Bioethics training program for Africans helps professionals bring expertise home

Students include doctors, nurses, others

Major corporate research sponsors and large institutional sponsors in the United States increasingly are conducting clinical trial research overseas. Sometimes this raises concerns among IRBs and human subjects protection leaders about human subjects protection measures taken by these organizations.

These international trials establish ethics review boards and seek community input, but how well do these fledging board members and new researchers understand human subjects protection?

This question is being answered in part by bioethics training programs funded through the International Bioethics Education and Career Development Award of the Fogarty International Center of the National Institutes of Health (NIH).

One of the first five recipients of the Fogarty award led to the development of the Johns Hopkins Fogarty African Research Ethics Training Program at Johns Hopkins Bloomberg School of Public Health in Baltimore, MD. Now in its seventh year, the program has been training African professionals in bioethics, so they can bring their experience and knowledge back to their home countries and peers.

"It is critical for African professionals to know where their international collaborators are coming from and what perspectives they have," says Adnan A. Hyder, MD, MPH, PhD, an associate professor in the departments of international health and health policy & management at the Center for Injury Research & Policy and Berman Institute of Bioethics at Johns Hopkins University Bloomberg School of Public Health.

"Training in the U.S. makes our colleagues in Africa understand the bioethical perspectives taught here and how they are used to analyze issues internationally," Hyder says. "It will develop their capacity to discuss and contribute to the global dialogue on this issue."

The Johns Hopkins bioethics training program has trained 23 professionals from Africa, including a dentist trainee from Nigeria, a nurse from Uganda, and a pediatrician from South Africa, says Nancy E. Kass, ScD, a Phoebe R. Berman professor of bioethics and public health in the Johns Hopkins Berman Institute of Bioethics.

"The only restrictions on eligibility are that trainees come from Africa, which is the focus of our training program, and that they have finished college or what most people call university," Kass says. "Beyond that, what we look for is not only someone who is talented, but someone who is committed to making a difference in improving an area of Africa."

In terms of commitment and enthusiasm, the program would appear to be a great success.

At the recent seventh-year reunion, 19 out of the 23 trainees returned to Johns Hopkins and took part in a public health community discussion that centered on a viewing of the controversial film "The Constant Gardener," in which HIV/AIDS research in Africa is portrayed as politically and financially corrupt.

"We had the panel of experts, including alumni trainees, discuss what in the movie seemed truthful, and what did not," Kass says.

Other evidence of the trainees' enthusiasm includes these examples of what they've done since they completed the one-year bioethics training program:

• Several trainees established their own IRBs or research ethics boards in their home countries, filling a void; these include one person from the Democratic Republic of Congo who established an IRB in the DRC and a second IRB in Kenya, Kass says.

"He got a federal-wide assurance from the U.S. government so the IRB could be recognized and get funding, and he did it all by himself," Kass notes.

• The Ugandan nurse trainee developed a two-week ethics training workshop for nurses in her home country.

"She developed one week on clinical ethics and one week on research ethics and did an evaluation to see if people learned things and made changes in their practice," Kass says.

• Another trainee now is a speaker and consultant for international organizations when they have a project and need an ethicist to say whether it's ethical, Kass says.

"All of these people have returned to their countries," Kass says. "A few went on to get other advanced degrees, and three have finished their degrees and then returned to Africa."

So far, none of the trainees have chosen to leave their native African nation, which is another positive aspect of the program: it seems to reverse the trend of the mostly trained and educated professionals leaving their developing world nation to live in resource-affluent countries.

One of the reasons the trainees have brought their knowledge back home is because of the way the program is set up. The first half is in the United States, but the second half is in their home country.

It's intensive, and for the first six months, trainees live in Baltimore and take three graduate courses in ethics at Johns Hopkins, Kass says.

"They take one course in public health ethics, one in ethics of research, and one in ethics issues that come up in public health in developing countries," she explains. "And they take three special seminar series courses, including one in quantitative research methods, qualitative research methods, and one seminar course that is designed just for the trainees."

The special seminar series is run by Kass and Hyder, and it's a combination of having trainees read more core literature related to research, writing case studies for ethical issues in Africa, and listening to guest speakers, Kass explains.

"We bring in guest speakers who are relevant to the trainees," she adds. "So one year we have someone who is a malaria researcher talk about ethical issues in conducting clinical trials."

There also have been several speakers who talk about the ethics of conducting HIV protocols in Africa, the ethics of nutrition studies, etc.

Also, as part of their first six months of training, the students are required to observe four to six meetings of an IRB, Kass notes.

Trainees do all of this and one more task during their first six months: they develop and write a practicum for a big project they'll do during the second six months of the bioethics training program, Kass says.

"The second six months is back in Africa, and we give them a seed grant in order to jump-start their professional life as an ethicist when they go back," Kass says.

While at Johns Hopkins, the trainees meet regularly with Kass and Hyder as they develop the 40-page protocol for their special project, Kass adds.

"Many of our trainees are deeply committed to training their colleagues in ethics, and many have undertaken that as a full focus of their practicum," Kass says. "They're clearly committed to bringing more knowledge to their colleagues."

And it's this commitment that has kept the trainees focused on staying in their home countries, despite the more limited resources.

Although the bioethics training program directly impacts only a few people each year, its indirect impact can be felt across Africa, Kass and Hyder say.

"Each person is a stone in the pond, and his or her ripples are already being felt in their countries and regions," Hyder says. "As one of the fellows said, they are not only working locally and nationally, but they are also 'going global.'"

The program's and the trainees' influence also might help keep other African professionals in their native continent, where their expertise is badly needed.

"In Africa 10 years ago, it was hard to find bioethics training in Africa," Kass says. "But now, partly through our program and others similar to ours, there are five training programs in bioethics that are on the African continent."

The NIH funding has grown to about two dozen similar programs that train people in developing countries in bioethics, Kass notes.

Bioethics trainees have a personal impact on a one-by-one basis, Hyder says.

"And it is as a community that they will affect regional dialogue," he adds. "The hope of Africa must rest with Africans."