Situating Global Health Fieldwork Ethics within the Right to Health

Rachel Hall-Clifford

When I began working as a medical anthropologist on childhood illness in Guatemala over a decade ago, I wanted to explore what the right to health meant for communities targeted by global health initiatives and how local people experienced those programs. I had training in anthropology and public health, including field methods and research ethics, and I felt ready to take up my small area of work in global health, ultimately motivated by a desire to make the world a bit fairer. As the years progressed, I came to the realization shared by all seasoned fieldworkers that research projects and implementation programs rarely go to plan and the problems encountered are not the ones you anticipated. There were instances in fieldwork, as foreign research staff, local implementation teams, and community members interacted, that gave me ethical pause yet did not violate the Common Rule or break from ethics board-approved research protocols.

I likely would have continued to push the ethical grey areas of my work to the side, using instinct to fill in where formal research principles were absent or inapplicable to the real world situations in which global health is enacted, in order to prioritize project goals and to focus on making the right to health come to life. But then my friend died. My Guatemalan friend and colleague was brutally murdered due to his work to support the right to land, education, and access to primary health care for an indigenous community—goals we both shared. This tragedy forced me to recognize the deficiencies of my thinking about fieldwork ethics, to reckon with the responsibility of decisions made in the field, and to grapple with the ambiguities of their aftermath.

My own particular ethical challenges reflect more broadly the inadequate attention to fieldwork ethics in global health. Clarification of how ethical principles should be applied in global health fieldwork is complicated by the hugely varied and difficult contexts in which global health projects are conducted. Moreover, the interdisciplinary nature of global health also means that we must contend with varied disciplinary approaches and ethical traditions, marking an ethical echo of the sentiment from Paul Farmer that, “global health remains a collection of problems rather than a discipline” (2013: xiii). Further, the emphasis on evidence-based practice in global health may encourage a focus on data at the expense of acknowledging the often messy realities from which they arise.

Global health bridges research and practice in its endeavor to realize health rights. In doing so, global health implicitly draws upon moral values, as it focuses on reducing inequality and promoting health and social justice. However, global health must more fully consider the asymmetries embedded in our own practice—imbalances of power, access to resources, and decision-making—many of which come to a head in fieldwork contexts. How can we balance a moral imperative to act with the ethical principle to do no harm? The opportunity to explore these broader fieldwork ethics concerns with colleagues in global health are infrequent—and much more likely to take place in informal conversations rather than within the literature or formal professional discourse.

In an effort to move toward more open dialogue surrounding fieldwork ethics, researchers and practitioners from government, non-governmental organizations, and academic institutions came together for a workshop on global health fieldwork ethics co-organized by David Addiss (Task Force for Global Health), Robert Cook-Deegan (Arizona State University), James Lavery (Emory University), and myself, in Atlanta, Georgia, US, in April 2018. The workshop participants represented a wide range of disciplinary backgrounds and fieldwork expertise, and each participant shared a case scenario in which they encountered an ethical grey area in their work.

Drawing on this collective set of experiences, the workshop participants began to map global health fieldwork ethics challenges, in recognition that we need to acknowledge the challenges we face to be able to more systematically account for them and address them as a field. What emerged during the workshop was an incredibly rich and eye-opening discussion of a broad range of ethics topics, including: power dynamics within global health funding and agenda-setting; inequalities among foreign and local global health staff; the limits of consent, participant recruitment, data security, and resource allocation in contexts of crisis; challenges in training and supporting global health students; personal and moral injury to global health fieldworkers; gender-based violence in the field; and organizational and institutional roles in ensuring ethical practices. This workshop marked a rare opportunity to engage across disciplinary and researcher-practitioner boundaries in global health to address fieldwork ethics and human rights concerns.

Though our experiences of fieldwork challenges and ethical dilemmas may be specific to our disciplinary techniques and geographic contexts, they are united by the underlying aim to improve the health of populations. As global health works to facilitate the right to health in all of its complexity, we must also position fieldwork within our considerations of what the right to health entails. Health and Human Rights will include a special section on “Global Health Fieldwork Ethics: Values, Realities, and the Right to Health” in the June 2019 issue. We welcome contributions to the important conversation on global health fieldwork ethics.

Rachel Hall-Clifford is assistant professor of anthropology and public health at Agnes Scott College, Decatur, Atlanta, US. Email: rhallclifford@agnesscott.edu