Children are vulnerable to the priorities and decision-making of adults. Usually, parents/caregivers make the difficult healthcare decisions for their children based on the recommendations from the child’s healthcare providers. In global health work, healthcare team members from different countries and cultures may guide healthcare decisions by parents and children, and as a result ethical assumptions may not be shared. As a result, ethical issues in pediatric global health are numerous and complex. Here we discuss critical ethical issues in global health at an individual and organizational level in hopes this supports optimized decision-making on behalf of children worldwide.
Key points
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Poverty and health disparities intensify the ethical challenges of pediatric health care.
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Ethical challenges in the pediatric global health context can arise at the individual and organizational levels.
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The individual ethical challenges in pediatric global health range from respect for aid recipient autonomy to balancing outreach work with other life priorities.
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The organizational ethical challenges in pediatric global health range from scarce resource allocation decisions to coping with corruption.
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Respectful and collaborative cross-cultural communications are key to the resolution of any ethical challenge in the pediatric global health context.
Introduction
Children constitute a disadvantaged and vulnerable subset of the population, both as recipients of health care and as research subjects. Because children may not be able to speak or be heard about their wishes or interests in matters related to their health, their care depends on the reasoning and decisions made by adults: their parents, caregivers, and/or health care providers, a situation that can generate significant ethical challenges. Most adults care deeply for children, but may face difficult decisions that balance the child’s immediate needs with other pressing interests, such as the needs of other dependents. These challenges are universal but exacerbated by poverty, scarce health resources, and social inequities, the very essence of pediatric global health work.
Ethical issues affect many key areas of pediatric global health, including clinical care, medical education and training, health system improvement, and research. In this article, we discuss the complex ethical challenges that arise in the pediatric global health context at individual and organizational levels from the viewpoints of both low-income and middle-income countries (LMIC) and high-income countries (HIC). Decisions can range from issues pertinent to a single child’s health, such as whether caregivers should solicit his or her assent to a surgical procedure, to issues that occur at a national level, such as whether receipt of age-appropriate vaccinations should be mandated for school entry. Collaborative and respectful communication can help resolve many of the ethical issues that arise in a pediatric global health context.
Slow progress in child health
Child health is historically neglected. More than 6 million children died in 2013, with more than half succumbing to preventable and/or treatable conditions. Diarrheal diseases, pneumonia, and measles continue to be the leading causes of death in children despite the availability of vaccines, oral rehydration therapy, and antibiotics to prevent, treat, or cure these illnesses. In 1982, the executive director of the United Nations International Children’s Emergency Fund (UNICEF), James P. Grant, called the high number of deaths in children a “silent emergency” to emphasize the global lack of awareness of this problem. Despite considerable progress in reducing child mortality in the past decade, the total number of deaths in children younger than 5 years has gone from more than 8 million in 2005 to 6.6 million in 2012, the gains have not been evenly distributed. A child born in a low-income country (LIC) is 30 times more likely to die before his or her fifth birthday than a child born in an HIC. Such disparities are both unethical and unjust.
Drug development for childhood illnesses has lagged behind the development for diseases that primarily affect adults for several reasons, but certainly the lack of financial incentive for the pharmaceutical industry has been an important driver. Most of the world’s children are dying in LICs from diseases associated with poor infrastructure. In these settings, there is little or no market incentive for companies to invest in drug discovery and development. Although an estimated 80,000 children who are negative for human immunodeficiency virus (HIV) die each year of the infectious disease tuberculosis (TB), one for which we have effective treatment, a lack of child-friendly formulations has made treating children with TB a challenge. In at least one low-income setting, Tanzania, parents and caregivers report having to crush tablets, measure a specific fraction of the powder, and then mix it with food or drink to mask the bitter taste to administer each dose of medication to their child. Despite having had effective medications for TB for more than 50 years, the first child-friendly formulations are expected to be available next year. Due to consistent advocacy, the history of unethical neglect of childhood morbidity and mortality is ending and child health issues are receiving greater attention and funding.
The exclusion of children from research trials for new drugs or diagnostics may have been motivated by the desire to protect children from potential harm, but has had the unintended consequence that interventions proven successful in adults were denied to children because of the lack of data in younger-age cohorts. Commenting on the dearth of data on TB in children as compared with adults, South African pediatrician Peter Donald remarked, “the time has come for the hidden epidemic of childhood TB to emerge from the shadow of adult TB and be seen as a neglected child health problem of considerable proportions….”
Introduction
Children constitute a disadvantaged and vulnerable subset of the population, both as recipients of health care and as research subjects. Because children may not be able to speak or be heard about their wishes or interests in matters related to their health, their care depends on the reasoning and decisions made by adults: their parents, caregivers, and/or health care providers, a situation that can generate significant ethical challenges. Most adults care deeply for children, but may face difficult decisions that balance the child’s immediate needs with other pressing interests, such as the needs of other dependents. These challenges are universal but exacerbated by poverty, scarce health resources, and social inequities, the very essence of pediatric global health work.
Ethical issues affect many key areas of pediatric global health, including clinical care, medical education and training, health system improvement, and research. In this article, we discuss the complex ethical challenges that arise in the pediatric global health context at individual and organizational levels from the viewpoints of both low-income and middle-income countries (LMIC) and high-income countries (HIC). Decisions can range from issues pertinent to a single child’s health, such as whether caregivers should solicit his or her assent to a surgical procedure, to issues that occur at a national level, such as whether receipt of age-appropriate vaccinations should be mandated for school entry. Collaborative and respectful communication can help resolve many of the ethical issues that arise in a pediatric global health context.
Slow progress in child health
Child health is historically neglected. More than 6 million children died in 2013, with more than half succumbing to preventable and/or treatable conditions. Diarrheal diseases, pneumonia, and measles continue to be the leading causes of death in children despite the availability of vaccines, oral rehydration therapy, and antibiotics to prevent, treat, or cure these illnesses. In 1982, the executive director of the United Nations International Children’s Emergency Fund (UNICEF), James P. Grant, called the high number of deaths in children a “silent emergency” to emphasize the global lack of awareness of this problem. Despite considerable progress in reducing child mortality in the past decade, the total number of deaths in children younger than 5 years has gone from more than 8 million in 2005 to 6.6 million in 2012, the gains have not been evenly distributed. A child born in a low-income country (LIC) is 30 times more likely to die before his or her fifth birthday than a child born in an HIC. Such disparities are both unethical and unjust.
Drug development for childhood illnesses has lagged behind the development for diseases that primarily affect adults for several reasons, but certainly the lack of financial incentive for the pharmaceutical industry has been an important driver. Most of the world’s children are dying in LICs from diseases associated with poor infrastructure. In these settings, there is little or no market incentive for companies to invest in drug discovery and development. Although an estimated 80,000 children who are negative for human immunodeficiency virus (HIV) die each year of the infectious disease tuberculosis (TB), one for which we have effective treatment, a lack of child-friendly formulations has made treating children with TB a challenge. In at least one low-income setting, Tanzania, parents and caregivers report having to crush tablets, measure a specific fraction of the powder, and then mix it with food or drink to mask the bitter taste to administer each dose of medication to their child. Despite having had effective medications for TB for more than 50 years, the first child-friendly formulations are expected to be available next year. Due to consistent advocacy, the history of unethical neglect of childhood morbidity and mortality is ending and child health issues are receiving greater attention and funding.
The exclusion of children from research trials for new drugs or diagnostics may have been motivated by the desire to protect children from potential harm, but has had the unintended consequence that interventions proven successful in adults were denied to children because of the lack of data in younger-age cohorts. Commenting on the dearth of data on TB in children as compared with adults, South African pediatrician Peter Donald remarked, “the time has come for the hidden epidemic of childhood TB to emerge from the shadow of adult TB and be seen as a neglected child health problem of considerable proportions….”
The human right to health
In recognition of the heightened vulnerabilities of children to abuse and neglect, the United Nations (UN) codified the rights of children in 2 landmark documents. Its 1948 Universal Declaration of the Human Rights provided a broad framework for basic human rights, but it left significant gaps with regard to the unique needs of children. Consequently, in 1952, the UN adopted the Declaration of the Rights of the Child and urged all of its member states to abide by these principles to protect and nurture its children. Concerned that the this general guidance needed specific actionable mandates, the UN General Assembly passed the UN Convention on the Rights of the Child in November 1989 and swiftly moved to implementation a few months later. Aimed at ensuring that governments, institutions, citizens, and families all act in a manner that promotes the best interests of the child, this was the first legally binding international document on protecting the rights of children. These important foundational documents were followed years later by the creation of the UN Millennium Development Goals, which place significant emphasis on the health, education, and welfare of children. Despite having high-level guidance regarding the treatment of children from a human rights perspective and admirable development targets designed to improve the welfare of the world’s poorest children, ethical dilemmas involving children still occur.
The perils of acting in loco parentis
Children are generally dependent on adults for their basic needs, such as food, shelter, and care. Generally, those adults will behave in accordance with the best interests of the child. When this is not the case, such as in cases of abuse or neglect, the child is best removed from that setting. Poverty complicates all of these dynamics.
The decision to remove the adult as a surrogate decision-maker is straightforward in extreme situations, it is unclear how to achieve the best interests of the child when the parent or caregiver is merely responding to complex incentives or when adults from different cultures, LMIC parents and HIC health care providers, for instance, perceive the best interests of the child differently.
Parents in many impoverished countries must choose between food for the family and education even when they know education is important to child well-being. Irregular attendance at clinic appointments or nonadherence to treatment recommendations can occur not from lack of commitment to a child’s well-being but because competing demands such as work and care of other children preclude them. We saw this dynamic frequently in our pediatric HIV clinic in Dar es Salaam, Tanzania, where children frequently missed appointments or doses of needed HIV medications not due to a failure to understand the importance of these interventions, but because their parents needed to provide care to another, acutely child in the family.
The Convention on the Rights of the Child, although an earnest attempt to establish the essential rights of children worldwide, does not resolve the complex background values, social structures, or provide a universally accepted approach to pediatric decision-making. Except in the case of emancipated minors, parents or guardians have considerable latitude in making decisions for their child. Local religious, social, and legal frameworks across countries generally support this practice. Health care providers have a duty to act in the best interests of their patients. Ethical conflicts can arise when medical recommendations are at odds with the decisions parents or guardians are making for their child.
In the context of a global health partnership, individuals from LMICs can come into loose collaboration with individuals from HICs, such as the United States. As those individuals may not share cultural assumptions, and thus see the prioritization of various aspects of child health differently, ethical issues can arise. As an example, an HIC provider may perceive a child as neglected because he or she is doing manual labor instead of attending school, whereas a parent from an LMIC may prioritize obtaining adequate resources to feed the family over child education. In such cross-cultural interactions, ethical issues can arise that may have different resolutions depending on the resources available and locally prevalent cultural assumptions.
The complexity of such decision-making requires respectful and culturally humble interactions between individuals from different areas of the world.
Ethical Issues That Arise for Individual Providers
Major ethical issues that arise at a provider level in the pediatric global health context include respect for the autonomy of aid recipients, scope of professional duties in LMICs, and balancing outreach work with other life priorities ( Box 1 ).
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General issues
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Lack of adequate consultation regarding issues pertaining to LMIC site
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Unequal burdens and benefits of partnerships
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Inadequate identification and evaluation of benefits to LMIC
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Funding differentials
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Individual providers
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Respect for autonomy of aid recipients
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Assent, consent, and disclosure
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Scope of professional duties in LMICs
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Balancing global health work with other priorities
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Organizations
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Allocation of scarce resources
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Conflicts of interests
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Corruption and kickbacks
Abbreviation: LMIC, low-and middle-income countries.
Respect for the autonomy of aid recipients
What moral responsibility, if any, do HICs have to assist LMICs in the care of their pediatric population? Many types of assistance are provided through bilateral funding, direct health care service delivery, technical assistance, training, and donations of materials and supplies. In some instances, this assistance can range from beneficial to neutral to harmful. Much of the assistance HICs have provided to LMICs has been paternalistic, with wealthy countries deciding what poorer countries must need, or should have. One notable example is the frequency with which inappropriate drug donations have been made to LICs, particularly in postdisaster or crisis situations. These donations are frequently not appropriate for the needs of the population, are misused, and can interfere with local pharmaceutical policies and production. Thus, the legacy of colonialism can continue through the practices of humanitarian assistance long after colonized countries achieve their independence. Such paternalistic actions are not only unhelpful, they disrespect the recipient country’s autonomy, and worse, burden the country with the challenge and cost of disposing of inappropriate or expired medications. These ill-conceived programs violate the precept of nonmaleficence in medical bioethics, and also the important medical axiom “primum non nocere” or “first, do no harm.”
Fortunately, today more global health initiatives are being led by recipient countries, thereby ensuring that they are responsive to their actual needs. For example, the Rwandan Human Resources for Health program is fully led by the Rwandan Ministry of Health (MOH). In addition, the Rwandan MOH contracts directly with US medical schools for their faculty time rather than having a US-based entity as the intermediary. Additionally, adding the voices of high-income activists and policy-makers to those of our low-income partners has been effective in advocating that resources and research be directed to the previously neglected childhood diseases that result in the disproportionate number of deaths of poor children. Organizations such as the Global Alliance for TB Drug Development, based in New York, or Drugs for Neglected Diseases initiative (DNDi), based in Geneva, are 2 such examples of groups that advocate and support drug development and distribution for otherwise neglected diseases among vulnerable patient populations, including children. This can help ensure that pediatric global health engagement is focused primarily on the true needs of the host countries and not on the ego gratification that can come to people from HICs who choose to work in LMICs.
Engaging in support and assistance of others from a culture different from one’s own is fraught with ethical challenges. Although the goal may be to benefit the pediatric population in that country or community, well-intentioned outsiders wanting to act benevolently but who do not understand the cultural context can do a significant amount of damage. Too often, we try to impose our cultural and social priorities onto those we are trying to assist, disrespecting their autonomy and acting in an offensive (at best) or dangerous (at worst) manner. Attempts to provide aid or care to others without a deep sense of the cultural complexities or social dynamics of the recipient community or an understanding of its priorities are generally doomed to failure.
One of the most difficult ethical challenges in pediatric global health has been how to approach the practice of female genital mutilation or cutting (FGM) in many countries in sub-Saharan Africa. Most Westerners find this practice abhorrent and unethical. This raises the distinction of moral universalism, the stance that some ethical dictums are absolute regardless of cultural, religious, or other belief systems, and moral relativism, which holds that standards of what is right or wrong will vary by culture. For the moral relativists, to indicate there is a universal moral code is akin to moral imperialism. For moral universalists, FGM is simply wrong in any setting. However, showing respect for another’s culture and traditions need not require that one agree with its beliefs. The World Health Organization and human rights groups consider FGM a violation of the human rights of girls and women. What, then, is the ethical responsibility of health care providers in this situation? It is important to understand that parents who subject their daughters to the FGM typically do so because they love their daughters. Recognizing the power and importance of local traditions should guide how physicians approach this culturally bound practice. However, the health risks and detrimental consequences associated with FGM are significant, and physicians have a duty to inform parents of these if considering FGM for their daughters. Some pediatricians have found that a respectful dialogue, held in a neutral, nonjudgmental manner, allows parents to speak openly about this practice. In the countries in which FGM is still practiced, broad community mobilization efforts focused on improving health literacy and education about human rights have been shown to be effective and have been successfully replicated.
Other issues related to sexual health can also present an ethical quagmire for health care providers. Discussions of sexual debut, contraception, and prevention of sexually transmitted disease including HIV can be a source of potential tension in the provider-parent-patient (child) triad. The question of gradual gaining of independence and when agency is fully conferred to the child will vary by community and can even differ at the level of the family or individual. Determining a family’s views in an open and nonjudgmental manner will again be an important guide for health care providers, but the ethical challenges arise when parental beliefs differ from what the medical and social science evidence indicates. In cases in which there is disagreement between the parent and provider, does the provider’s duty to the patient (child) supersede the parental authority for deciding what health information the child receives?
Similar to sharing sexual health information, the issue of when to disclose HIV status to an infected child can lead to ideological standoffs between parents and providers. At our pediatric HIV clinic in Tanzania, our first foray with this challenge occurred when a grandparent (a respected physician in the community) told providers that his 13-year-old grandson was too young to be informed of his HIV status. (Fortunately, this situation was eventually resolved via tactful negotiation with local physicians.) When the provider or organization is an outsider to the community, this tension is often further exacerbated. Examples abound of situations in which local families or communities have been angered by what they construe as foreign providers or international organizations promoting a Western ideology that is in direct conflict with their culture and social belief system. One such program that we have been affiliated with uses soccer coaches to educate youth about HIV prevention through promoting personal efficacy. Despite its foundation in social learning theory and youth mental health development, this program initially faced criticism for importing a presumed Western approach to more traditional cultures in Southern Africa. Engaging in an ongoing respectful dialogue with parents and/or community leadership and allied community-based groups is essential to resolving such ideological clashes. The health care provider should, however, uphold his or her ethical obligation to provide sound, evidence-based health information that will promote the health of the patient. Doing this against a backdrop of open inquiry and honest conversation with respect for individual and local beliefs will be the most effective approach for reaching a mutually agreeable resolution.
Assent, consent, and disclosure
Perhaps the most prevalent ethical challenge that arises in the care of children worldwide revolves around the balance of paternalism with respect for patient autonomy. The youngest children cannot give true informed consent, yet respect for child autonomy mandates that adults involved in their care attempt to engage their autonomy in an age-appropriate fashion. The term for a child’s approval of an intervention for which they cannot give full informed consent is “assent.”
The age threshold above which providers should seek not just assent but full consent varies according to local custom and also according to the intellectual and decision-making capacity of individual children. The treatment of infectious diseases exemplifies this dynamic. An infant with a severe ear infection is treated with antibiotics without asking permission, whereas clinicians providing intravenous antibiotics to an 8-year-old boy hospitalized with pneumonia would ask the boy’s assent before inserting the intravenous catheter. By contrast, an adolescent with a sexually transmitted disease might be treated without parental notification should the adolescent request it.
In a global health context, judgments about the age of assent versus the age of consent, and which health issues can be handled privately may vary by country and may be informed by cultural factors about which a provider may be only partially aware. As a result, a provider from an HIC who is comfortable providing treatment for an adolescent with a sexually transmitted disease without consulting the parents may face staunch parental opposition when practicing in a country in which the prevalent culture prioritizes parental authority over child privacy, in contrast to the provider’s home country.
There is no single correct approach to the resolution of the ethical conflicts that arise as a result of such different base assumptions. Ultimately the HIC provider may provide the same level of care to the adolescent with a sexually transmitted disease in an LMIC context as would be done in an HIC setting, but perhaps put more emphasis on encouraging parental consultation in the LMIC context out of respect for the locally prevalent practices. To shape defensible ethical decision-making, ideally the HIC provider should consult with host country providers and community leaders regarding local cultural assumptions that might influence general pediatric health care so that when sensitive individual situations arise, the response can be respectful of such host country cultural preferences.
Scope of professional duties in low-income and middle-income settings
Resource scarcity is a daily challenge for individuals working in pediatric global health. In many ways, scarcity can conflict with provider professional obligations. Health care workers can feel unable to execute on the mandate to provide the best care possible for patients, for instance, if resources are too scarce to allow for the provision of standard medicines and surgical procedures. Simple acceptance of what is possible given local resource limitations can be expedient, and may even be seen as culturally competent, but may perpetuate local resource limitations by representing a failure to fight those limitations. Yet, pragmatically, health care providers working in LMICs need to care for children with the resources available to them. They must, therefore, make transparent decisions about what kind of care they can provide responsibly within those locally specific limitations, and which kinds of care are simply precluded until pitched efforts to improve funding succeed. Health care workers, both local and foreign, can, and should, advocate for improved conditions and better resources for their patients in such settings.
A key component of the satisfaction of professional obligations to provide the best care possible within the limits of the local context is a commitment to working within the scope of one’s professional practice. It is common for students and other early-career providers to be asked to provide a level of service that would be deemed outside the scope of their professional practice in an HIC. For instance, we have mentored medical students asked to perform unsupervised delivery of babies in Africa and another who performed unsupervised cranial burr hole procedures in adolescents with intracranial bleeding after traumatic brain injuries while volunteering in a South American jungle clinic. In both cases, students were told that without their help the patients would die. Situations like these pose a difficult ethical challenge: pediatric global health providers may feel obligated to choose between denial of services or the provision of services they would never attempt in their host country.
There is no simple solution to this conundrum. LMIC medical systems have shown that nonphysician providers can be trained to render high-quality care to children. For example, in areas with low numbers of physicians, nurses and other nonphysician providers (eg, community health workers or peer-counselors) can deliver high-quality antiretroviral therapy (ART) to children with HIV. This is a good reminder that the system of health care provision in HICs like the United States can be wasteful and inefficient and likely benefit from adopting innovative community-based approaches proven effective in LMICs. Yet it is important for providers from HICs not to enforce inadequate access to appropriate quality services in LMICs by allowing or encouraging trainees to practice outside of their scope for the purposes of their own education, by engaging in such practices themselves, or by accepting ad hoc medical services by inadequately trained providers who seem to address a pressing medical need but in fact do not do so sufficiently. One way of discriminating between innovation and unprofessional provision of substandard of care is to measure outcomes and engage in quality improvement work to improve them when needed.
Balancing global health work with other life priorities
Health care providers who care for children in a global health context are often highly committed people who want the best for children. Given the enormity of the obstacles to optimal child health in such settings, providers can be impelled to work demanding schedules that conflict with other life priorities, such as giving attention to their own families and/or provision for personal health and well-being. Although potentially appropriate in short-term crises, an excessive engagement with the work of pediatric global health to the exclusion of other personally meaningful life priorities is usually not sustainable and may in the long term undermine the efficacy and durability of pediatric global health work through the development of burnout. As a result, there is an ethical argument to be made that the ideal approach to pediatric global health work is a balanced engagement that promotes long-term commitment and is not ultimately undermined by neglect of other major life obligations and enjoyment. Not only can trumpeting this concept help protect sustained global health work, but it can improve recruitment to the work if potential candidates recognize pediatric global health work can be balanced with other life goals.
Ethical Issues That Arise at an Organizational Level
Individual health care providers working in pediatric global health face formidable ethical challenges that are complementary to but somewhat different from those faced by people leading organizational or governmental pediatric global health efforts. These ethical issues include scarce resource allocation decision-making, the potential conflicts of interest that can arise with pediatric global health interventions, and even corruption. We address each of these issues in the following sections.
Allocation of scarce resources
Health care providers working in LMICs all face challenging decisions about the allocation of scarce resources. Children are usually unable to advocate for resources themselves, so their health needs are frequently prioritized lower in disbursements from governmental and other aid agencies. This problem is particularly acute in the sphere of pediatric global health. This can bring core health needs of children into conflict, for instance when funding for preventive measures like vaccines or nutritional interventions is seen as diverting support from efforts directed at acute and lethal illnesses, such as the treatment of diarrheal diseases and malaria.
Choices between competing health needs of children can be made all the more challenging by the balkanization of aid efforts in pediatric global health. If one agency supports vaccine development and another distributes oral rehydration solution for pediatric diarrheal disease, then health programs may feel obligated to choose between them or divide resources in ways that do not capitalize on potential synergies (eg, separate and distinct trainings for each rather than one on comprehensive child health). One way of eluding this trap of dichotomous thinking is for aid efforts to move from vertical to horizontal approaches to health care, such as has been promoted through the integrated community case management of childhood illness. This strategy still places emphasis on childhood illness assessment and treatment rather than the marrying of illness assessment with disease prevention and health promotion, but has certainly been a step in the right direction.
The identification of synergies between potentially competing priorities in pediatric global health, and thus the trap of categorizing child health in distinct disease silos, helps, yet amid inadequate resources some challenges are unavoidable. From there, the optimal approach involves both a pragmatic response to the limits of funding and vigorous resistance of those selfsame limitations. In addition, respect for the autonomy of children in global health settings mandates partnership with host country decision-makers so that allocation decisions reflect local priorities and not solely those imposed by HIC providers. Further, an iterative collaborative process of reassessment of the wisdom of resource distribution decisions, and an alignment of the next wave of decisions to evolving health needs, is critical. This can avoid inadvertent misallocation of resources, such as can occur if the most effective organizations target pediatric health needs that are less urgent than those prioritized by less effective organizations. The proper allocation to prioritized health issues is a key role of host country governments, which can help align the distribution of nongovernmental organizations to national pediatric health priorities.
Conflicts of interest that can arise when pediatric global health interventions are motivated by commercial, religious, political, or research agendas
Pediatric global health interventions can be implemented or affected by commercial, religious, and political agendas. These can be promulgated by service agencies themselves, such as when pediatric formula companies offer free or cut-rate access to substandard nutritional options or medications to mothers in LMICs. An internationally decried research example is the unregulated experimental provision by Pfizer of the nonstandard antibiotic trovofloxacin to pediatric patients with meningitis in Nigeria in 1996. Another example, this time involving a government-supported organization, comes from the President’s Emergency Plan for AIDS Relief (PEPFAR). In its early days of program implementation, PEPFAR disbursed funds only to organizations that abided by its pledge against sex work and abstinence-only education programming even though the former could endanger adolescent sex workers, and the latter was demonstrably less effective than other prevention measures in keeping youth safe.
Corruption and kickbacks
Corruption occurs worldwide, but by virtue of their dependent status, children are especially vulnerable to it. It is thus unsurprising that child mortality rates are associated with corruption. Corrupt individuals, and organizations, can cadge funds from both governmental and nongovernmental organizations in HICs and LMICs alike. Corruption may be widespread in particular countries like Nigeria, in which it has been described as part of the fabric of certain segments of the local culture, but it is particularly distressing when it depletes funds meant for children in need. Outrage is appropriate, as is a systematic avoidance of corrupt individuals and organizations. These natural and ultimately productive inclinations, however, should be modulated by the recognition that definitions of corruption can vary from culture to culture, and even when a particular activity is universally understood as corrupt, it may appear more egregious when perceived across a gradient of cultural difference. This sensibility should lead to collaboration with local leaders who can help health care providers working in a pediatric global health context to identify collaborative guidelines for the definition and response to corruption.
The Crucial Need for Global Health Ethics Education for Trainees and Faculty
In recent years, there has been rapid development of global health programs at US universities, with faculty and trainees actively engaged in service, education, and research missions. Given the complex ethical issues this engagement will engender, academic institutions and departments engaged in pediatric global health programs should implement competency-based curriculum in global pediatric health for trainees and faculty. The Consortium of Universities of Global Health Education Committee recently published a broad, interprofessional global health competency framework, which may lead to further curricula development, implementation, and evaluation. It is crucial to have meaningful and ethical experiences for trainees and other health care providers engaged in short-term global health research or service projects, protect communities from potential harm, and foster sustainable partnerships to improve global health and reduce disparities. A Working Group on Ethics Guidelines for Global Health Training (WEIGHT) has developed best practice guidelines. An innovative, 10-case online curriculum “Ethical Challenges in Short-term Global Health Training” (freely available at http://ethicsandglobalhealth.org ) has been developed by Johns Hopkins Berman Institute of Bioethics in collaboration with Stanford University Center for Innovation in Global Health. This and other freely available online curricula related to short-term global health ethics education are depicted in Box 2 . Given the wide array of ethical, social, and cultural issues in global health research conducted in LMICs, there is a growing interest in the development of Consultation Services in Research Ethics (CSRE) to complement the traditional institutional review board ethics review. The role of CSRE may be particularly useful to implement global health research projects funded and implemented by organizations and researchers in HICs. The conduct and design of pediatric global health research should comply with current international research regulations and conform to high ethical standards to protect the rights and safety of research participants. The ethical issues related to child health research in LMICs are shown in Box 3 .
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