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Navigating Murky Waters: Our experience addressing political challenges in global surgery research

Author: S. Ariane Christie, MD

Date of Publication: Thursday, May 25th, 2017

Successful research is usually hard won, and nowhere, perhaps, is this truer than in global surgery.

Despite extensive preparations, unforeseen situations crop up which can fundamentally change our experiences and even threaten our work. Often, however, these experiences provide the fodder for extreme growth and reveal questions and issues of which we would have otherwise been unaware.

I had spent much of the last two years planning a community-based study in Cameroon and in January 2017 we had finally started data collection. Over the first couple weeks, we experienced the usual bumps in the road, but nothing that our team wasn’t able to handle. On the whole the study was running smoothly. Things were working.

Then, suddenly, there was a shift in the Cameroonian political climate which stopped our (seemingly) successful endeavor in its tracks. The relationship between the majority Francophone and minority Anglophone contingents of the country, which had been peaceful for over 50 years devolved into civil unrest. Widespread protests were held in the Northwest and Southwest regions where we conducting our research, and unfortunately for all involved, violence ensued.

Of course, the safety of our research team was the top priority. We halted research and pulled our team from the conflict region to try to wait things out. However, as days went by we seriously considered terminating the work. This was a devastating option for our entire team, including seven Cameroonian medical students who had been counting on our data to use for the senior thesis required for the completion of their medical training.

Eventually, the political situation seemed to stagnate, if not completely resolve. Protest days were becoming less frequent and compliance with the protests decreased. This left our team in a quandary regarding how best to proceed. Our Cameroonian colleagues favored resuming data collection on days when no protests were organized, but the situation till seemed tenuous. There was no way to ensure that the situation would not escalate, which understandably made our home institution in the United States uncomfortable. My Cameroonian research assistants offered to proceed with collection alone, if we were unable to secure the permission to re-enter the region. It seemed grossly unacceptable to us to expose our Cameroonian team to risks that we were unwilling to tolerate ourselves. At the same time, it felt patronizing to dictate to our Cameroonian colleagues what was or was not prohibitive risk in their own country.

In the end, after a three-week hiatus we collectively decided to trial resumption of data collection. We permanently moved our home base to an area outside the conflict zone and made excursions into the Southwest for data collection only. We contacted our mentors in the United States and in Cameroon each time we moved into or out of the region, and above all, we agreed to terminate collection if any further signs of unrest manifested.

Fortunately, no escalation occurred. Our team completed data collection without incident, and our medical students went on to complete their thesis projects. Although we were very fortunate that the political tensions calmed when they did I can also summarize a few actionable decisions that contributed to our success. Although I hope that you never face the prospect of attenuating a study, in case you do, we found the following considerations very helpful in steering our judgments.

  1. Establishing the priority of team safety with all stakeholders up-front. Things can get quite murky in these situations and having this understanding solidified among all team members served a touchstone for decision-making in the face of differing tolerances for acceptable risk.

  2. Reliance on close contact with a diverse network of local collaborators to help interpret events in a culturally appropriate context. We absolutely depended on our Cameroonian colleagues for accurate information in an arena largely ignored by the foreign press and, critically, to interpret that information. While this is always necessary to enact successful collaborative research it would not have been possible for us to continue without that foundation of trust and mutual respect.

  3. In borderline situations, define responsible metrics for continuing and aborting work and stick to them. Reassess these metrics frequently through as many sources as possible.
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