BY BRUCE COMPTON
CHA's Guiding Principles for Conducting Global Health Activities are in their fifth anniversary year. When they were first written by a work group made up of CHA members, no one could have foreseen how much they would resonate with the experience of a global pandemic.
In this article, my good friend and colleague, Georgia Winson, shares her thoughts on the principle of prudence in relation to her work in medical surplus recovery. Having been in medical surplus recovery myself, it felt appropriate to pair this principle with this activity, because although prudence is the ability to look at a concrete situation and know what ought to be done, it is never quite that simple in global health. Prudence gives us the knowledge of what must be done, when it must be done, and how it must be done. How does prudence play into the close partnerships that must exist when working in global health and medical surplus? This article provides practical guidance around the guiding principle of prudence.
PRUDENCE
GEORGIA WINSON, MS, LCPC
In recent years there has been increased understanding of the complexity and substantial impact, for both good and ill, of medical supply and equipment donations to low- and middle-income countries, or LMICs. High quality donations can result in immediate improvements for health care providers and their patients. A relational donation process, marked by respect and careful planning between donor and recipient, can build health care capacity and improve community health for years to come. Unfortunately, recipients in low- and middle-income countries also have been discouraged and burdened by inferior products and unilateral processes that fail to recognize their particular needs and the essential knowledge they bring to the table. Positive changes in global health, including standards and accreditation for product donation, are providing hope for improved interactions and outcomes.
Improved global health initiatives need to be guided by prudence, authenticity, honesty, patience, excellence and humility, all six of the Guiding Principles. In modern parlance, prudence can evoke a sense of timidity or a rule-bound approach. Neither of those characteristics are helpful responses to the urgency, nor do they inspire major investment in the creativity needed for decisive action in global health today. St. Thomas Aquinas' virtue-based ethics gives us a much better understanding: he describes prudence as a cardinal virtue that seeks what is truly good. The truly good allows one to flourish, prepares one for the future and ultimately provides the abundant life that the Good Shepherd provides. More than a dull, intellectual process, prudence is the charioteer in a high-stakes race, understanding the obstacles on the track and directing the powerful virtues of justice, fortitude and temperance with agility, strength and precision. Prudence is the robust, practical and action-oriented virtue we need in global health!
Stronger relationships, better decisions, higher quality donations and commitment to improved health outcomes in LMICs are possible if three components of prudence are integrated into medical product donation.
These components of prudence are: thoughtful counsel with God, oneself and others; correct judgment in considering all relevant information; and commanding action that is consistent with counsel and resulting judgments. The case study that follows is an example for how organizations providing medical product donations to LMICs might incorporate these three components of prudence.
1. Thoughtful counsel: To receive counsel one needs real openness to the experience of others, including openness to God who interacts with the world. Prudence in global health, and specifically in medical product donation, requires commitment to a recipient-donor relationship that both reveals and documents the needs, capacities, limitations, motivations and future plans of all those involved. Discerning the appropriateness of a product donation, if it is to be prudent, needs to engage multiple perspectives including persons with clinical, technical and administrative/financial responsibilities. To provide counsel from past experiences and set a better course for future endeavors, both formative and summative evaluations are needed to build upon successes and create remedies for errors. While these written assessments are to clarify needs, the dialogue and shared problem-solving are what build bonds among stakeholders. These personal bonds dramatically improve access to quality product and supply chain practices in LMICs. Receiving counsel regarding cultural differences and being attentive to power imbalances are essential to productive, cross-cultural relationships in global health. Finally, thoughtful counsel is essential to prevent temporary relief for immediate problems at the expense of sustainable solutions that offer what is truly best for all concerned.
Case study: A Catholic hospital in Haiti has plans to open a laboratory with the potential to meet critical needs and generate necessary revenue. Hospital leadership realizes that robust information results in careful planning, producing sustainable outcomes, and preserving both precious time and resources. Essential preparation for making correct judgments includes in-depth discussion and solid information about the market for proposed services, equipment needed, access to necessary consumable and replacement parts, as well as preventive maintenance schedules. The hospital, the medical product donor and others involved use multiple and diverse methods when discerning the best way forward. The product donor shares past experiences with lab donations, including the difficulty in receiving consumables in LMICs. Hospital personnel consult with local vendors on the availability and means of accessing consumables. Focus groups of local health care providers provide accurate information about the need for laboratory services, prioritization of specific tests and the ability of locals to purchase services.
2. Correct judgment: For the sake of prudence, correct judgments must rely upon the careful analysis of all the information gleaned through thoughtful counsel, all the relevant data and participants' experiences.
Case application: Analysis of all information results in a judgment that the laboratory is necessary and has potential as a revenue source for the hospital. Judgments are made regarding operations, including but not limited to priority services, pricing, potential vendors, marketing and the best fit for equipment.
3. Commanding action: Good counsel and sound judgment point the way to constructive action, but prudence has not accomplished its task until the charioteer has guided the team to the finish line. St. Thomas tells us that prudence applies the intellect and commands action. He echoes Aristotle in stating that prudence is "right reason applied to action."
Case application: Acting on thoughtful counsel and sound judgment and building upon trusted relationships, prudence commands the following actions:
• A schedule of services aligned with current and future needs of local health care providers
• Service and fee agreements with potential customers of the laboratory
• Vendor contracts for parts, consumables and service as needed. Equipment acquisition for a harmonious inventory, utilizing equipment that can be supported with supplies and parts available through local vendors
• Preventive maintenance schedule and supply chain processes necessary for a fully functioning laboratory able to meet customer agreements
• Selection of donated equipment consistent with the hospital's needs
• Engagement of allied nonprofits and manufacturers to supply equipment not available through the primary product donor. Preparation of all equipment for donation, including the provision of manuals and initial stock of consumables;
- assessment, repair and calibration as necessary;
- crating to ensure safe transport;
- coordination of shipping logistics for equipment; and the
- ongoing evaluation for mid-course corrections and recommendation of process modifications.
Obviously, building a self-sustaining laboratory service in a low- to middle-income country will involve much more than outlined above, but the case study shows how prudence can lead to the attainment of a true good.
GEORGIA WINSON is the president and executive director of Hospital Sisters Mission Outreach and the Leadership Council Chair for the MedSurplus Alliance, Taskforce for Global Health at Emory University. She is grateful to Fr. Richard Chiola, PhD, for the engaging discussions and prudent editing of this article.