conceptual models by ethicists and field workers.19 ,93 ,95 ,96 A set of practical questions to help guide HCPs as they evaluate medical ethical issues in humanitarian situations has also been developed.30 The importance of providing opportunities for open discussion, understanding local perspectives at the personal and societal levels, and remaining reflective and humble have been emphasised.19 ,94 In order to strive for equal and higher standards of care in LRSs, guidelines should be formed based on basic human rights and the providers’ moral duties for beneficence and non-maleficence, and should guide but not dictate care provided.5 ,11 ,26 There are similarities in the moral and ethical issues in each humanitarian setting, but there will be situations that are unpredictable, so guidelines could help medical providers to resolve issues, though improvisation, common sense and learning through experience are needed.30
Humanitarian medical aid is increasingly being viewed in a rights-based approach, specifically that it is our moral duty as global citizens to alleviate the suffering of others and to address the rights to health and protection. The ultimate goal of providing foreign medical assistance to a resource-poor area is to provide local residents with greater access to medical care, and to decrease the burden of disease. However, the process towards achieving this goal is complex and multifaceted, and necessitates creating long-term professional partnerships, establishing effective healthcare delivery systems, advancing medical education, and improving local public health and care standards, among others. Therefore, these efforts need to be carefully designed and organised in order to deliver effective and sustainable care, promote the efficient use of limited resources, and to ensure that greater harm is not being caused to patients and their communities. For the reasons illustrated above, more comprehensive technical training would better prepare Western HCPs for different conditions encountered in LRSs, and would likely improve their efficacy and effectiveness. Ultimately, however, only individual HCPs know best which conditions they feel comfortable diagnosing and treating, and which procedures they feel comfortable doing, and each must remain loyal to his or her moral duty to treat within their ability. For this reason, character building and proper mentorship during medical education are vital. Higher educational and service standards (either applied or self-imposed), continuous and open discussion, thoughtfulness, humility and openness, and adherence to moral principles by HCPs and their supporting organisations will likely promote a higher quality in patient care, interaction with local systems and communities, and education of trainees.
Given new trends in short-term medical volunteering, HCPs can provide effective care in a LRS for several weeks or less without putting patients or communities at risk, but only if they have the proper knowledge, skills and ethical preparation. Remaining modest in the context of local healthcare systems, humanitarian medical volunteers should hold themselves to high levels of excellence and efficiency. As global health and, thus, low-resource medicine are more widely accepted and established as unique fields, the need for proper educational resources, ethically driven guidelines, and evidence-based standards will be emphasised in order to ensure quality humanitarian medical care. Minimum standards for training or patient care in LRSs are important; however, they may have unwarranted effects of easily becoming the maximum rather than the minimum in areas such as training sought out, the quality of care that is offered, and resources that funders will be willing to grant. Therefore, continuous reflection, re-evaluation, and attempt for higher standards are paramount.
Contributors All authors listed on the manuscript have contributed sufficiently to the study to be included as authors, and all those who are qualified to be authors are listed in the author by-line. RA has made substantial contributions to conception and design of study, analysis and interpretation, drafting the manuscript and revising it critically for important intellectual content, and the final approval of the version to be published. EJ has made substantial contributions to conception of study and its analysis and interpretation, drafting the manuscript and revising it critically for important intellectual content, and the final approval of the version to be published.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
↵i Examples of such career medical humanitarians include long-term medical aid providers for organisations, such as Doctors without Borders, Partners in Health, Medecins Du Monde, International Confederation of Red Cross and Red Crescent, International Rescue Committee, and the many medical providers that relocate to another country to work in local hospitals and clinics long-term.
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