from the excellent blog
Catalyst for BreakfastSocial Justice, Medical Aid, and Acupuncture. Part 1: Voluntourism
Since I will be taking a four month trip to learn about traditional Thai and Chinese medicine in Thailand next year, I have been pondering the significance of medical volunteer work abroad. What is the goal of medical service in other countries? Why do we volunteer in other areas when there are certainly people in need of free medical services in our own countries, states, cities and communities? It can seem like the flight of fancy of a privileged class of practitioners, or an extension of the colonial or missionary mindset, but on the ground what does it offer to the travelers and to the communities they work with? 
Travel can teach people about different cultures and can open their minds to new ways of acting in the world, but traveling is a privilege and should be recognized as such. In the case of medical-practice-based traveling, at least the traveler can offer something in return for the opportunity to live in a new place for a short period of time. What kind of “return” does this look like in practice?
This thorough 2009 qualitative study summarizes some of the conundrums of global health and international medical volunteer work: Perceptions of short-term medical volunteer work: a qualitative study in Guatemala(1). The entire article is worth a thorough working-over, but here I provide the general background, minor discussion and conclusions:
…..There is growing interest among healthcare providers in the field of global health; over 25% of all 2008 United States (US) medical school graduates participated in global health experiences during medical school. Beyond medical school, there are countless opportunities for physicians to volunteer their services abroad in resource poor countries, frequently in the form of medical missions that last for a week or two at a time. Several editorials in the medical and social sciences literature have raised important questions about potential unintended consequences of such short-term medical volunteer work [1-9]. Editorials such as these raise concern about the ability of short-term volunteers to provide safe and effective medical services in the setting of language and cultural barriers that impair clear communication between patients and healthcare providers. They also raise concerns about a lack of follow-up care for patients who receive treatment from groups with a short-term presence. They raise ethical concerns about people without formal medical training participating in these groups, or medical professionals practicing beyond the scope of their expertise and practice at home, in a setting where they are not held accountable for the consequences of medical interventions made.
In addition to basic questions pertaining to patient safety, these editorials raise important questions about the impact of short-term medical missions on the larger medical systems in the countries they visit. For example, it is suggested that short-term medical groups that are not integrated with local medical systems do not understand local medical needs, and consequently, their efforts will be misguided.
Furthermore, there is suggestion that groups providing free medical care in other countries undermine the livelihood of medical providers who depend on payment from patients in those countries. The literature in medical anthropology is filled with examples of unintended consequences of medical programs that pay insufficient attention to local conditions and culture and, perhaps more importantly, fail to consider the potentially incompatible and harmful cultural assumptions and values embedded in those programs [10,11].
With countless groups from wealthy countries participating in shortterm medical volunteer work abroad, it is critical that we evaluate the safety and effectiveness of these interventions for patients, as well as the larger implications and consequences of such work on the development of medical systems and the health of communities where this work takes place. The editorials summarized above were written by medical professionals from wealthy countries with an interest in global health, and these writings serve as an important starting point in this discussion. Even more important, however, are the opinions and perspectives of those who live and work in the countries where this work takes place, and thus far, their voices have not been heard.
…Short-term medical volunteer work may be seen as one extension of those interests in the post colonial era. As such, short-term medical volunteers often bring with them, albeit unconsciously, attitudes that foster dependence and lack respect for local practitioners and local knowledge and practices related to health. Understanding how short-term medical volunteer work is perceived by those living and working in receiving communities is a critical first step in designing and implementing healthcare programs that provide needed healthcare services to supplement and complement local healthcare systems without undermining their efforts. Specifically, we sought to explore the perceived utility and perceived impact (positive and negative) of short-term medical volunteer work in Guatemala from the perspective of healthcare providers and health authorities in Guatemala. Because of the short time available for the research, this study focuses on the perceptions of these individuals and not on the impact of short-term volunteer programs. Its purpose is to identify and describe the range of perceived issues surrounding short-term medical volunteer work as a basis for future indepth studies.
…Our study, although small in scope, is one of the first to systematically and critically examine the effects of shortterm medical volunteer work. All major thematic areas in our results underline the challenges of outside groups working as equal partners. Is it paternalism or cooperation? Is it charity or aid? Is it experimentation or quality care? Have all stakeholders been properly identified? Let us say that a recipient community has been appropriately consulted and involved to develop the most suitable intervention with strong community ownership. Omitting other healthcare providers, organizations, and the Ministry of Health may nevertheless jeopardize the long-term success and sustainability of any effort. The very real power and wealth differential between short-term medical groups and their host communities make trust, understanding, and true partnership difficult.
…According to our results, recipient communities may perceive very tangible benefits from short-term volunteer groups: Free or discounted care, improved access to healthcare overall, access to highly-trained specialists, and access to procedures not always possible within the local infrastructure. Local providers enjoy exchanging experiences and knowledge with foreign visitors, and appreciate the influx of supplies that accompany volunteer groups.
White Coat = Authority
On the negative side, it appears some of the least sophisticated groups offer services or treatment that are seen to be at best duplicative, and at worst, harmful. For example, though some drugs may remain effective 1–2 years past their expiration date, the perception of harm may arise from using drugs that are no longer considered safe, legal, or effective in the US. Similarly, a surgical group not planning for appropriate local follow-up could also be seen as acting recklessly and creating the potential for harm. Such issues may be easily solved with proper planning and supplies. On the other hand, many situations described by our respondents do not present the opportunity for an easy fix. Well-intentioned, well-prepared groups provide services that may help many but may harm others though unforeseen externalities. For example, free care from outsiders improves access in the short-run, but may undermine local healthcare providers, and in the long-run may reduce access: The government might close public clinics with patient volumes that are dropping, and private physicians might leave for areas without competitors providing free care. This could only further increase the dependence on external assistance.
…Finally, it is our hope that this paper will stimulate studies into the economic, political, and health outcomes of short-term volunteer programs to critically assess their quality and effectiveness. What is the effect of the concentration of such services on the government investment in healthcare infrastructure and services in those areas? Do free or very low cost services provided by short-term volunteers truly draw patients away from private practitioners or state services? Are outcomes for procedures (e.g., cataract removal) or conditions (e.g., diabetes) different when care is provided by the regular healthcare system versus by short-term medical volunteers?
The above article brings up so many good points that have only begun to be addressed in a systemic way over the past few years. As recently as March 2011, a narrative article was published in Health Affairs which succinctly illustrates the challenges of participating in (much less creating and operating) a short-term medical volunteer program. Dr. Teeb Al-Samarrai, an MD with a strong interest in international health and development, wrote this article as a 2nd year resident who traveled to Uganda with Yale’s medical study abroad program to work in a hospital in Mulago. Here are some key excerpts from Adrift In Africa: A US Medical Resident On An Elective Abroad. (2):
“Virtually on her own and unsupervised in a Ugandan hospital, a young doctor develops suggestions for improving overseas medical training.
…“This wasn’t part of my orientation,” I thought. I’d prepared to work alongside senior Ugandan physicians, not to become a senior physician at the country’s major hospital before the end of my first day. But I’d trained in a medical culture of multitasking efficiency and realized there was no time to waste.
So we began making the medical rounds on forty-some patients, in a hospital I did not know, in a country I’d just arrived in, and in a language in which all I could muster were, “Hello, how are you?” and “Thank you.” My hours of studying Luganda, the complexities of Uganda’s colonial history, and the subtleties of HIV care seemed irrelevant.
Patients’ “vital signs” were only occasionally measured or noted. The medicine ward contained no blood pressure cuffs or thermometers, unless an intern happened to have one in his pocket. The interns’ responsibilities were dizzying, and their knowledge base varied. The economic and technological limitations of the medical care they could deliver verged on paralyzing.
…Inside, I was numbed by the realization that Mulago wasn’t an isolated rural clinic in the middle of nowhere: It was the premier referral hospital in a crowded metropolis in a country heralded as an HIV/AIDS success story. If this was success, I wondered, what did failure look like? My mind whirred, trying to calculate the incalculable other Mulagos, the smaller Mulagos throughout Africa, in more remote regions and poorer countries. It continued to whir as I tried to count the uncounted, the patients who never made it through Mulago’s doors, who never made it to any hospital at all.
Before the end of my third week at the hospital, I asked to work on an infectious disease ward. After all, that was the work I’d come for. I was told that it was still exam time at Mulago, and there’d still be no one to supervise me. I insisted. Although no expectations were laid out for me, I tried to set realistic ones for myself. Feeling more comfortable and familiar with Mulago, I began on the men’s infectious disease ward. Each day the ward intern and I did rounds on nearly sixty patients. I let him lead the way, both of us having growing confidence in what I knew and had to offer.
Interns from adjacent wards began to wander over, asking questions, wanting to present challenging cases. I didn’t always know the answers. But I taught the importance of performing a careful exam, listening to a patient’s medical history and personal story, and then creating a differential diagnosis (weighing the probability of one disease versus other diseases) while remaining willing to reassess it. Each day I was humbled by the dedication of the interns I worked with, who were eager to learn as much as possible. I was also humbled by the patients we treated and by those whom we could not treat, and by the caring and patience of their families. Day by day, we lived Mulago together
When I returned to my residency program in the United States, I asked faculty members what their expectations were of the role of visiting medical students and residents at Mulago. Although they were devoted to Mulago and to the experience of residents there, I didn’t get a clear answer.
Nor did I find clear guidance when I reviewed the medical education literature. There appears to be no standard for medical schools in the United States that outlines the necessary supervision for medical trainees—or delineates their roles, responsibilities, and expectations while they are working abroad. Moreover, many medical trainees go abroad with little more than a naïve desire to help and find themselves unprepared for the academic, emotional, and cultural challenges, not to mention the morally ambiguous situations, they might face.
Like many medical trainees, I went abroad to learn, to serve, and to be challenged. I and others want to be pushed out of our comfort zones and see the realities and necessities of medical care in resource-poor settings. We are drawn to this work because it helps us appreciate the dedication and skills of colleagues abroad as well as giving us a sobering perspective on health care disparities and priorities in countries that differ from our own. We can see diseases we’ve only read about, and we can hone diagnostic skills that atrophy in the technology-driven American health care system.
Even more, it is a form of service. We want to help. Ideally, we work with the guidance of seasoned physicians from our host country, home institution, or both.
Although I had ideas I could have tucked into the Mulago suggestion box, the most important recommendations I have now pertain to medical schools on this side of the Atlantic:
Suggestion:Determine the roles of US medical trainees and their responsibilities for patients during an international elective.
Suggestion:Determine who is responsible for supervising the trainees.
Suggestion:Define what kind of supervision the host institution is to provide for the trainees.
Suggestion:Determine how trainees’ home institutions can support host institutions in defining responsibilities for teaching and patient care.
As those of us in the United States consider our continuing role in international health and medical education, I hope we can do so realistically and creatively. Perhaps a portion of tuition fees at US medical schools could be devoted to helping host countries and institutions hire local physicians to deliver patient care and also to teach US trainees. Such a system would provide a sort of counterweight to the brain drain that both drives and is driven by the global hierarchy of medical care. Or, as my residency program now does, perhaps an adviser from the home institution could spend part of his or her time at the host institution, both to advise US students and to offer targeted instruction for students at the host institution.
Although my experience in Uganda was not what I expected it to be, it was incredibly valuable. I realize that many medical educators would maintain that this means “living Mulago” was a successful international elective. Well, yes and no. In the absence of guidance and supervision, I initially struggled to define my role and responsibilities, yet I ultimately gained a clinical and ethical foothold that gave me one of my most meaningful clinical and learning experiences. In the process, I acquired a lens that allowed me to glimpse some of the gaps in our approach to international medical education.
As medical schools continue the process of shaping and fine-tuning international medical curricula, I hope many of us will ask how much more students and residents could benefit clinically, culturally, and emotionally if they had more guidance and supervision. Separating the difficult from the impossible is something that can be accomplished. We need to continue to heighten our skills in distinguishing between the two when shaping global health programs. Surely, when future doctors benefit, their future patients—wherever they might be—will benefit, too.”
Al-Samarrai’s experience sounds disconcerting, as the mechanisms of “aid” and the failures of communication between host and guest institution were laid bare before her eyes during her time in Mulago. Significantly, she lands solidly in favor of such a medical service endeavor, especially when organized with a clearer set of responsibilities and expectations for the guest institution as well as greater investment by the guest institution in training members of the host institution.
The way Al-Samarrai describes this medical program reveals an imbalance of benefit. Providing this form of medical service gives the volunteer a significant learning experience, while the patients of the host institution may be receiving more limited care due to the limitations of not only the host institution but also the lack of efficient usage of guest institution expertise. Assumptions or ignorance of the hospital’s clinical reality, in combination with a lack of accountability on the part of the guest institution’s leadership, created a fragmented experience for the intern. These kinds of assumptions and lack of accountability leave the door open for abuse by interns who might have more self-interest than social responsibility. Luckily Al-Samarrai exhibited a true commitment to the spirit of her profession and took further steps to help bring more effective exchange of knowledge to the program in which she took part.
However, when left unstructured, this kind of medical aid project has the potential for reproducing the more imperialist leanings of some development projects which bring in foreign “experts” that consequently pack up and don’t leave any knowledge behind when they complete their volunteer time period. Or even worse, some medical aid projects bring much-needed medication to the area or begin to vaccinate parts of the population but run out of resources and leave the remaining population high and dry. Although the Ugandan medical endeavor is not overtly imperialistic in the way that some pharmaceutical-based “aid” projects have been, Al-Samarrai’s experience on the ground reaffirmed the heavy responsibility of the guest to create a clear exchange of services, in a well-defined and accountable way.
Another article outlines the concept of “voluntourism” as it is practiced in the allopathic medical community.
The excerpt below is taken from the article: Fly-By medical care: Conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists (3). It provides further recommendations for the practice of culturally and socially aware medical volunteering.
The Association of American Medical Colleges’ (AAMC’s) offers four foundational ethical considerations prior to embarking on global health voluntourism: (1) ensuring high ethical and moral standards, (2) developing a social contract with the communities served, (3) subordinating self-interest to the interest of the communities served, and (4) ensure that core humanistic values (honesty and integrity, caring and compassion, altruism and empathy, respect for self and others) are at the forefront of all activities [23]. These ethical considerations point to a number of specific social responsibilities that physicians involved in voluntourism hold, such as ensuring that compassionate and respectful care is provided that meets the highest ethical and moral standards that the context allows for. What these guidelines lack are specific, concrete strategies for enacting ethical, socially responsible care. The 4Rs that were developed by Aboriginal leaders in Canada to guide researchers in working with their communities, which are summarized in Table 1, offer some suggestions for specific strategies [63].
Generally, socially responsible medical voluntourism is a collaborative process that considers the full participation of local communities, local healthcare workers, and local health authorities [54]. It complements principles of international solidarity and social capital within the context of civil society, where voluntourists act voluntarily and without seeking personal profit to share benefits. Physician volunteers are encouraged to develop a sense of professional and personal growth, and to examine critically what it means to be a socially responsible practitioner [93]. For example, many voluntourists seem to believe that being socially responsible means charity [60]. But charity can create dependency relationships whereas social responsibility aims at social justice, understood as developing sustainable relationships based on mutual respect. It involves working with and for communities to enable what they feel is best for them rather than using a paternalistic approach. Dickson and Dickson [60], identify a list of personal attributes that physicians need to develop as part of their professionalization and to act responsibly that include: a concern with global equity; a commitment to redressing injustices in healthcare; respect for diversity; openness to mutual learning; and embracing ethical values like human rights and social justice. The professionalization of physicians gives them norms by which their social responsibilities as voluntourists are increasingly clearly stated. It also gives physicians the information and expertise with which they may act on these norms.
The 4Rs of Ethically Sound Research -
Ethical, Principle, Strategy.
1. Respect: Valuing cultures’ and communities’ diverse knowledges regarding health matters and developing knowledge that contributes to communities’ and cultures’ health and wellbeing
2. Relevance: Ensuring that research (or practice) is relevant to the culture and community
3. Reciprocity: Incorporating a two-way process of knowledge exchange and learning, where all parties benefit from these opportunities and the development of relationships
4. Responsibility: Fostering empowerment through allowing for active participation and rigorous engagement by all parties.
These guidelines seem reasonable on paper. Any thorough international medical organization can meet the first two R’s, but it seems like the second two R’s pose the biggest challenge. Those two R’s also represent what is missing from health care in general in the U.S.- so how do we expect to be able to accomplish them abroad? Or is medical voluntourism an opportunity to hone these personal and organizational skills abroad and then bring them home to create a more just health care system in the U.S.? Please feel free to share your opinion, since this type of debate is currently raging and unresolved.
Two excellent talks regarding these issues:
TEDx Talk Rainier: Dr. Wendy Johnson – A New Paradigm for Global Health: Solidarity
Through her national and international health advocacy work, Johnson believes that the key to overcoming disease burdens in both developed and developing countries is to strengthen and rebuild public health care systems. And that is exactly what she is doing. As clinical faculty in University of Washington’s School of Public Health and Director of New Initiatives for Health Alliance International (HAI), Johnson develops projects to strengthen public primary health services and advocates for universal health care access in low-income countries.
TEDx Talk Rainier: Dr. Stephen Bezruchka
Dr. Stephen Bezruchka seeks to expose why health disparities among nations around the globe are at record highs and empowers people to address the socioeconomic inequities that have most impact on the health of populations. He is especially interested in how people in the USA don’t live very long or healthy lives. Bezruchka’s work takes him from teaching at the University of Washington’s Department of Global Health to remote regions of Nepal, where he wrote the first guidebook to travel there, set up a community health project, organized a rural hospital for the Generalist Doctor Training Program, worked with Nepali doctors to improve surgical services in district hospitals, and now consults on population health issues.
Bezruchka worked in clinical medicine for 35 years. He received the UW School of Public Health’s 2002 Outstanding Teacher Award and the 2008 Faculty Community Service Award. He founded the Population Health Forum to raise awareness of, promote dialogue about, and explore how political, economic and social inequalities interact to reduce the overall health status of our society.
To see some aspects of the debate regarding humanitarian aid and medical voluntourism, you can check out Nassim Assefi’s TED Talk page. The question below prompted an interesting discussion.
What’s the most effective model of global health aid/development, given interventions can have complex, unpredictable and longterm impacts?
A debate is raging between those who believe humanitarian aid is corrupt, ineffective, and harmful (eg Dambisa Moyos of the world) and those who believe it is the moral imperative of wealthier nations to help the poor (Bill Gates, Nick Kristof, Paul Farmer, etc). As an idealistic young doctor with a privileged life and education, I wanted to give back to the world, starting some 20 years ago when I joined my first NGO. Since then, I’ve seen many different models of global health with variable effectiveness–Doctors Without Borders approach of relieving suffering but not building infrastructure, more standard NGOs that combine the two, large UN agencies (eg UNICEF, WHO, UNFPA, ICRC), medical diplomacy (free exportation of Cuban health workers), social entrepreneurship (eg Acumen Fund), missionaries, Gates Foundation/Global Fund/World Bank, international medical research posing as aid, etc. While objective successmetrics and monitoring and evaluation plans are now the standard part of most health interventions, what do we really know about the longterm, complex outcomes of our well-intentioned health interventions? Have we propped up an illegitimate government or strengthened a democratically-oriented one? Have we destroyed local economies or sustained them? Have we exacerbated brain drain or created jobs for internationals who want to return home? Weakened local infrastructure or strengthened it? Educated or misled? Oppressed the people we were supposed to help or empowered them? Please help me figure out the most effective way to use my medical and public health skills to improve health in a global context, and in doing so, help many others who are struggling with these issues. I would love to hear your experiences, perspectives, and ideas about how to do global health work right and how you might measure the complex, longterm impacts of what you propose. (Meanwhile, ironically, the US still lacks a decent, universal, and cost-effective health care system.)
The next post here will investigate how Traditional Chinese Medicine fits into this framework for socially responsible medical voluntourism.
Meanwhile, enjoy the excellent music of radical Portland folk-punk-hardcore band Adelitas! The lyrics for the song in English can be found at the end of the article.
Adelitas: Hay Que Luchar
References:
1. Green T, Green H, Scandlyn J & Kestler A. (2009 Feb) Perceptions of short-term medical volunteer work: a qualitative study in Guatemala. Globalization and Health. 5:4. Retrieved from: http://www.fresno.ucsf.edu/global_health/downloads/PerceptionsGuatemala.pdf
2. Teeb Al-Samarrai.(2011 March) Adrift In Africa: A US Medical Resident On An Elective Abroad. Health Affairs. (30)3:525-528
3. Snyder J, Dharamsi S & Crook V. 2011. Fly-By medical care: Conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists. Globalization and Health. 7:6. Retrieved from: http://www.globalizationandhealth.com/content/pdf/1744-8603-7-6.pdf
Hay Que Luchar:
Get up, raise your voice- Can’t you see that so many silences wound us? Time goes by, there seems to be no solution. And when you lose hope, know that I understand you.
Wake up!
It’s not the time for remorse, bitter pasts. Let’s not let this suffering detain us. Our thoughts torment us, and knowing what to do, we end up paralyzed. And what if our hands had the power to break down the old walls, and nothing could stop us?
The future remains unwritten, in spite of the illusion of control- If we want anarchy, we have to fight for it – with militancy and love. It’s coming to end, this cruel empire. centuries of dementia, oppression, extermination. Let the storm rain down, drown this hell and we will know how to swim..
Organizing resistance with strategy and persistence- For freedom, for humanity never giving up. I know how easy it is to lose hope in this world of war and fear but come on we have one life nothing more- let’s fight for a better world. And you’ll see that our hands do have the power to make our dreams real, to build a new reality.
