By Lawrence Loh, MD MPH
In the June 2011 issue of the American Journal of Medicine, a piece by Wilson and others explore potential guiding principles that could be used to engage further development of short-term global health volunteerism.
Rules of Engagement: The Principles of Underserved Global Health Volunteerism
(may require access via institution or subscription)
The piece starts out with a recognition that such trips offer “unique personal experiences for volunteer healthcare providers” but that the concerns of longer term, meaningful, lasting benefits for the community remain. After reviewing potential benefits to participants as well as potentially harmful actions, the authors propose four categories of ethical principles–service, sustainability, professionalism and safety–that could serve as a framework for such short term trips.
Our group is extremely encouraged by the appearance of this work in published literature. It may represent a shift to recognition of short-term efforts in academia, which could hopefully engender more interest and solutions to make sure that we get improve the quality and quantity of such efforts. That said, the paper itself still represents the old paradigm in more than a few ways:
- In the first table that describes the potential benefits realized by trainees going on these trips, the authors identify:
- Opportunity to encounter diseases not typically encountered in United States
- Opportunity to see more advanced stages of select diseases not commonly seen in United States
- Opportunity to improve physical examination skills and procedural skill sets (via less reliance on laboratory, radiology, or consultation options)
- Opportunity to understand the fragile socioeconomic relationship among local government, hospital, and local medical clinics
- Greater awareness of cultural sensitivity and importance of patient communication
Save for the fourth bullet, this list still comes from the lens that presupposes all medical trips are solely to improve training and healthcare delivery in the developed world. It is ultimately speaking of the benefits received by trainees as being what they ultimately bring back to practice in the U.S. or wherever they hail from. It doesn’t look at the potential benefits of medical trips to individuals as they develop a greater awareness and ability to include global health experiences in their future careers.
The same Wisconsin study we looked at two weeks ago showed that interested young professionals are keen to incorporate some form of global health into their future careers – away from the day to day at home. In that sense, getting to go on short term medical trips means they have the chance to forge connections with a community abroad, and continue to contribute to a cause that they personally feel worthwhile and experienced in dealing with.
Some other possible benefits: networking and developing important connections that could transpire into ongoing global health experiences and career work. Identifying a personal niche in global health that could guide their work and their inspiration. Valuable research and publication opportunities that could kickstart a career. Mentorship from experienced preceptors as to how to best balance their desire to make a difference with the need to grow their career and specialty at home.
2. In discussing the harms, there was no balancing of the viewpoint by discussing potential benefits of such trips to these communities. Indeed, stand alone trips likely have a greater balance of harms, but there is always that potential that the community could benefit from coordinated efforts, or from a sudden, passionate commitment by a changed young professional to devote a good chunk of their career into helping the community they’ve been welcomed into.
Inasmuch as these trips can harm, figuring out how they can genuinely help communities (and what is the best way to make that happen) should become a greater academic focus – look for the successful models. The authors do make this point in their final discussion, concluding that provision of vaccines, basic sanitation and hygiene, and other such initiatives may actually have a more lasting benefit than acute care models.
3. The ethical principle of “doing no harm” is discussed as the very basis of much of this work. And in a world where many of these short term trips amount to nothing more than medical tourism, moving to “doing no harm” is definitely a worthwhile and worthy goal. But supposing we do manage to minimize the harms within the community and in the care delivered to these populations. Leaving our ultimate goal as to “do no harm” in that sense implies that while benefit would be realized by the U.S. organizations and trainees carrying out the work, the receiving community would not benefit beyond just not being left in a worse off position than they were before. In that sense, the ideal of social justice and equity may still represent the ultimate ethical underpinning of our work; as Bruce Springsteen famously said, “Nobody wins until everybody wins.”
It is encouraging to see academic literature grow on this subject. It will be curious to see how things will unfold over the coming years, as a new generation of global health leaders comes forward with passion and ideas.
Dr. Lawrence Loh is Chief Medical Officer of The 53rd Week, and a physician in Toronto, Ontario, Canada.