Reflection and Understanding

Introduction

It might be overwhelming to consider that all of the lessons in this training curriculum will be applicable to your Global Impact experience. We have put forth many definitions, theories, and postulations about best practices for which the importance or magnitude of effect will not be made tangible until you are on the ground, living the realities and complexities of international community development. Now that you have a better grasp of Unite For Sight’s mission and methods, however, you can approach challenging or unfamiliar situations with an appropriate mindset, informed perspective, and knowledge base attuned to the necessity of capacity-building, local leadership, and sustainability. All too often in academic disciplines, theorists commit the “fallacy of misplaced concreteness,” formulating complicated conclusions that claim to delineate how things should be done, but fail to appraise real-life applications.(1) The methods presented in our training modules, time and time again, have proven successful in reducing patient barriers to care, strengthening local competencies, and directly linking assets with outcomes. Abstraction will become actuality. Theory will become truth.

The realization of Unite For Sight’s goal—to improve eye health and eliminate preventable blindness—is highly dependent on the willingness and ability of volunteers to take to heart the significance of social entrepreneurship, asset mobilization, and grassroots empowerment in successful community development. You are an essential component of this vision.  You bring your own unique set of interests, academic history, personal experience, and passion—all qualities that have the potential to dramatically enhance the impact of Unite For Sight’s partnerships with local eye clinics. Ashoka, a leading social entrepreneurship agency working to stimulate the global citizen sector to creatively address societal needs, has said that everyone has the capacity to be a changemaker.(2) In a bold article, Chairman and Chief Executive Officer of Ashoka William Drayton stated:

"Multiplying society’s capacity to adapt and change intelligently and constructively and building the necessary underlying collaborative architecture, is the world’s most critical opportunity now. Pattern-changing leading social entrepreneurs are the most critical single factor in catalyzing and engineering this transformation."(3)

As seen in many of the vignettes and research put forth in the training modules, Global Impact Fellows (and volunteers in any international pursuit) have the power to do both incredible good or, conversely, incredible harm. If the principles of sustainable community development are not incorporated judiciously, or if the rules of volunteer comportment are not taken seriously, the efficiency and efficacy of the clinic’s initiatives could be severely jeopardized. If you take the proposed best practices seriously, however, you have the opportunity to contribute to the propagation of one of the most promising contemporary development models: Asset-Based Community Development (ABCD).

There are several key principles of ABCD that parallel the expectations of Unite For Sight for its volunteers:

Investing in these principles will give you, as a Unite For Sight Global Impact Fellow, a sizable advantage in creating high-impact, lasting change. Community developers who fail to heed these fundamental principles typically end up compromising relationships with locals, damaging trust, offending cultural values, and generally being unsuccessful. Seize this opportunity to reconstruct your concept of service, re-imagine traditional altruism, and reinforce your confidence as a global changemaker. Live with philosopher Lao Tzu’s proverb about an outsider’s role in development:

“Go to the people. Live with them. Learn from them. Love them. Start with what they know. Build with what they have. But with the best leaders, when the work is done, the task accomplished, the people will say, ‘We have done this ourselves.’”(5)

To help you tie in all that you’ve learned throughout this training experience, consider the vignette below involving a volunteer in a challenging situation. Read the summary of her challenge, and then think about how YOU would have responded in the same circumstances, keeping in mind the lessons from the training modules. Then, compare and contrast your response with our re-cap of how the situation should have been dealt with.

The Situation

Madeline is at an outreach and sees that more than 200 patients are waiting to be seen. The ophthalmic nurse asked Madeline to be at the medication and eyeglass dispensing station today with George, who is another Unite For Sight volunteer. Madeline sees that a bottleneck to patient flow is accumulating at the patient intake station. Disgruntled about the backup of patients, Madeline thinks to herself, “If the community translators had arrived today on time, we wouldn’t have this problem. People here are so fickle about punctuality.” Madeline is accustomed to the daily routine enough that she feels like she can get started taking patient histories on the dozens of individuals lined up. Madeline also has an ophthalmoscope that she brought from medical school, and decides that today will be a good opportunity to practice looking at the retina for each patient as her own learning opportunity. “My hospital advisor back home would be so proud to hear that I am taking what I’ve learned in the States to a developing country,” she thinks. Although she doesn’t have a translator to assist her, this is not a deterrent—she has picked up enough words in the local language to hold a basic (albeit somewhat broken) conversation. Besides, as Madeline said, “Unite For Sight had high aims to reach the greatest number of people possible, and eliminate preventable blindness, and I want to contribute my skills to this goal.” One older woman she sees tries to tell her something with very emphatic hand gestures and quick, incomprehensible speech. Since Madeline cannot completely understand, she records the few tid-bits she can interpret, assures the woman that she has gotten everything down, and moves on to the next patient. “What does one crazy woman’s babbling matter anyways? The doctors are the experts. They’ll solve her problems when they see her.” The additional patient intake station that Madeline created is not part of the standard station flow that was set up by the ophthalmic nurses at the start, and the patients rotating through Madeline’s intake station are skipping the visual acuity station and walking directly to the ophthalmic examination and diagnosis station. The ophthalmic nurses are silently confused about how today’s setup is causing so much chaos amongst the patients, and they need to take extra time to redirect the patients to the visual acuity station. The patients are also telling the ophthalmic nurses that they were already examined.  By the time the ophthalmic nurses notice that Madeline set up another patient intake station and is looking at patients’ eyes with an ophthalmoscope, she had gotten through 23 patients.

What are Madeline's errors, and how should she have acted in this situation?

The Discussion: Lessons to Remember

While Madeline had good intentions, she also had several lapses in judgment. Let’s discuss a few of them.

1. First of all, Madeline should have remembered that timeliness is not a universal value. As mentioned previously, “[i]n some traditional societies, punctuality is seen as a Western eccentricity.”(6) It was good that, even though Madeline had noticed this cultural difference during her first couple of weeks, it didn’t change her habit of arriving to work on time. However, she still became frustrated when the translators arrived late. While different countries may have varying perspectives of time, volunteers should assume (unless told otherwise) that just because patients or supervisors periodically arrive late does not mean that volunteers can show up any time they want. 

2. Second, Madeline practiced beyond her abilities—and beyond her responsibilities. While she was justified in wanting to utilize her background as a medical student, which undeniably would have been an asset with proper monitoring from supervisors, she stepped outside of the boundaries permitted by proper volunteer ethics by using a medical instrument (the ophthalmoscope) without authorization. As Lynn Payer, medical journalist and scientific writer, demonstrates in her book Medicine & Culture, the medical community of the United States is characterized by a “can-do” attitude, one that makes Americans more inclined “to feel it is better to do something rather than not do anything.”(7) This makes American medical professionals much more likely to favor more aggressive, intensive procedures, and more initiative and risk-taking, than do practitioners from other countries. While independence, drive, and resourcefulness are championed in the States—and can be useful with proper regulation—Madeline’s behavior was in fact denigrated by her superiors. They interpreted her actions as overly bold, abrasive, and disrespectful. As discussed in previous modules, Unite For Sight takes great pride in the fact that outreaches are led and managed by the local eye care professionals. Madeline subverted the local professionals’ authority by making a unilateral decision about her tasks for the day. She should have inquired as to whether it would have been a good idea to set up an additional patient intake station. If her superiors had found this suggestion useful, they could have then directed Madeline to a more strategic spot. Instead, Madeline brazenly disrupted an already efficient system by placing herself in a location that caused patients to skip the visual acuity station.

Likewise, the patients who saw Madeline also expressed dissatisfaction with the way they were treated. Many felt under-valued due to the linguistically complicated and terse encounter. Some of them never returned to the clinic for their surgeries or subsequent consultations. But not only did these patients forgo sight-restoring surgery, they also told fellow villagers how poorly managed the outreach was, discouraging even more people from coming forward to access quality care from the local eye care professionals. Thus, even though Madeline’s decision may seem like a small mistake, it forever changed the attitudes of several locals about eye care. Similarly, the patients who did return despite their discontent with the way they were treated were still circumspect to accept everything the doctors recommended. Hence, Madeline inadvertently created new barriers to care: fear and skepticism. She threatened the patients’ trust in the providers, as the patients did not understand why they had to be examined twice. Madeline placed an additional burden on the ophthalmic nurses, who had to explain to the patients that their first “examination” was not an examination at all, but rather, a fledgling student’s impulsive attempt to inspect their retinas without authorization or guidance. The nurses felt disgraced by the patients’ consequent puzzlement.

As described in Anne Fadiman’s book, The Spirit Catches You and You Fall Down, lack of trust and non-compliance result when the doctor-patient relationship is compromised. In this poignant anthropological account, Fadiman depicts the tragic case of Lia Lee, a Hmong immigrant from Laos who, not too long after arriving in California, develops epilepsy. The American doctors try to communicate proper protocol for seizure control to Lia’s parents (who do not speak English) through elaborate gesticulations, color-coded pill charts, and carefully drawn suns and moons on Lia’s orange medication bottles, to indicate the time of day at which Lia must take her pills. The Lees, however, are uncooperative and hostile towards Western medicine, as it fails to take into account ancient Hmong beliefs about spirituality and bodily phenomena. A pattern of miscommunication, frustration, and cultural altercations take place, ultimately weakening Lia’s already precarious neurological health.(8) As this account demonstrates when patients feel slighted in the least, a chain of unfortunate consequences can result.

If Madeline had taken time to contemplate her actions with an attitude of cultural humility, she might have realized that the worth she placed on autonomy was ethnocentric, and not considerate of value differences between cultures. To avoid Madeline’s mistake, “[w]e must begin by acknowledging our own social history because recognizing the attitude we bring to our patients enables us to deliver effective care.”(9) It also seems, based on her comment about impressing her hospital advisor back home, that Madeline might not have been in this trip for the right reasons. In examining the motivations behind “tree-huggers’” travel propensities, Maryann Bird exposes the hedonism and naïveté behind “environmentally friendly” expeditions in her Time Magazine article entitled “Ecotourism or Egotourism."(10) The travelers she describes, all of whom pursue such trips to show how much more respectful and knowledgeable they are about the earth than conventional tourists, end up discrediting themselves by booking airlines, staying at hotels, and consuming imported foods, all of which cause their carbon emission tally to skyrocket. This article illustrates the important idea that volunteers should enter any foreign situation enthusiastic about humbling themselves enough to realize just how little they know. Madeline did just the opposite—she was excited to show just how much she knew, and acted accordingly to inflate her own ego. Again, while Unite For Sight does not want you to squelch your skills, we do want you to use them appropriately, with the permission of both cultural norms and supervisor approval.

3. Lastly, it is important to consider Madeline’s interaction with the elderly patient. There are two primary issues with Madeline’s attitude toward this patient.

A) In Dr. Paul Farmer's book Pathologies of Power, there is a section entitled, “Double Standards of Medical ‘Ethics’ for the Developing World." Farmer discusses the deplorable “ironies of inequality” perpetuated by some development agencies and research universities who transport their testing procedures to developing countries.(11) As Farmer states, “the proper beneficiaries of the Universal Declaration of Human Rights—however inexpedient this point might be in our age of individualism and affluence and relativism—are the poor and otherwise disempowered”—those who “are most likely to have their rights violated.”(12) Similarly, Madeline should have been prepared to provide the same standard of care to the villagers as she would expect in the United States. Madeline would likely not have tried to surpass her hospital advisor’s stamp of approval in the U.S. in order to examine patients with an instrument she was not authorized to use on her own. Using the villagers as educational guinea pigs was a presumptuous and disrespectful decision.

B) Dr. Arthur Kleinman—a prominent medical anthropologist and leading figure in global health, social medicine, and cultural psychiatry—makes clear in his book Illness Narratives the importance of carefully recording and interpreting all of the meanings behind a patient’s illness as determined by the patient’s description of his or her interaction with sickness (its perceived etiology, physiological repercussions, and effects on social relationships).(13), (14)

“Illness narratives edify us about how life problems are created, controlled, made meaningful. They also tell us about the way cultural values and social relations shape how we perceive and monitor our bodies, label and categorize bodily symptoms, interpret complaints in the particular context of our life situation; we express our distress through bodily idioms that are both peculiar to distinctive cultural worlds and constrained by our shared human condition.”(15)

Because the ways in which individuals perceive and respond to bodily abnormalities are delicately wrapped up in deeply cultural webs, the practitioner’s role is “the sensitive solicitation of the patient’s and the family’s stories of the illness, the assembling of a mini-ethnography of the changing contexts of chronicity, informed negotiation with alternative lay perspectives on care, and what amounts to a brief medical psychotherapy for the multiple, ongoing threats and losses that make chronic illness profoundly disruptive.”(16)

Unite For Sight volunteers (and Madeline, in this example), need to understand that although “[t]here may well be enough universality in facial expressions, body movements, and vocalizations of distress for members of other communities to know that we are experiencing some kind of trouble… there are subtleties as well that indicate our past experiences, chief current concerns, and practical ways of coping with the problem. These particularities are so much a part of local assumptions that they are opaque for those to whom our shared life ways are foreign.”(16) In other words, there are certain expressions of or explanations for illness that can only be understood by members of the same cultural background as the patient. Madeline should not have been so quick to dismiss the woman’s explicit communication of distress. The use of an interpreter, and deeper investigation into and understanding of cultural beliefs, would have helped Madeline record the woman’s concern more accurately and compassionately.

Conclusion

Much of this training commands that you, as an international volunteer equipped with an exceptional understanding of the rules for successful community development, surrender your preconceptions and defer to the authority of local cultural norms. While there is much to be said about the power of humility and sensitivity, this does NOT mean that you have to abandon what makes you you—your experiences, your personality, your passions. While you are called to be an “ethical” volunteer, we also hope that you are able to learn and grow from your experience by asking questions, applying your unique, invaluable academic and experiential background, and taking time for reflection and introspection. When contemplating what you witness each day, ask yourself the following questions:

One helpful way to answer these questions is described in Bruce L. Berg’s book Qualitative Research Methods for the Social Sciences. While the following advice is contained within a section about how to write an ethnography—an anthropological examination of a particular community’s values, customs, struggles, and triumphs—it still provides kernels of wisdom concerning how individuals should observe and interpret their social world. In reading the following quotation, envision yourself as “the researcher,” navigating new, unfamiliar surroundings and trying to make sense of your experiences.

"The “reflexive characteristic implies that the researcher understands that he or she is part of the social world(s) that he or she investigates … Reflexivity further implies a shift in the way we understand data and their collection. To accomplish this, the researcher must make use of an internal dialogue that repeatedly examines what the researcher knows and how the researcher came to know this. To be reflexive is to have an ongoing conversation with yourself. The reflexive ethnographer does not merely report findings as facts but actively constructs interpretations of experiences in the field and then questions how these interpretations actually arose. The ideal result from this process is reflexive knowledge: information that provides insights into the workings of the world and insights on how that knowledge came to be.”(17)

Sometime throughout your participation as a volunteer, you are going to experience confusing or frustrating emotional responses to certain events. Embrace these moments as opportunities to better understand your worldview. As Scottish author Robert Louis Stevenson said, “There are no foreign lands. It is the traveler only who is foreign.”(18) If you are ever struck by curiosity, perplexity, astonishment, or even repulsion, remember: the local people may be just as perplexed by you. Noting differences of culture with an air of discrimination or intolerance is only an activity of the narrow-minded. Avoiding this takes active practice in cultural reverence, humility, and, ultimately, self-awareness. As long as you value and harness these traits, your volunteer participation will be educationally informative, personally enriching, and immeasurably rewarding.

Footnotes

(1) Cobb Jr., J., and Daly, H. For the Common Good. (Beacon Press, 1994): 25.

(2) “About Us.” Ashoka: Innovators for the Public. Accessed on 17 May 2010 <http://ashoka.org/about>.

(3) Drayton, W. “Everyone as a Changemaker.” Innovations: MIT Press Journals. 1.1 (2006): 80-96. Accessed on 17 May 2010 <http://www.mitpressjournals.org/doi/abs/10.1162/itgg.2006.1.1.80>.

(4) Campfens, H. Community Development Around the World. (University of Toronto Press, Inc., 1999): 23.

(5) Tzu, L. “Lao Tzu Quotes.” Accessed on 18 May 2010 <http://thinkexist.com/quotation/go-to-the-people-live-with-them-learn-from-them/348565.html>.

(6) Leggat, P., and Stewart, L. “Culture Shock and Travelers.” Journal of Travel Medicine. 5.2 (1998): 84-88. Accessed on 18 May 2010 <http://www3.interscience.wiley.com/cgi-bin/fulltext/119944355/PDFSTART>.

(7) Payer, L. Medicine & Culture. (Henry Holt and Company, LLC, 1996): 131.

(8) Fadiman, A. The Spirit Catches You and You Fall Down. (Farrar, Straus and Giroux, 1998).

(9) Roberts, M. “Duffle Bag Medicine.” JAMA. 295.13 (2006): 1491-1492. Accessed on 18 May 2010 <http://www.med.umich.edu/medschool/globalreach/students/docs/Duffel%20Bag%20Medicine.pdf>.

(10) Bird, M. “Ecotourism or Egotourism.” Time Magazine 18 August 2002. Accessed on 18 May 2010 <http://www.time.com/time/magazine/article/0,9171,338585,00.html>.

(11) Farmer, P. Pathologies of Power: Health, Human Rights, and the New War on the Poor. (University of California Press, 2005): 128. Accessed on 18 May 2010 <http://books.google.com/books?id=2sbP7J-lckoC&printsec=frontcover&dq=pathologies+of+power&hl=en&ei=VgL0S46ZIYP48Aax98i2Dg&sa=X&oi=book_result&ct=result&resnum=1&ved=0CDAQ6AEwAA#v=onepage&q&f=false>., page 200-201.

(12) Ibid, page 212.

(13) “Arthur Kleinman, Professor.” Harvard University: The Department of Anthropology. Accessed on 19 May 2010 <http://www.fas.harvard.edu/~anthro/social_faculty_pages/social_pages_kleinman.html>.

(14) Kleinman, A. Illness Narratives. (Basic Books, 1988).

(15) Ibid, page xiii.

(16) Ibid, page 10.

(17) Berg, B. Qualitative Research Methods for the Social Sciences. (Pearson/Allyn & Bacon, 2007): 198.

(18) Stevenson, R. “Quotation.” Accessed on 19 May 2010 <http://thinkexist.com/quotes/like/as_the_traveler_who_has_once_been_from_home_is/173153/4.html>.