In spite of good intentions, international volunteer work that does not follow best practice principles can be wasteful, unethical, and harmful. Worst practices are serious public health concerns that create new and oftentimes more substantial barriers to patient care, thereby reinforcing health disparities and the cycle of poverty. Furthermore, these worst practices often violate concepts of social justice and human rights. Volunteer abroad programs must apply best practices in order to make a significant, high-impact difference. Committed to spreading best practices and eliminating the worst practices that are prevalent in other organizations with volunteer abroad programs, Unite For Sight developed an evaluative framework by which one can evaluate volunteer abroad programs worldwide.
Many organizations have programs that rely solely on visiting volunteers to provide healthcare or other services. Due to high costs, schedule constraints and complicated logistics, these global health endeavors take the form of short-term medical missions, which undermine the local health care system, cause significant harm, and reinforce poverty.(1) Medical missions or "volunteer vacations"(2) can be seen as: (1) self-serving: providing value for visitors without benefitting the local community, (2) failing to meet expectations: sending volunteers who do not have appropriate language or medical training or accountability, (3) ineffective: providing temporary, short-term therapies that fail to address root causes, (4) Imposing burdens on local health facilities: providing culturally irrelevant or disparaging care and leaving behind medical waste, and (5) inappropriate: failing to follow current standards of healthcare delivery or public health programs.(3)
A team of physicians from the United States made 140 trips to 27 institutions in 19 countries in order to sponsor pediatric cardio-surgical missions. While these medical missions accomplished many good things such as training local caregivers,(4) a few of their programs had mixed results. Three institutions did not see an increase in the number of cases nor the complexity of cases being performed in the facility since the team intervened. (5) Researchers documented a number of reasons for the failure of their missions. Such reasons included the economic situation of the country, hospital and national politics, personality conflicts, and continued lack of resources. Interpersonal disputes within the institution always led to failure of progress. “Political appointees, by either the hospital or government, of individuals who were not capable of advancing the program, perhaps because of ego, were another reason for failure”.(6) One final challenge that impeded progress was the difference in language between the team and the host country. All of these problems stemmed from the nature of the short-term intervention. Without stable, collaborative partnerships with local physicians and community workers, it was difficult for the medical missionaries to sustain practices and ensure institutional memory.
Proper training is essential for volunteers. Volunteers who are not both practically and psychologically competent to work abroad can end up being a burden to the global health organization and its local partners. On the other hand, well-prepared volunteers can make an immediate, high-impact difference. Those traveling to developing countries must first be educated about local culture and familiarize themselves with their target communities. Without such preparation, volunteers can fail to relate to local patients and workers, which can undermine the relationship between a global health organization and its partners. Furthermore, volunteers must be competent to carry out their duties which may include education, basic medical tasks, and more. Incompetent volunteers can do more harm than good by propagating false information, or interfering with proper medical care. All global health volunteers must therefore have a basic knowledge of international development and best practices in global health.
When volunteers have relevant skills, they should be applied to maximize the impact of a global health initiative. No volunteer, however, should ever provide services beyond their level of expertise. Allowing medical providers to practice beyond their abilities is one of the worst practices in global health. Often times, medical students and residents see medical missions to developing countries as opportunities to gain unbarred exposure to techniques and procedures they couldn’t perform in their home countries. Other times, visiting physicians feel compelled to treat patients outside their specialty, simply because there is no specialist available. Lowering the standard of medical care for those in developing communities is unprofessional, unsafe, unethical, and oftentimes illegal. Students who pretend to be a doctor, or act in the role of a doctor, do so illegally and unethically.(7)
In newspaper articles, on blogs, and on the websites of NGOs and other organizations, there are countless descriptions of frightening and dangerous practices of non-medical professionals reveling in the unauthorized practice of medicine. The following account of a first-year medical student’s mission experience clearly illustrates the dangerous pitfalls of relying on untrained medical volunteers:
“After finishing my first year of medical school, I participated in a mission trip to Mexico. Before flying to Mexico, I was not given any cultural, medical, or other training, nor could I speak Spanish. Upon arriving, I was assigned to a clinic where there were hundreds of patients seen by only one physician. I remember vividly seeing a frail 11-year-old boy with polyuria, polydipsia, and nocturia. My lack of medical training limited my differential. With only a scattered history and no other tests, I told him to limit caffeine intake and see if that helps. Thinking back, he could have had a urinary tract infection, any number of renal abnormalities, or worse, I sent him out without ruling out diabetic ketoacidosis. And while I was seeing patients by myself, other first year medical students were performing surgeries in the other clinics and later bragging about it.”(8)
By ignoring local healthcare providers, many volunteer programs undermine the local healthcare infrastructure, create new barriers to care, and cause harm. Patients may decide to wait until Western doctors or teams visit instead of seeking care by the local doctors. Oftentimes, it is rich patients who take advantage of free surgical care provided by visiting surgeons despite being able to pay, simply because they incorrectly believe that the Western visitors provide higher quality surgery.
“While [Western medical] teams provide temporary but sporadic access to health care, overall, they do not improve long-term access and they may, in fact, undermine existing services. It is unclear whether the short-term projects are treating only individuals who under current circumstances would have absolutely no access to medical care because of an inability to pay for it, or if they are diverting some otherwise paying or potentially paying patients from local practitioners and facilities. Local practitioners who must earn a living in the community cannot compete with the volunteers who donate their services. Furthermore, they cannot provide the same volume of free care over sustained periods and remain financially viable. Because the patient population… has not been closely analyzed, it is difficult to assess the precise impact on the local health care delivery system. If these groups actually do compete with local providers, the possibility exists that they could be put out of business, further restricting access to health care.”(9)
Surgery provided by visiting physicians without collaboration with local surgeons is considered one of the worst practices in global health. Even the most experienced surgeons cannot overcome the significant harm and risks of short-term surgical missions. When visiting surgeons do not work with their local counterparts, there is no surgeon to provide follow-up care or to treat infections that may arise after the operating surgeons depart. In addition, the ramifications of botched surgeries affect more than just the surgical patients and their families. A poor surgical outcome can lead an entire community or region to fear doctors and surgery.
For example, a study of anesthesia care provided by Operation Smile volunteers found that although the complication rate associated with facial-cleft surgery in the field was similar to rates in developed countries, the brevity of missions may contribute to avoidable illness and death.(10)
“Complications may be inevitable, but when they affect a poor patient in a developing country who is being treated by a volunteer physician, the situation can be politically as well as emotionally charged. Operation Smile volunteers have been accused by local surgeons of "dumping" their complications when their mission is over, though the organization refutes this charge.”(11)
Furthermore, surgical residents frequently see international electives as "an excellent opportunity to see large volumes of advanced pathology, provide good surgical opportunities, and at the same time provide benefit to the location population."(12) However, encouraging and providing an opportunity for surgical trainees to operate beyond their capabilities and beyond parameters and regulations in their home country, encourages trainees to see patients from other cultures as opportunities for training, "reinforcing the undesirable view that some patients are more valuable than others”. It also unfairly distributes the risk of training beginning surgeons to developing countries and contributes to the ethos of the global health inequity."(13)
(1) Pinto, A.D., Upshur, R.E.G. "Global Health Ethics For Students." Developing World Bioethics. (Blackwell Publishing Ltd., 2007): 1-10: 7-8.
(2) Bezruchka, S. “Medical Tourism as Medical Harm to the Third World: Why? For whom?” Wilderness and Environmental Medicine. 11.2 (2000): 77-78. Accessed on 20 October 2008.
(3) From P. Suchdev et al., “A Model for Sustainable Short-Term International Medical Trips,” Ambulatory Pediatrics 7, no. 4 (2007): 317-20.
(4) Novik WM et al. Paediatric cardiac assistance in developing and transitional countries: the impact of a fourteen year effort. Cardiol Young. 2008 Jun;18(3):316-23.
(5) Novick WM, Anic´ D, Ivancˇan V, Di Sessa TG. International pediatric cardiac assistance in Croatia: Results of the 10 year program. Croat Med J 2004; 45: 389–395.
(6) Novick WM. Academic cardiac surgery in Croatia: perspective through the eyes of an international collaborator. Croat Med J 2004; 45: 382–386
(7) Banatvala, N., and Doyal, L. "Knowing when to say 'no" on the student elective: Students going on electives abroad need clinical guidelines." BMJ. 316 (May 1998): 1404-1405.
(8) Shah, S. and Wu, T. “The medical student global health experience: professionalism and ethical implications.” Journal of Medical Ethics. 34 (2008): 375-378. Accessed 20 October 2008.
(9) Montgomery, L.M. “Short-Term Medical Missions: Enhancing or Eroding Health?” Missiology: An International Review. 21.3 (1993): 333-341. Accessed on 09 September 2009.
(10) Fisher QA, Nichols D, Stewart FC, Finley GA, Magee WP Jr, Nelson K. Assessing pediatric anesthesia practices for volunteer medical services abroad. Anesthesiology 2001;95:1315-1322.
(11) Wolfberg AJ. Volunteering overseas--lessons from surgical brigades. N Engl J Med. 2006 Feb 2;354(5):443-5.
(12) Boerma, T. and Abou-Zahr, C. “Monitoring global health: Bottom-up approach is more likely to be successful.” BMJ. 330 (January 2005): 195-196.
(13) Ramsey, K.M., and Weijer C. "Ethics of Surgical Training in Developing Countries." World Journal of Surgery.31.11 (2007): 2070-2071.