Setting: A remote area of a country where a long-standing civil war has been halted by a recent cease-fire.

Scenario: Two months ago, an international medical NGO established a project to support local health clinics and provide treatment and prevention programs for malaria. The NGO had not worked in this community before but has projects underway in other parts of the country. The team includes two expatriate nurses, an expatriate physician, and three community health workers who are from the provincial capital. The team has struggled to build relationships with local healthcare providers and community leaders.

The project includes the introduction of a new malaria treatment program that consists of taking two pills once a day for three days and it would replace the currently available treatment of daily injections. Local health professionals are hesitant about the change in treatment protocol when it is presented to them. The local community, including some local health workers, voice their concern about this treatment; in their opinion injections are better than pills, and more pills are better than a few.  Some local health workers are also sceptical that this new treatment regimen will be available once the non-governmental organization leaves the area. What’s more, community health workers have heard that some local health providers have discouraged patients from accepting the new treatment.

The team has just received a formal letter from the community leadership council expressing discontent with the actions of the NGO suggesting that the community may cease to cooperate with the project. They express that they have not been consulted and feel the changes are being imposed upon their community. They also state that malaria is not the biggest concern in their community and question why the NGO is emphasizing this condition over other needs including widespread malnutrition.

Analysis: Apply this case to the Humanitarian Healthcare Ethics Analysis Tool (HHEAT). The HHEAT  is intended to facilitate discussion and deliberation for those involved in ethically challenging situations and will assist humanitarian healthcare workers in implementing well-considered decisions.  The six steps are designed to help you or your team structure reflection and deliberation on the ethical dilemma presented in the case study. You may skip questions that appear less relevant to the issue or explore dimensions pertinent to the context but not listed in the tool.

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Disclaimer: Case studies in the ENHA (Ethics Narratives in Humanitarian Aid) series are based on the reflections of humanitarian healthcare workers on ethical challenges experienced in the field. While the stories presented in the cases draw on real events and the accounts of real persons, many stories are composites in which similar experiences are woven together. In all of the stories, details such as names, dates, locations, career and life stage, gender, and profession have been changed, obscured, or omitted. Any resemblance the stories may bear to actual persons, places, and events is co-incidental.

While the stories often aim to show what the protagonist is thinking or feeling, the Humanitarian Healthcare Ethics Research Group’s intent as the stories’ author is not to suggest that the values and assumptions held by a story’s protagonist are those of all or many humanitarian healthcare workers. Similarly, the values, opinions and actions of a protagonist or other actors in a story should not be understood to reflect those of, or be endorsed by, the Humanitarian Healthcare Ethics Research Group.

How to cite: Humanitarian Healthcare Ethics. 2014. ENHA Case Study Series: Injections Better than Pills? www.humanitarianhealthethics.net.

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