Global Health Fieldwork Ethics: Mapping the Challenges

As Paul Farmer has observed, “global health remains a collection of problems rather than a discipline.”1 An exclusive focus on technical problems and the quest for solutions obscures how global health is actually enacted and implemented through fieldwork. In this special section, we consider “fieldwork” broadly to include any on-the-ground research or program design, implementation, or evaluation conducted by or with local participants and communities, which often involves collaborators from abroad. At the very heart of global health fieldwork, relationships—real-world connections among people and across institutions—give meaning to the goals and projects of this multidisciplinary field. Those relationships inspire us and compel us to act to reduce health inequalities and promote health and social justice. Yet, in working toward these goals, we must more fully consider the asymmetries embedded in global health practice—imbalances of power, access to resources, and decision making—many of which come to a head in the context of fieldwork. The dynamics of global health fieldwork and the nature of the relationships that emerge through it have been conspicuously underexplored in global health scholarship. This special section of Health and Human Rights Journal highlights the ways in which participants interact and experience the work of global health. It is an effort to shed light on some of the ethical challenges of fieldwork and to explore terrain that might lead to practical ethical guidance for global health fieldworkers. Research regulations and traditional research ethics fall short in helping navigate many of the challenges that arise in global health practice. The US Federal Policy for the Protection of Human Subjects, first adopted in 1991 and known as the Common Rule, establishes procedures and regulations for research involving human participants and builds on the 1979 Belmont Report ethical principles of respect for persons, beneficence, and justice.2 Most of the ethical issues raised in this special section fall outside the scope of the Common Rule, which has become the de facto international standard, due in part to the power and reach of US federal funding. The dominance of the Common Rule paradigm allows for adherence to procedural ethics without attending to many broader ethical questions that emerge from global health fieldwork, such as guidance on financing, “ownership” of programs and appropriate engagement with stakeholders, and, increasingly, data sharing and the implications of big data. Moreover, there is very little emphasis on institutional or organizational ethics in global health research, which belies the centrality of interpersonal and institutional relationships that are at the heart of the global health enterprise. These relationships are shaped by inherent power imbalances between high-income and low- to middle-income countries that are not fully acknowledged for their deep influences on how we think, work, and evaluate success in global health. Yet it is precisely through these relationships that the relevance and value of the right to health becomes tangible. As a multidisciplinary field, global health does not have clear or consistent guidance for fieldwork ethics. Perhaps our unshakable belief in our shared mission to improve health and the lives of marginalized populations across the globe has made us too complacent about the ethical stakes involved in the complex interpersonal and institutional relationships that fuel all global health efforts. This has significant implications for human rights—the very ideals we seek to promote—since it has allowed breaches of ethics, inadvertent or otherwise, to go underreported and under-examined. Local collaborators, project communities, and fieldworkers themselves are made vulnerable by the gap between procedural ethics and the complex ethical realities of fieldwork in global health.