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Global health experiences – do they do more harm than good?


Summertime for many university students, reeling from aftermaths of their exams, may mean relaxing on the beach with friends. However, for many eager and forward-looking students, it is an opportunity to gain experience: international experience.

Today, one can hardly walk through a university campus without noticing posters taped to lamp posts or bulletin boards with words “international”, “service”, “volunteer” and “experience” highlighted across them. It is a growing trend among undergraduate or medical students to spend their summers working on projects in underprivileged settings around the world, ranging from providing shelter, teaching English, or gaining medical experience. The industry is growing at an exponential rate in North America and Europe, but are there potential pitfalls to these popular programs?

Imagine walking into a clinic and discovering a new face behind the doctor’s desk. You realize that it is a young physician, working alone and without knowledge of your language. You are seen briefly and told to limit your caffeine intake to “see if it helps” with your chief complaint of polyuria. What you do not realize, however, is that the “doctor” was in fact a first-year medical student, who did not have the training to rule out serious or fatal diagnoses for your symptoms. And if you thought things at your clinic were troubling, other first year students were performing surgeries in another clinic and bragging about it.

Unfortunately, this is not a fictional scenario, but an anecdote reported by a participant of a “global health experience” in Mexico.

Global health experiences are common: a 2012 survey of American and Canadian medical students reported 30% of graduates having participated in a global experience during medical school. Though it is unlikely that these ethically unjustifiable practices are the norm, it is alarming that recent studies suggest altruism may not be the motivation for participating in these opportunities. In interviews with 68 Canadian youth returning from short-term volunteer placements in the developing world, researchers reported “the desire to help others” ranked second-last among the most important motivations for their participation. The top three motivations were testing a career choice, cross-cultural understanding, and personal growth. Indeed, most youth justified their time spent in the host communities in personal, rather than humanitarian terms.

When vulnerable individuals and societies are considered mere stepping stones that lead to one’s self-improvement, does it not rob them of human dignity, and along with it our moral compass?

Equally important is that international volunteers very often lack cultural competency. Typically, we answer calls of support for student-oriented projects to “Africa” or “third-world countries” while not being fully informed of the cultural contexts of the destinations, whether community consultations had taken place, or if the project respects the local citizens who are on the receiving end of our benevolence.

This importance of understanding and being adaptive to the local community context was illustrated to me during a conversation with a leading international development organization. I discovered the group’s initial goal of providing literacy expanded into a clean water and alternative incomes project, upon their realization that children were unable to attend the newly constructed schools due to their obligation to spend hours securing potable water for their families, many of whom unable to afford the loss of their children’s assistance. Seemingly straightforward projects may need to be altered based on community input, but these voices may not be heard when learners “parachute” in and out of international projects. More broadly, I wonder whether one summer spent in an under-resourced community with limited support is truly long enough to justify benefit to anyone but the learners themselves.

Should we as students therefore cease our international volunteer efforts? No, but we need to be much more thoughtful about both our reasons for wanting to volunteer abroad, as well as what kinds of initiatives we should become involved with. Thoughtful engagement in development efforts based on mutual understanding and collaboration serves to benefit both learners and the communities that receive them. However, let there be no mistake that providing care to others is a privilege that requires accountability.

It can be difficult to ask probing questions of development efforts. We might worry that we will be perceived as lacking in generosity. Meaningful, constructive and balanced dialogue on the ethics of short-term international assignments can be perceived as opposition to the very concept of international aid. The result, unfortunately, is that we are too hesitant to say “no” to projects that are likely to cause more risks than benefits.

Our ability to probe and assess humanitarianism in our roles as participants or their supporters, no matter how difficult, is the compass that navigates us away from unintentional harm. Educational resources and theoretical frameworks have been developed and should be implemented as part of an accreditation body that provides certification to international service-learning providers. A quote I vividly recall from years ago rings true: while a perfect aseptic environment is not possible, it does not mean that we do surgeries in a sewer.

We can do better, and we must do better – good intentions are not good enough. It’s time that we ask some hard questions of these global health experience programs, and of ourselves, before signing up.

Yan Xu is a medical student at Queen’s University. He was the former coordinator of a student-directed seminar, “Ethics of International Service-Learning”, at the University of British Columbia.

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7 comments

  1. J Joseph

    Fantastic article, addressing key challenges in ‘global health’ trips! Do you think establishing partnerships between hospitals in N America and developing countries might provide room for bilateral learning?

    • Yan Xu

      Hi J Joseph,
      Thank you very much for your interest and comment! My feeling is that the learning exchanges and partnerships between North American hospitals and under-resourced countries provide a fantastic opportunity to reflect on different ways of thinking about our models of patient care delivery, the place of health care in our communities, and how we can innovate together to achieve common goals. I think that we are increasingly starting to recognize that we have as much to learn from those in developing nations as the knowledge we have to offer them (ie. Reverse Innovation Challenge from Ivey: http://sites.ivey.ca/healthinnovation/colour-outside-the-lines-reverse-innovation-challenge/).

      The key ingredient, in my view, is how to identify and proactive avoid potential unintended harms that can occur – how will we ensure continuity in these programs such that we won’t offer promises and hope that we later on cannot keep? How can we ensure that our partners are fully involved not only in the development of the format of the partnerships, but more fundamentally, the objectives that these partnerships aim to achieve?

      Of course, it is not to say that most programs and partnerships are deficient in these considerations, but these are just my musings…

      • Sharon Wilton, Project Share

        Yan……

        egads… sorry I missed the deadline on this 🙁 … however….. is reverse innovation like ” reverse isolation” ( i.e. keep the “well’ in a pathway? )

        Anyway the ” geographic destiny” ( erase borders); roadside warriors ( rogue providers ignoring the pathway); wars and rumors of wars means someone at IVEY has been reading Robert D. Kaplan ( whom I adore! ) …and whose writings have been discussed as a “breakthrough analysis for the past 15 years ( in political advice and Longwoods health debates (I have great notes on that :)…..P.S. NEVER travel without reading his books).

  2. BigDuke6

    Good Post. What are the ethical considerations in sending an undertrained person from a developed country to experience medical conditions and provide service in underdeveloped countries?

    Many local medical students in underdeveloped countries do far more than med students in Canada; they graduate having done appendectomies and c-sections as the surgeon, routinely do more stuff like casting and fracture reductions and simple anesthesia and deliveries. Maybe those responsible in the receiving countries do not understand the very limited scope of medical students in this country, in terms of independent practice.

    There’s also a definite racist/classist dynamic at play here: it’s OK to practice on “others” but when ya get back to Canada ya gotta be supervised in anything ya do. The Med Ed people by granting credits for these visits fully support this. Practice on the poor folk, the others, we won’t ask too many questions and give you credit for that practice. Even if you made a few beginner’s mistakes through lax supervision: no Canadians were harmed for these credits.

    ER interns used to go for a month to that legendary public hospital on the South Side of Chicago, where they would see more gunshot wounds in a month than they would see in a year here in Canada. That’s a public hospital, which in the States means it treats poor people and black people. Was the experience there in terms of supervision according to Canadian standards any different? Were Canadian interns catapulted into Trauma Team leader positions after a couple days?

    The ironic thing is that it makes for better doctors here in Canada. Most Canadian doctors have never seen a case of measles. I saw tens of cases in a third world pediatrics rotation as a med student. I routinely did LPs, which sometimes felt like a pointless exercise cuz half the time they did not have antibiotics to treat the meningitis; but I learned the skill and my patient care here was better for it. Ask any white South African doc about their training at Baragwanath Hospital in Soweto back in the day, they saw and did lots in what’s arguably an ethically equivalent situation: undertrained rich folks parachuting in to provide poor folks with service, minimally supervised. They learned on the job, made mistakes, and brought back the fruits of that learning, some only to their own constituencies.

    Some might argue that equivalent situations arise in Northern communities, I’m not familiar enough with the care up there, but I see the potential.

    On the positive side, let’s not forget exposure to the medical systems around the world can only make us as Canadian doctors more appreciative and understanding of the system we have here, frankly. You have to see inequity to appreciate the incredible resources we routinely provide to all just by virtue of citizenship – although that experience is becoming more canadian with the IFH cutoffs. It’s gratifying and professionally rewarding to diagnose meningitis in a kid for the first time: It’s pretty deflating to realize that the diagnosis will make no difference cuz there’s no antibiotics in the hospital and the parents cannot afford antibiotics. From that experience a solid understanding of the benefits of our system comes.

    • Dr. McFly

      I love your comment.

      Personally I am incredibly disheartened by the current trend of medical students, residents, staff, and pre-meds gallavanting into poor countries, probably in Africa, where they do all sorts of “altruistic” work.

      Then they get credits for it, as you mentioned above, and pad their CVs with “Africa” trips.

      Africa mission trips are becoming somewhat of a check-box for medical school applicants. I mean, what good can they do over there that they couldn’t do here? We have poor people too.

      Why can’t the residents and staff go to Nunavut instead of Burkena Faso? Oh, right, its because its not sexy enough. Nobody cares about the poor on our own doorstep, but Africa and AIDS and all of that…so trendy!

      The issue of practicing on the poor is bad enough, but to me what’s worse is the hierarchy of poor people that deserve our concerted medical efforts. Africans? Emphatically yes! Natives? Not so much. Downtown homeless? Get a job!

  3. Dr. RATAN SARKAR

    Good article .Good intention for humanitarian job always bring good impact .Hence partnership between like minded health institute of developed countries and health institute of developing countries will must benefit needy community people and it will be a good source of learning to all related person.Hence welcome proposal for such partnership.

  4. Sharon Wilton, Project Share

    This is a VERY important article as we are in the midst of “recreational” packaging of much needed humanitarian aid services.

    It is not limited to medical provision it is also present in missionary efforts recruiting short term “holidays to help”

    In the past highly qualified specialists would go to countries but now it is simpler to have the cases requiring their services come to them.

    Part of the problem was the way NGO’ ( non-governmental organizations) were structured in terms of phases ( versus stand alone programs) and using specialists simply for tasks [ e.g. ensuring water quality and health station setup while equipping locals to operate as trainers ( promoteurs)].
    Then there are highly organized teams that move as a unit ( e.g. “doctors without borders” refusing access inside their performance standard and no time, patience, or desire to “build capacity” in locals) which may not be viewed as a problem but more as ” incomplete”.

    The brighter light on the horizon is the switch from NGO to CSO ( Civil Society Organization) where a Population Health perspective considers the medical, non-medical determinants of health and works “inside” existing government structures. The glitch is the ” government structures and how they both distribute and procure ( e.g. not every government is a Federation model…yet…. ).
    This CSO model of “good” far exceeds the limits of “right” medical practice as it builds the ” right” economy and trade relations to sustain the society itself…and removes NGO funders overnight ( e.g. CIDA) in favor of pursuing infrastructure building.
    Professional services have to face legal constraints in these blossoming democracies where personal AND professional behaviors away from home have legal ramifications.
    Even in past years I had the pleasure of meeting a life committed missionary physician placed under house arrest ( for years) ,in China, for making her own intravenous solutions and equipment in a time of crisis and there were no other options.

    In many ways the universities themselves can be liable ( if they are the promoters )just as they were in the days where promoting ” student painting services” failed to consider workplace safety issues and liabilities.

    What to do?
    It seems realistic to have students provide a packaged service where simple essential skills ( such as intravenous therapy and non-invasive procedures ) can maintain patient safety while awaiting the ministrations of experts. Another option is to focus on much needed restoration procedures that they could specifically train for: e,g, fistula repair resulting from birthing that cause longterm alienation for women in some countries ).

    As disappointing as it may be that the ethic is not noble … the end result may still have some value to the recipient who has limited , or no, other options.

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