Growing recognition of the potential in short term trips

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:

  1. 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.

Short term volunteer trips abroad: an answer to the challenge of incorporating global health into one’s career?

By Lawrence Loh, MD MPH

Finishing a recent residency rotation in New York City, I had the opportunity to speak with some of the residents there about their plans for the future. All of us final year residents had plans to head back to some combination of clinical work and public health, but those of us with global health aspirations seemed a little bit more cynical about the possibility of pursuing our chosen field. In describing her plans for the future, one of the residents mentioned she would be signing up with Doctors Without Borders (MSF), despite significant debt load and familial obligations. We also talked about the likelihood she would be engaging in work that was not commensurate to her training – starting out from the “very bottom” of the totem pole, as it were.

Her response was one almost of resignation: “Well, that’s just the way it has to be, right? If they want me to pour tea for them, then I’ll do that. Whatever it takes to get your foot in the door.”

Therein lies the great irony for most young professionals pursuing work in global health and development – unless your family is independently wealthy and with the right connections, you’ll spend an immense amount of your personal time and finances to gain mixed experiences that will potentially land you that (often poorly) paying first job in some sort of long-term arrangement for the sake of “getting yourself in the door.” And for many, that’s a dream too far – and many global health aspirants end up throwing in the towel and embracing “reality”, giving up their pursuits abroad for the sake of staying home and paying back their seemingly insurmountable educational debt, and maintaining their certifications and ties that are so critical for ensuring they can do so effectively.

Yet every global health career day you go to, every fair that you visit, the same stories come out. The same unfollowable tales from those who have “made it” (almost a la Hollywood or entrepreneurship) – these folks either had a lucky break, a person who paid them a living wage in pursuing the dreams abroad, or a family that let them do unpaid internship after unpaid internship until they landed that first position. They sold all their worldly possessions and moved to Africa for 10 years, gaining that experience, sacrificing family, earning potential, and time, to succeed in finding a job that filled their passions and skills.

It really shouldn’t be like that.

The current global health workforce set-up and “road map” to success strings along young professionals who may have the skills and passion to succeed, but lack the resources or support to do so. It results in the privileged gaining those posts and those positions, regardless of their abilities or skill set – but simply because they’re the only ones who can pour enough money and time into building those networks and those collaborations. And perhaps this is like “anything else” in life, but moreso in global health does it seem truly like whoever has the money and whoever knows the right people has play.

So where has this paradigm led organizations today?

In a news article published in the Canadian Medical Association Journal (CMAJ) just a year and a half ago, MSF in Canada described their recruitment shortages and the pending crisis in recruiting Canadian physicians.

Médecins sans Frontières seeks for more Canadian physicians

The comments from the MSF recruiter are incredibly interesting. On one hand, the recruiter recognizes that high debt loads, the demands of residency and life in Canada affect the ability of young Canadian physicians to go abroad for more than 1-2 weeks at a time. At the same time, the recruiter goes on to denigrate the work of interested young physicians who can contribute that amount of time, calling them “tourists” and “people who are [only] interested in cross-cultural experiences, in doing a couple missions for their resume […] their primary motivations are not the humanitarian objectives of our organization.”

But in other articles, we know that humanitarian reasons and improvement of work abroad is a reason why many people pursue medical volunteer trips – regardless of how long they are. A survey of Wisconsin residents and medical students found that 82% of students wanted to continue incorporating global health in their future career, with 63% wanting to work with underserved populations abroad:

Needs assessment of Wisconsin primary care residents and faculty regarding interest in global health training

If that doesn’t sound like a disconnect, I don’t know what else there is.

MSF and the rest of the global health community needs to think long and hard about how things are. Taking six to nine months off for young physicians is not something those from less-financially advantaged backgrounds can do, in the face of crushing debt loads, familial obligations, timing, and training requirements. Short-term medical trips represent the only opportunity for these young professionals, ironically so, since despite the enormous financial and personal investments that go into it, such short-term work often represents the “placebo” of global health: both the receiving community and the visitors feeling “good about themselves” without anything ever really changing.

There needs to be a paradigm shift, a challenge, a purpose and improvement of such opportunities. The future of the global health workforce might be how well we as a society adapt to remote technologies, allowing people to be involved for weeks at a time abroad and remotely from home – by leveraging the internet, collaborative models, and shared resources and vision.To stick to the romanticized version of the solo doctor in Africa represents the potential waste of a huge groundswell of passion and talent from young physicians. At the same time, we know short-term work as it stands is also untenable.

It’s time to make these opportunities both accessible and valuable. We see the interest. Let’s figure out  how best to harness it, instead of turning people away – instead of having them just serve tea – and instead of leaving them to languish in “medical tourism” venture after venture. Young professionals have so much more to offer – in fresh eyes, passion, skills, and ability.

As we implement our coordinated model of short-term care, we hope to move the conversation forward in providing at least one innovative way to open those opportunities to those young professionals who want it and are good at it, not merely those who can afford it, while also ultimately benefiting those populations abroad that these short term trips aim to serve.

Dr. Lawrence Loh is Chief Medical Officer of The 53rd Week, and a physician in Toronto, Ontario, Canada.

Coordination challenges

By Lawrence Loh, MD MPH

We’ve talked a lot about the value of short-term medical trips and the benefits that the local community, the young professional volunteers, and the organizations themselves could potentially derive from coordinating such efforts. Such coordination is obviously challenging, though; with growing numbers of participants, there are always myriad opinions, ideas, and suggestions that would shape any such model.

Thus far, the biggest barrier faced in implementing a successful coordination model has been structural: a genuine lack of time and effective programs. A proposed website (as described in our previous post) involves significant technical knowledge and programming, as well as up-front aesthetic designs. At present we are in the midst of developing a prototype, but it will obviously need to be piloted by key stakeholders before being put into active service. Making this harder is the general lack of time – as young professionals passionate on the subject, we’re busy doing this off the side of our desks while working our regular day jobs.

Other challenges have been in reaching out and managing the expectations of all the parties involved. We are fortunate that there are so many different teams with differing histories, experiences, skill sets and ideas that are working in the community in question. It challenges us, however, to work with leaders and form consensus, trying to determine a process for what we need to do – how will we standardize protocols? Why have a real-time inventory, and how would we get people to participate? We also work alongside the local leadership to identify gaps and needs that can be fulfilled by projects run by the teams in tandem, and then work with the teams to figure out how best to broadly address these and implement them effectively.

The diversity of opinions and ideas, while valuable, can often times conflict with one another. Different folks have different priorities and different thoughts on the way forward, and of course, the local leadership have their needs and gaps to be met as well. The challenge is in ensuring that everyone feels a valued part of the team – because everyone is – and further to that, ensuring that key aspects of their vision are included in an overarching, shared vision that teams together can take ownership and pride in.

For the most part, though, such challenges are immensely rewarding – the exchange of information and opinions strengthens and galvanizes everyone’s efforts in the common cause. Perhaps the most important aspect of everything is despite the differences, the opportunity to speak and to keep things front of mind is a valuable intangible benefit in keeping everyone involved motivated and committed, eyes on the prize.

In this case, a challenge can be a strength – both in learning how to manage critical relationships, but also, towards improving things by asking the impertinent questions about how best to work together to produce those outcomes that we seek.

Dr. Lawrence Loh is Chief Medical Officer of The 53rd Week, and a physician in Toronto, Ontario, Canada.

So what would a website look like?

By Lawrence Loh, MD MPH

In our last post at the beginning of April, we started to talk a bit about what a potential coordination website would look like. Most of what we’ve come up with has been through informal discussion with lots of people – the local community we’re building the site for, the other teams that have significantly longer and diverse experiences participating down there, and what programmers feel is feasible. We’ve settled on a few common elements that are going to form the basis of our product.

The keystone of things will be a centralized calendar and contact database. After all, if we’re going to be working together and coordinating together, at a baseline we should know who everyone is, and where everybody can be reached at. Further to this, this calendar and contact system can one day form the basis for recruitment – trying to find specific young professionals who happen to have a week to come down and join a group for a week – with that group as part of the wider project going on. At the least, this will let everyone know who is who, when someone is heading down, and who to contact that might be on the ground right now or imminently.

Then comes the information sharing. And we had a long think and some very fruitful discussion with the other great people heading down there. From a disease perspective, it comes down to standardizing everything – protocols, program logistics, and information sharing. So we’d look to have team reports, that would be part of a record of what’s been done, but also serve as an information source for upcoming teams. We’d like to see some real-time inventory and tracking of projects that the teams are working on. We’d love to standardize protocols based on best evidence identified by teams (something to do while home and not on the ground there!) as well as experience. And of course, building a wiki of information on cultural customs, what to expect when heading down there, general tips and suggestions – filling into the idea of a virtual library of ideas that will eventually form a valuable knowledge base for anyone doing short or long term work in the community.

Then the biggest part of the interaction – a forum for discussion and communication. Teams can share ideas for new projects, plan how they’re going to go down, set goals, objectives, and indicators for how they’ll measure progress. They can give heads-up to teams heading down after them, or check-in with teams before them to see if there’s something that needs to be followed-up on. A continuous stream of information shared between teams, all on the same side, still individually autonomous, but using technology to push towards the same goal, with the local leadership always at the forefront of making sure things go.

And for those young professionals looking for a shot in, they can join a trip; read up on the locale through the virtual library and ask questions on the forum; source meds in their home community that are identified as in need on the inventory; head down on their trip with their team, and then come home and keep track of what they’ve started and participated in down there virtually until their next trip down in a year, or six months, or whenever.

In today’s busy day and age, it would mean that our valuable week down there becomes something more – it becomes part of solving the puzzle of work down there and turns our investment into something more valuable, part of a mosaic. It’s working together. And in our next post, we’ll talk about how we’ve started discussions with other folks, the general reception, and challenges we’ve faced in the development of our web platform.

Dr. Lawrence Loh is Chief Medical Officer of The 53rd Week, and a physician in Toronto, Ontario, Canada.

A new paradigm in a published paper and big, tragic global health news

By Lawrence Loh, MD MPH

As we’ve worked towards getting our web platform ready we took a brief hiatus over the last little while to devote ourselves to making sure things are ready to go for the collaboration model we’re building with our partners here in North America and abroad. But in the wider global health world, a stunning announcement: after four decades of front-line work and research, the Global Health Council (GHC, website at www.globalhealth.org) is shuttering its doors. This is a stunning reversal of fortune for one of the largest non-profit global health organizations, and leaves an incalculable void as well as plenty of speculation as to what has gone wrong.

It falls to the rest of the global health community to think about how to best challenge the paradigms that a traditional organization like the GHC might have had in adapting to today’s interconnected world with targeted funding and a young, time-and-finance limited workforce. We’re hoping to be part of a new wave of solutions that will enable global health research and projects to continue being a strong

To that end, we have published a commentary / letter to the editor that appeared in Canadian Family Physician with other like-minded colleagues that appears at the following link.

http://www.cfp.ca/content/58/4/376.full

Back to our regularly scheduled programming next week, as we continue to work on bringing you more information about how we plan to maximize the benefit of short-term global health work abroad.

Dr. Lawrence Loh is Chief Medical Officer of The 53rd Week, and a physician in Toronto, Ontario, Canada.

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Coordination of short-term trips: how the locals benefit

By Lawrence Loh, MD MPH

One of the first tangible benefits of an online web platform to coordinate short-term medical trips will be for the local leadership that receives these missions week after week. Often a hospital or a small local organization, these community leaders spend a lot of their energy on telling visiting teams what to bring down, what to expect, and what programs and issues need to be met, in hundreds of emails a day to dozens of teams with questions. On top of that, they coordinate the logistics, food and lodging, and questions that arise from teams that are already down to visit.

The leaders of these already resource strapped organizations are taken away from what they really should be doing: sharing their expert advice on what these short term volunteer trips should be focusing on, and leading their communities, building links between the visitors and their citizens, and understanding exactly what their community’s crucial, long-term needs are. Instead, they field emails and queries and the end result is that most of them serve as merely facilitators, instead of participants, giving a “laissez-faire” attitude to teams where anything and everything goes.

A coordinated web platform crowdsources that day to day information they have to provide. Instead of asking for an update on what’s on the ground, a team coming down and read about the last five teams’ trip reports, and review an up to date tracker in this web community to better understand exactly where the coordinated long-term projects are at. A real-time calendar and inventory allows the teams to plan ahead, thinking on what they need to source and bring. A wiki or forum of discussions and protocols shares trip preparation, trip debriefs, and answers the basic questions that new teams might have about heading down to help.

By doing so, this takes the burden of administrative work off the local leadership, and frees them up to do what they do best: lead. And of course, they could do so by easily being connected into the web platform community themselves.

So how would a website like this work? How are we developing ours? And where are we planning to implement it?
Our next post will begin to answer some of those key questions.

Dr. Lawrence Loh is Chief Medical Officer of The 53rd Week, and a physician in Toronto, Ontario, Canada.

Short term volunteer trips: the global health dilemma

By Lawrence Loh, MD MPH

When it comes to short-term volunteerism, young professionals from all stripes are keen to make a difference abroad. Speaking to the issue of global health, which our organization is most familiar with, numerous studies have shown that young health-care professionals in training and recently out of training express an interest in altruistic work abroad with indigent populations. These young physicians, nurses, pharmacists, dentists, allied health and public health professionals today live in a modern world with internet and communications links that bring the worldwide need for their skills into stark focus, with a globally interconnected transport system that opens the doors to these opportunities like no other time in human history.

But at the same time, modern professional training in these fields have saddled many of these young professionals with crushing debts. Training demands and vacation restrictions limit the amount of time they are able to invest in their passions, which in turn keeps them from gaining valuable experience needed to incorporate global health into their career. And often times, despite the sea of plenty, there is a difficulty locating opportunities; most opportunities are not well publicized and often come up by chance, through word of mouth or a fortuitous strike online. Translating these experiences into sustained careers is also challenging, as many entry positions into the global health world often have significant demands for experience and credentials that starting young professionals may not have. At the same time, if all the young professional has had opportunity for is short-term trips (ranging 14-90 days abroad), the global health community tends to look on such experiences with muted disinterest at best, and disdain at worst.

So young health professionals pursuing such dreams to make a difference fall into two categories. The lucky ones, who either strike a scholarship lottery or come from families well off, are able to take gap years and gain the necessary experience abroad, but this in turn delays the completion of their training. Since remuneration and finances are not an issue, it’s just a matter of time, and they invest in it and eventually end up within the very community they are striving to make a difference in.

But for the vast majority of young professionals who want to make a difference, they’re not as fortunate. They may have the passion and skills and desire to help, but with their limited finances and time, they do most of their global health work off the side of their desks. These young professionals invest what limited money and time they have access to, leveraging their lines of credit and their spare vacations, in order to pull together enough short-term experiences that might help them network or land an opportunity. Much like actors trying to “make it”, these youngsters deeply invest in the hopes that they’ll someday land a job that pays them to do what they’re passionate about – about making a difference to the people abroad.

The result is that short-term trips are increasing in popularity, since they are the only option available to real people who have real jobs and can’t afford the time and money it would take to volunteer abroad for years on end. It thus falls to us to figure out how to make these experiences valuable and viable for these young professionals – how to make sure that growing short-term medical trips are beneficial for the communities abroad, for the organizations doing them, and for the young professionals pursuing them.

By coordinating such trips, we can make it easier for the young professional to figure out where the opportunities are. Got a week off in May and there’s six trips going to three different places that need a nurse or doctor? Sold. The website shows the ongoing projects, which the young professional can read up on to prepare for the trip. When they arrive there, they can lend their expertise as planned towards a shared, common effort; and when they return home, they can keep contributing remotely by monitoring the project online, sharing and discussing ideas, and even signing up for a return on another vacation week at a future date. They get to be part of something bigger than just going on a “do good” vacation for a week, and their investment is ultimately maximized.

Of course, the biggest concern with any work abroad is the idea that the community abroad must benefit – being already vulnerable and challenged. Once we link young professionals to the opportunities they seek (and the experience they ultimately need and gain by participating both on-site short term and remotely), we must make sure that the communities abroad also benefit. Our next post will discuss just how they’ll benefit from coordinated short-term volunteer work.

Dr. Lawrence Loh is Chief Medical Officer of The 53rd Week, and a physician in Toronto, Ontario, Canada.

Short-term volunteer trips: coordination, collaboration, cooperation

By Lawrence Loh, MD MPH

In our previous entry, we talked a bit about how the short-term volunteer trips are generally felt to be low impact, especially by the global health community. After all, how can anyone accomplish anything in just one week abroad? How can one learn about the local community, overcome cultural and logistical barriers, quickly assess the situation and develop a remedy in just 14 short days? It is this mindset and thinking that has left current short-term efforts ignored by bigger organizations, and tackled by smaller organizations that barely have the resources to actually make things work.

From week to week, at a local level, teams from all over the world visit communities abroad. Uncoordinated efforts result in duplication and wastage. Some teams do things one way; others have other ideas, naturally. Reversals occur and status quo is maintained by well-meaning people. Young professionals are constrained by time and finances to going on these trips, but leave feeling good about what they did – and just remembering a wonderful vacation without being able to follow-up or keep up to date with where their project is going.

Now imagine a properly coordinated locale with a functioning web platform specifically designed to coordinate a string of consecutive weeks. Take every week at a local level, fill it with its own autonomous, hard-working, passionate team – and give the wider volunteer community a common database. A list of protocols, inventory, and a schedule that would let them plan exactly when they’re heading down and read up before they even get there. An online library with a general primer and information that gets updated in real-time.

For the teams, it all starts with the schedule, connecting them with the contact information for the team preceding their visit, who can share with them what is already on the ground there, and what projects are on the go. They get this information ahead of time: needed meds and supplies, progress of shared projects, and ideas for follow-up before they even land on the ground. While they’re there, they link with the other teams abroad to rely on their shared knowledge, and they put in the work towards a long-lasting, effective, sustainable project instead of handing out pills and mismatched charity goods. Then they return home, passing on the cycle by posting their own findings, ideas and thoughts on their trip. They remain connected when they come back and add to the instantly available expertise that teams on the ground rely on. And they work with the local leadership to figure out what projects and plans will work for the local community – and how to get everyone to agree on those common goals.

For the local community, it means improvement and development and a voice. They lead the discussions on the web platform. They engage. They tell what the community needs, and the teams work on meeting that. And the website drives recruitment and programming: engineering projects are able to source engineers for teams heading down by advertising widely and finding someone with a schedule match. Instead of just acute care medicine, teams work to develop health promotion programs or implement basic public health measures that prevent disease instead of providing care that does little to change the underlying factors that made the local citizen sick in the first place.

Ultimately, young professionals also benefit. No more floundering around with a free week and wondering how to make a difference. The web platform allows them to easily access potential opportunities. They can figure out which projects have teams that are heading down to a locale of interest during their one or two weeks of vacation. And because of the bigger goals targeted by these projects, they can get involved in something that is having impact, and still remain as remote participants after their two weeks are done. Any amount of time they can spare is cherished and put towards good, rather than demanding large financial and time sacrifices that they simply cannot afford at the start of their career. You got a free week? Here’s a project – and it’s more than just handing out pills. It’s working to build something bigger than each individual volunteer, each individual team.

That’s the idea of The 53rd week. Individually, a week abroad can only do so much. 52 weeks abroad uncoordinated are just that, 52 weeks. But put them altogether, and something extra, bigger, larger than the individual can collectively occur. Everyone wins – the teams that invest their efforts and money; the young professional looking for valuable, pertinent experience; and most importantly, the local community abroad which benefits from realistic, sustainable, long-term goals over acute, short-term efforts.

Short-term efforts can make a difference. They just have to be part of a bigger picture. And what is that bigger picture? Where does this lead us? What are we looking at?

Our next post will consider the wider phenomenon of who are these people that are going on short term trips, and why they do it.

Dr. Lawrence Loh is Chief Medical Officer of The 53rd Week, and a physician in Toronto, Ontario, Canada.