Hoping to Help: a full review
September 27, 2016 |
Despite mounting criticism of “voluntourism”, 25-40% of American medical students travel abroad during medical school alone (Drain et al, 2014). Judith Lasker describes the promise of personal growth, skills training, and bragging rights for volunteers, at the cost of objectification of the poor, neglect of local needs, and promotion of dependency. In discussing both sponsoring organizations and host communities, the author is skeptical of such endeavors, but ultimately focuses on improving the experience for all.
Many different motivations
Lasker describes four categories of sending organizations: faith based groups, secular NGOs, educational institutions, and corporate sponsors. Educational institutions, for their part, are active in efforts to adapt to ethical norms, and have produced national guidelines for practice abroad. Corporate sponsorship of trips by pharmaceutical and tech companies has become a common means for demonstrating social responsibility. Faith based trips range from those on one end who view faith as their motivation for action, to questionable practices where “conversion is the primary goal and health care the means for achieving it” (p. 212). All groups, however, threaten to compete unfairly with local professionals, and fragment health care in low income countries.
Such trips take many forms, from intermittent primary and surgical care, to year-round operations with volunteers providing support for local professionals. Volunteers are motivated by competing desires for professional development, adventure, and social justice: “Self-interest may shape the choice of activities through which people’s desire to be helpful is expressed” (p. 96). While volunteers may achieve personal satisfaction, the formation of friendships and intercultural experiences, and a global citizenship, there are concerns such trips may encourage “poor but happy” (p. 110) stereotypes of patients, and a “construction of the world in which there are simplistic boundaries between north and south”, with “young unskilled labor as a solution” (p. 110).
What do host communities want?
Lasker criticises sending organizations for a lack of selectivity in screening applicants, and for imposing on the resources of the host community. Pre-departure training is not universal, and may be limited to a general travel information brochure. Volunteers may arrive without an understanding of the local culture, language, and health needs – spending valuable time “figuring out” the novel setting and “trying to apply Western concepts of medicine and standards of care in a setting where resource limitations often make such concepts impossible to implement.” (p. 127)
Local staff nonetheless seem to value volunteers who are eager, humble, and possess strong communication skills. The volunteers bring money into remote communities, as well as an intangible mutual feeling of solidarity. Clinicians bring renewed vigour to their medical practice that may not be present at home. Lasker remains concerned, however, that benefits accrue disproportionately to the volunteers, and that NGOs “exploit poor communities for the benefit of people from wealthier countries.” (p. 216) Regarding the opportunity cost of such trips, it’s true that the thousands spent on short term medical trips could be more efficiently spent elsewhere, but it is more likely that it wouldn’t be spent at all.
How do we improve?
Last, the author turns her well-founded criticisms of voluntourism to constructively propose nine criteria for excellent trips. Such trips should foster mutuality between sponsors and local partners, and maintain program continuity wherever possible. Host communities should be active participants in community-based needs assessments, although “often there are few reliable data sources on the incidence and prevalence of diseases” (p. 181). She suggests ongoing evaluation of process and outcomes, a focus on disease prevention, and an emphasis on building local capacity by hiring and training members of the host community. Service delivery should ideally be coordinated to include dental care, eye care, and physical therapy, among other efforts. Finally, volunteers should stay longer, with a greater focus on adequate preparation. While many of these are not new suggestions (Maki et al, 2008; Seager, 2012), this is also their strength, suggesting an emerging consensus on a standard of practice for such trips.
The quotations drawn from her interviews with volunteers can be hair-raising at times, but perhaps the main failing for most volunteers seems to be an overabundance of optimism and idealism. In addition, with her useful suggestion of moving from outputs (patients seen, medications dispensed, and surgeries performed) to outcomes (measurable effects on behaviour and well being), the author seems to be asking for evidence of impact that would be nearly impossible to produce, whether in an underdeveloped or developed world setting. For example, while it would be difficult to show a measurable effect on population health for episodic care for sore throats, coughs, and other primary care interventions – this in no way suggests an absence of value.
“Hoping to Help” arrives perfectly positioned in the current climate of fashionable criticism of short-term medical trips to the developing world. Before signing on, those considering such a trip would be wise to understand exactly why and how they are likely to be criticized – as well as what questions to ask when discussing their role in the field. From this perspective, Lasker’s book is the most comprehensive description of the current state of affairs, and should be required reading for those traveling abroad.
Drain, P, Holmes, K, Gardner, P. Global health training and international clinical rotations during residency: current status, needs, and opportunities. Academic medicine: Journal of the Association of American Medical Colleges. 2014, 84(3): 320-325.
Seager, G. When healthcare hurts: an evidence based guide for best practices in global health initiatives. AuthorHouse. 2012.
Maki, J, Qualls, M, White, B, Kleefield, S, Crone, R. Health impact assessment and short-term medical missions: A methods study to evaluate quality of care. BMC Health Services Research. 2008, 8:121.
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