Medical Volunteering: First Research Update

I spent the first week of my research conducting a broad overview of volunteer tourism. After reading and synthesizing many articles, I decided to hone in on medical volunteer tourism, as I found the articles related to it the most interesting. I devoted this past week to conducting more research on medical volunteering. Currently, I am overwhelmed by the amount of sources I have flagged to look at. By picking apart bibliographies of sources I have actually read, I now have 14 pages of potentially useful sources. From those 14 pages, I have only looked at about 3 pages’ worth of sources. I also feel a bit stressed at times when I question what the end product of my research will be. One thing I have considered is to compile my knowledge of medical volunteering and NGOs and create some sort of a policy memo that tackles issues in the field. (A lot of medical volunteering is provided by medical schools that offer global health electives, so I am not sure how this would fit into my research). However, I am trying to focus more on the process and less on the product.

For my research, I am trying to sort what I have found into 3 categories: history of medical volunteering, ethical concerns, and suggestions that authors have brought up to improve the field.

I am going to bullet point the following notes because they are mostly to help me organize my thoughts.

 

History of Medical Volunteering/General Info

  • The number of medical volunteers sent by secular NGOs is growing, number sent by development NGOs (including faith-based organizations) is decreasing (Laleman 2007) → why?
    • Younger, secular medical NGOs (such as Medecins Sans Frontieres) growing fast (Laleman 2007) → why?
  • Early 2000s responding to AIDS crisis & lack of health workers in poor countries = sending professionals from abroad; employed by NGOs based in north (Laleman 2007)
  • Humanitarian organizations often work in emergencies & crisis situations or focus on AIDS projects; represent over half of all expatriate health volunteers in survey, with MSF the largest contributor (Laleman 2007)
  • Medical volunteering used to be career humanitarians (working with NGO), now more recently short-term medical volunteerism is growing (Asgary et. al 2013)
  • Short-term medical volunteer trips are becoming a part of training in health care professions, with around half of American medical schools providing such opportunities (DeCamp 2011)
  • Most international health volunteers spend less than two years in one setting; length of “short” missions ranges from 2-3 week to 2 years (Laleman 2007)
  • Trend: several organizations reducing the number of international health volunteers or stopping altogether (Laleman 2007) → I think I would like to investigate this further
    • One cause: changes in thinking about development, where establishing long-term relations with partners, capacity building and recruitment of local staff gets priority
    • Policy of donor governments may have contributed to this; ex. Dutch government used to subsidize deployment of international health volunteers, now discourages this by reducing budgets for expatriation programs; similar evolutions taken place in Scandinavian countries & Belgium
    • Difficulty recruiting qualified volunteers; high staff turnover because they prefer short contracts
  • By 2008, 47% of accredited MD-granting medical schools had established initiatives, centers, institutes, or offices of global health (Jesus 2010)
  • Over past 30 years there has been broadening of interest in humanitarian principles & increased usage of them by NGOs in mission statements & charters; have been used to develop inter-agency codes of practice (Hunt 2011)

 


Ethical Concerns/Criticisms

  • Factors that increase risk of harm to patients & communities: (Asgard et. al 2013)
    • Inadequate preparation – not being  aware of local epidemiology, healthcare systems, culture, etc.; can lead to misdiagnosis, inappropriate treatments, ineffective use of resources
      Also, aid puts stress on the community if brigades leave sites without means of follow-up care or if aid provides medical/surgical services that are locally unavailable because it can create complications that local healthcare systems cannot manage

      • Poor health & advanced disease increase risks & decrease potential benefits of some interventions in developing world (Wall 2011)
    • Use of advanced technology/Western medicine – can waste resources by bringing them to areas without supporting lab/pharmacy systems
    • Issues with clinical epidemiology & test utility – short-term medical volunteers are trained in settings with different disease epidemiology, need to educate themselves about local customs (e.g., regarding pasteurization, food storage, vaccination) before conducting tests
    • Difficulties with the principles of (clinical) justice – distributing resources requires triage; also must not exploit the vulnerability of populations in need by sending HCPs who are not prepared
    • Sociopolitical effects of foreign aid – foreign aid can be manipulated as a political tool when medical aid is recruited preferentially to one side in a civil conflict → I want to do more research on this! **
  • Ethical minimalism / “myth of mere charity” (DeCamp 2011)
    • Stray away from the “myth of mere charity,” where short-term medical volunteering is seen as a work of charity, regardless of ethical standards, because any volunteering program provides some benefit
    • Short-term global medical volunteer work is primarily an enterprise of charity. As such, so long as minimal ethical standards are met, any particular short term project is ‘‘ethical.’’
  • Limited medical personnel: the ethical question raised in these scenarios is whether or not the medical volunteer should intervene when he or she is not fully competent, knowing that non-intervention will leave the patient without another option for medical care (Wall 2011)
  • Lack of follow-up care: volunteers cannot be held responsible for the outcomes of their interventions; leave complications behind for patients and local medical personnel to deal with (Wall 2011); can cause harm (Jesus 2010)
    • Challenge in Haiti – many groups left after a few weeks, so rehab hospitals overwhelmed with patients who had been left without follow-up, referral systems were not well-established; communication between agencies poor, most worked in isolation from one another, standard databases & common definitions not shared between agencies (Langowski et. al 2011)
  • Ethical problems created by the contextual features of medical volunteer work (Wall 2011)
    • How to balance risks and benefits, what level of care below the standard is acceptable, how to distribute limited medical resources, when non-intervention is appropriate choice, and how to communicate and negotiate with patients who speak different languages and have different cultural beliefs and practices
    • Decisions about resource allocation, whether or not to provide medical & surgical interventions, and how to interact with patients with different cultural beliefs; decisions made in the field, without luxury of ethics committees; **volunteers must be aware of these problems & how to approach beforehand
  • Country experts viewed international health volunteers more negatively than positively (Sub-Saharan Africa Study) (Laleman 2007)
    • Volunteers mostly junior, inexperienced and ill prepared to work in low-income countries for cultural & professional reasons; gave many examples of young expatriates who had difficulties with cultural & language barriers, differences in norms & values, resulting from insufficient cultural sensitivity & awareness; often compounded by important differences in lifestyles & living standards between expatriate volunteers & local colleagues, sometimes fueling resentment
    • Shared perception that expatriate volunteers are too unfamiliar with local epidemiology, local practices of health care, organization of health system; often seen to have insufficient, undervaluing local staff knowledge; “these problems are especially disturbing if volunteers come for short assignments, resulting in high turnover and lack of continuity”
    • View that expatriate volunteers were unwilling to support the public health system, resulting from a lack of understanding of their role & lack of communication on mutual expectations; expatriates’ unwillingness to fit in the system & report to local managers, resulted frequently in power struggles & conflicts with authorities
    • Expatriate volunteers often highly focused on particular issues such as emergencies & AIDS, little contribution to general health services; often prefer to create new parallel systems & procedures rather than supporting or improving the existing one (e.g. assistance to refugees, creating tensions within the host population)
    • Widespread opinion that presence of expatriate volunteers is paradoxical in view of existence of urban unemployed doctors & nurses (with the exception of countries like Malawi, Mozambique, Zambia) **crowding out local labor!
    • Consensus that volunteers less cost-effective than locally hired staff
  • Difficulties obtaining consent & administering appropriate medical interventions in the setting of language & cultural differences (Jesus 2010)
  • Challenges of using limited or “substandard” medication/equipment in resource-poor environments (Jesus 2010)
  • Risks of allowing amateurs to practice medicine w/o the same oversight they would have in their home country (Jesus 2010)
  • Challenge in Haiti – response to January 2010 earthquake: over 600 health agencies responding, but lack of coordination of services = too many agencies trying to provide the same care in the same area while other sections of the city had no access to emergency care (Langowski et. al 2011)
  • Ethical concerns (Langowski et. al 2011)
    • Whether the recipient community has been consulted and involved in the needs assessment and planning of suitable programs or medical interventions by the short-term medical volunteers
    • Volunteers may be depriving local health care professionals of their livelihood
    • HCPs may be practicing in ways that would not be acceptable in their home countries (e.g., providing care outside their scope of competence)
    • Volunteers’ lack of accountability may leave someone who is injured as a result of medical treatment without recourse and worse off
    • Volunteers may undermine local efforts to work with governments to provide more regular care through domestic programs, strain local resources, reduce confidence of patients in local providers
  • Ethical issues in medical outreach left to individuals’ professional guidelines; argues this is rejected for clinical trials in developing countries, should be for outreach (DeCamp 2007)
  • Dependency on foreign aid or disenfranchisement w/ local health system (DeCamp 2007)
    • E.g., women in Haiti study preferred to get medical care from American volunteer rather than local physician when two jointly ran a clinic
  • Features that contribute to complexity of ethical issues: (Hunt 2011)
    • 1) Insufficient resources – triage necessary
    • 2) Population health concerns because resource scarcity, instability, widespread health needs
      • Some HCPs who do not have a background in public health may be challenged as they move between addressing the needs of individual patients in care & concerns of broader population
    • 3) Work styles & human resource practices in humanitarian agencies – HCPs work long shifts, limited opportunity to reflect on work, may overwork; working at high pace may limit opportunities to explore ethically complex issues while in the field; also high turnover in the field has implications for organizational memory, project continuity, development of local expertise; rapid turnover can be impediment to creating & maintaining trusting & collaborative relationships with local actors
    • 4) Important differences between cultural frameworks in how health, wellness, disease, disability are understood & experienced; language barriers common; need to consider how to address local cultural & spiritual understandings of health
    • 5) Imbalances of power inherent in health care interactions; amplified in humanitarian settings
    • 6) Expatriate HCPS in humanitarian work enter a field where there is less regulatory oversight & professional accountability than in home country

 

 


 

Suggestions/Moving Forward

  • Organizational Suggestions
    • More educational resource for international & low-resource medicine; sometimes these resources are only available to host organizations or inadequately distributed (Asgary et. al 2013)
    • Greater collaboration between NGOs & academic institutions; the current lack of collaboration has limited the spread & scope of resources; NGOs have more experience in education & practice, while academic institutions publish most of the global health literature (Asgary et. al 2013) → I’d like to do more research on this needed collaboration
    • Greater training in local standards of care & healthcare systems (Asgary et. al 2013)
    • In few countries where few categories of health workers available, informants would give priority to investment in increased training capacity to tackle human health resources shortages more structurally in the long term (Laleman 2007)
  • Lower Level/HCP Suggestions
    • Establish collaborative partnership with local community & amongst volunteers; before, during, after trip (DeCamp 2011); coordination with local health care providers to not imply their incompetence (Green et. al 2009)
    • Fairness in site selection; needs must outstrip supply (DeCamp 2011)
    • Commitment to benefits of social value (DeCamp 2011)
    • Educate local community and team members (DeCamp 2011)
    • Build capacity of local infrastructure – don’t interfere with it but also don’t disrupt it (DeCamp 2011)
    • Evaluate outcomes (DeCamp 2011) 
    • Engage in frequent ethical review (DeCamp 2011)
    • Appropriate patient selection & attention to payment systems as the best means to avoid creating dependence on foreign aid (Green et. al 2009) →  this is big as I’ve read multiple journals where medical volunteering crowds out local labor and government funding; I would like to research this more
      • Example in Honduras: the presence of health projects may impede growth of the area’s public healthcare infrastructure because, when deciding where to invest money in healthcare, the government considers the number of projects in the area, regardless of quality of services 
    • Limit # of people on visiting medical team to only necessary ones (Green et. al 2009)
    • Follow-up care; without continuity care is incomplete (Green et. al 2009)
      • While follow-up care not always possible, can provide patients with a record of what has been performed (ex. surgery) for future
      • **On the other hand, (Jesus 2010) argues that should avoid chronic care medicine & elective surgery bc of lack of ability to provide long-term follow up care
    • Learn about local culture/healing before departure (Jesus 2010)
    • Develop a system that identifies patients by medical needs & likelihood of benefit (triage) bc resource poor (Jesus 2010)
    • Sustainability (Jesus 2010)
      • A more rational and beneficent approach to serving communities in the developing world should involve teaching and training community members and local health care workers the skills required to provide necessary services in the absence of foreign medical assistance
      • Rec: initiative should focus on sustainability, such as transfer of relevant skills or education, to extend benefits beyond the presence of foreign medical assistance
    • Avoid delivery of care by unlicensed/unqualified (Jesus 2010)
  • Address underlying economic conditions in nation; broad changes in governmental priorities & initiatives (Ott et. al 2011)

 


These notes are not super organized and are more for personal benefit than anything. However, by skimming them, one could get a basic understanding of the ethical concerns related to medical volunteering. Most of what I have read on the topic has come from medical journals. My next step is to investigate this topic from a policymaker’s perspective and to look at policy journals that explore medical foreign aid.

 


Bibliography

Asgary, Ramin, and Emily Junck. “New Trends of Short-Term Humanitarian Medical Volunteerism: Professional and Ethical Considerations.” Journal of Medical Ethics, vol. 39, no. 10, 2013, pp. 625–631, www.jstor.org/stable/43282849.

DeCamp, Matthew. “Ethical Review of Global Short-Term Medical Volunteerism.” HEC Forum: An Interdisciplinary Journal on Hospitals’ Ethical and Legal Issues 23 (2011): 91-103.

DeCamp, Matthew. “Scrutinizing global short-term medical outreach.” Hastings Center Report 37.6 (2007): 21-23.

Green, Tyler, Heidi Green, Jean Scandlyn, and Andrew Kestler. “Perceptions of Short-term Medical Volunteer Work: A Qualitative Study in Guatemala.” Globalization and Health 5.4 (2009).

Hunt, Matthew R. “Establishing Moral Bearings: Ethics and Expatriate Health Care Professionals in Humanitarian Work.” Disasters, vol. 35, no. 3, July 2011, pp. 606-622. EBSCOhost, doi:10.1111/j.1467-7717.2011.01232.x.

Jesus, John E. “Ethical challenges and considerations of short-term international medical initiatives: an excursion to Ghana as a case study.” Annals of emergency medicine 55.1 (2010): 17-22.

Laleman, Geert, et al. “The Contribution of International Health Volunteers to the Health Workforce in Sub-Saharan Africa.” Human Resources for Health, vol. 5, Jan. 2007, pp. 1-9. EBSCOhost, doi:10.1186/1478-4491-5-19.

Langowski, Michele K., and Ana S. Iltis. “Global Health Needs and the Short-Term Medical Volunteer: Ethical Considerations.” HEC Forum 23.2 (2011): 71-78.

Ott, Barbara B., and Robert M. Olson. “Ethical Issues of Medical Missions: The Clinicians’ View.” HEC Forum 23.2 (2011): 105-13.

Wall, Anji. “The Context of Ethical Problems in Medical Volunteer Work.” HEC Forum: An Interdisciplinary Journal on Hospitals’ Ethical and Legal Issues 23 (2011): 79-90.

Comments

  1. emmalecki says:

    As I was looking through some of the Monroe blogs, this one caught my eye immediately! I think the topic you chose is very interesting and highly relevant to current questions of global development and the efficacy of “the west” in “aiding” development in other countries.

    I read an article last summer from the Community Development Resource Association’s Annual Report 1997/1998 called “Crossroads: A Development Story” that touches on some of the points you brought up here. Namely, that development and “aid” needs to be community based and designed, that it needs to be sustainable, and that individuals from “more developed” places are not automatically capable or skilled in the service they intend to provide. It gives some opposing viewpoints and is definitely worth a read if you have the time! I found that it opened interesting discussion on what voluntourism does and how effective volunteers can be in the amount of time they intend to show up for.

    Good luck on this project, can’t wait to see what you find!