Tuesday, October 30, 2007

The Ethics of International Public Health Collaborations

For the past three years I have had the privilege of being able to study the Indian Network for People Living with HIV/AIDS (INP+), an idealistic organization whose threefold mission is to provide networking, direct support services, and advocacy, for people throughout India with HIV/AIDS. My particular focus has been on the partnership between INP+ and the U.S. Centers for Disease Control (CDC) Global AIDS Program in India (GAP-I). My aim has been to learn about how a developed world entity like the CDC can best assist a consumer-driven organization like INP+ based in a very different cultural setting.

A case study of the productive five year relationship between INP+/GAP-I has recently been published in the journal “Organizational Ethics.” In the relatively lengthy case report I drew three potential lessons for developed world funders and donors:

First, like a couple early in a marriage, GAP-I and INP+ have struggled with the question of what they can reasonably expect from each other, how much to pressure each other for change, and how best to apply that pressure. This wasn’t easy. Their experience identified skill at calibrating an optimal level of tension for the partnership as a crucial capacity. Too little tension means expectations are too low. Too much tension leads to severed partnerships. Getting it right requires constant monitoring and frequent recalibration. (The same is true in my clinical specialty – psychiatry.)

Second, the international collaborations between entities like CDC, World Health Organization, Gates Foundation, and Doctors Without Borders, and community-based organizations like INP+, that are so central in the fight against the AIDS pandemic, recurrently bring together partners with different organizational cultures. Successful partnerships require a carefully designed process for bridging the potentially destructive cultural gap. GAP-I located the bridging process in the responsibilities of (a) an Indian man with a strong community background who (b) had a preexisting excellent relationship with INP+ and who (c) was a CDC employee. Whatever mechanism is used, successful collaboration requires robust bridging.

Finally, partnerships between managerially sophisticated, technically advanced developed world organizations like the CDC and community-based organizations like INP+ are especially challenging in the context of different national cultures. Dora Warren, the founding director of GAP-I described the approach she took to the collaboration as follows: “Progress and success is about having trusting relationships. Trusting relationships come partly from informal contact but also from really working together.”

In the course of the study I came to see the GAP-I philosophy of seeking to build a trusting partnership by working together more as a moral perspective than simply as a practical technique. The GAP-I approach is consistent with the concept of “Servant-Leadership” that envisions leading by serving those who are being led. In working with organizations that are strongly mission driven like INP+ the Servant-Leadership method is especially apt.

At a time when the U.S. is widely regarded around the world as trying to "lead" via militaristic bullying, studying the use of the Servant-Leadership approach by a U.S. government agency has been deeply satisfying.

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