Global Health Needs and the Short-Term Medical Volunteer: Ethical Considerations
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- Langowski, M.K. & Iltis, A.S. HEC Forum (2011) 23: 71. doi:10.1007/s10730-011-9158-5
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Never underestimate the ability of a small group of committed individuals to change the world. Indeed, they are the only ones who ever have—Margaret Mead.
Many licensed health care professionals from the United States and other developed nations travel each year to resource poor regions as medical volunteers. These trips, sometimes referred to as “medical missions” or “short-term medical missions” (STMMs), vary in scope, goal, professional expertise, and duration.1 Despite these variances, medical mission trips have become a prevalent and well-accepted means of providing health education, medical care, and essential surgeries in resource poor settings by licensed health professionals. However, in recent years, interest and participation in these trips has increased dramatically. Probably amplified, in part, by the 24 hour news cycle, access to telecommunications, the internet and internet social networks, and the ease and ability to travel to remote regions, we are now, indeed, confronted visually with the social, political, and health problems in resource poor settings, and have a better understanding that “health issues are increasingly transnational” (Battat et al. 2010). As interest has grown among licensed health professionals to participate in short-term medical mission work, interest has significantly increased among student populations wanting to participate in Global health experiences (GHE). Specifically, medical students, residents, other allied health professions students and even undergraduates actively participating in GHEs has expanded dramatically in the last 10 years (Battat et al. 2010; Crump and Sugarman 2008; Shah and Wu 2008). Here, we introduce readers to the medical mission concept and highlight the range of ethical issues that emerge from examination of and participation in this type of volunteer work. This number of HEC Forum brings together health care professionals with experience in short-term medical volunteer work and ethics to advance the discussion in the bioethics literature regarding the activities of short-term health volunteers.
Through many conversations with health professionals throughout the United States on such matters, I have come to a clear realization. Those who write and talk about the dream of global health equity can make people think, but can not make them care. It is only through direct involvement with the poor in the developing world (or here at home) that medical students and others in the medical profession at large will find reasons to care and, ultimately, find ways to change the health of the world’s most vulnerable—Edward O’Neil, Jr., MD (2006a, p. 848).
Medical volunteer trips often are planned in advance, though in some cases they are organized very quickly in response to a particular humanitarian crisis, such as a natural disaster. In those cases, individuals or groups may travel on their own or in connection with an organization that already has a presence in the host country. For example, after the January 2010 earthquake in Haiti many groups and individuals attempted to provide immediate aid to the injured in Haiti. Médecins sans Frontières (MSF) deployed the largest surgical team in the organization’s 40 year history, treating 55,000 patients and performing over 4,000 surgical interventions (Chu et al. 2011). Some trips occur on a regular schedule, with the same non-governmental organization (NGO) sending health care professionals to the same area on a routine basis. Those traveling may be repeat participants or new to the group. In other cases, a trip may be organized to a particular location on an ad hoc basis.
The scope of work in which medical volunteers engage varies broadly. Some groups specifically involve an educational component for host country professionals/students or for members of the volunteer group such as health professions students. Many medical schools and residency programs offer opportunities for students to engage in such work by offering GHE programs. These programs provide numerous benefits, but they also raise significant ethical questions and concerns (Crump and Sugarman 2008; DeCamp 2007; Green et al. 2009; Shah and Wu 2008). Nursing and other educational programs preparing students in the health professions also participate in such trips regularly. Non-governmental organizations (NGOs) also play a major role in providing health care through short-term medical missions. While some may provide general health care services, others provide highly specialized services, such as Operation Smile, which organizes volunteers to repair facial deformities including cleft lip and palate, and others serving a broader range of needs. Within the realm of medical missions and global health service, non-governmental organizations (NGO) have expanded dramatically in terms of numbers, funding, and influence in the developing world. According to O’Neil, author of the books Awakening Hippocrates and A Practical Guide To Global Health Service, both AMA publications, in the past decade, NGO funding has nearly doubled from $6.4 billion in 1995 to an estimated $12.3 billion in 2002 (Organizations for Economic Co-Operation and Development (OECD) 2004, p. 134; O’Neil 2006c, p. xxvii). There are hundreds of Health NGOs seeking all members of the health professions and provide a broad range of medical and educational services in the USA and around the world (O’Neil 2006b, p. 68). NGOs provide invaluable health services and have contributed to improvements in global health. Nevertheless, O’Neil notes, “NGOs frequently don’t have to answer for the consequences of their actions, a luxury that governments and world bodies like the UN and World Bank do not share” (O’Neil 2006b, p. 64). Additionally, although recent literature has begun critically to assess various programs and approaches, it is interesting to note that most NGOs extol the positive benefits of their programs, steps implemented to avoid pitfalls and problems, and conclude based on their self-critique that their programs are working. Certainly, many of the ethical issues confronted in the context of providing medical care and education in resource poor settings add to the difficulties of doing reliable, qualitative research with scientifically sound results assessing the true outcomes of a program’s work, its impact on the community, benefits and harms to patients and families. Difficult yes, impossible no (see, for example, Green et al. 2009).
Medical mission trips have long been lauded as reflecting the ideals of healing and service that characterize the health professions, and much good can come from such efforts. In recent years, much greater attention has been paid to the complex ethical issues such work raises and that emerge when engaging in health care delivery or education in the context of medical mission trips (see, for example, Suchdev et al. 2007; Chu et al. 2011; Wolfberg 2006; Federico et al. 2006; Roberts 2006; O’Neil 2006a, b, c; Anderson and Wansom 2009; Ansbacher 2006; White and Cauley 2006; Crump and Sugarman 2008; Farmer and Kim 2008).
Over 600 health agencies responded to the Haiti earthquake, but few had the relevant experience, competence, or capacity to provide the infrastructure needed to support emergency surgical services. A lack of coordination of services resulted in 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. Many military and humanitarian groups left after a few weeks, leaving thousands of post-operative patients behind. MSF’s post-operative and rehabilitation hospitals were overwhelmed with patients who had been left without follow-up for their amputated limbs, wounds, and fractures. Referral systems were not well established. Communication between agencies was poor and most worked in isolation from one another. Standard databases and common definitions were not shared between agencies and the total number of operations and interventions performed during the months after the earthquake is unknown (Chu et al. 2011, p. 1).
Other ethical concerns such trips might raise include 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, the possibility that volunteers may be depriving local health care professionals of their livelihood, the possibility that language and cultural barriers may pose safety risks to patients, the possibility that health care professionals may be practicing in ways that would not be acceptable in their home countries (e.g., providing care outside their scope of competence) or that students may be allowed to perform procedures they would not be permitted to do at home or with less supervision than would be required in their home countries and hence using a double standard for what is acceptable medical behavior, and the possibility that people who would not be permitted by law in the U.S. to perform specific procedures or engage in various activities would be acting as health care professionals.
Those who travel to underdeveloped countries that need better nutrition, a clean water supply, sanitation, housing, medical care, education opportunities and freedom from environmental hazards and infectious diseases are often stunned to find out that what we are bringing may be of little use or benefit to those we seek to help. From a medical standpoint, I personally have been most disappointed in the inability to provide anything but a band-aid to those patients we have seen in rural clinics. Despite bringing medications for the treatment of acid reflux, gastrointestinal problems, hypertension, malaria, skin conditions, and knowing that a 30 day supply of pharmaceuticals is insufficient for those who will not see another medical care provider in the next 12–18 months, leaves one wondering just what was accomplished (Ansbacher 2006, p. 5).
A better understanding of the ways in which medical volunteer work in resource poor settings can help a community and the ways in which such trips should be structured and conducted to minimize the possible harmful effects on the host community can avoid some of the ethical and practical concerns these trips can raise.
Student interest in international electives stems from laudable motives. Most students are aware, in theory, of the vast disparities in health care around the world and wish to make a positive contribution through volunteer work. Many may even be anticipating careers in which international work is central. The question of who is helped most by these experiences is nonetheless a valid one. Students typically spend a few weeks or a month in a variety of settings in a country in which the culture, language, clinical practices and common illnesses are unfamiliar. While students may provide helpful assistance, their knowledge, skills and goals may not always be congruent with the needs of the host community, resulting in opportunities for misunderstanding and sometimes risks to students or patients (White and Cauley 2006, p. 851).
In addition to ethical concerns that medical mission trips, including student GHE trips, might raise in themselves, medical volunteers are likely to encounter ethical concerns in the course of their work. For example, health care professionals may be uncomfortable with differences in decision-making authority structures in other cultures, clinicians may be unable to communicate well with patients and be uncertain about whether patients understand the risks of a procedure or whether the clinician has understood the patient well enough to make an accurate diagnosis. Volunteers may find that their knowledge of common conditions in the host country is limited and may be unsure of their ability to treat patients safely. They may also face the need to turn away patients with significant health needs. Many other issues that might roughly be categorized as clinical ethics issues—issues that emerge in the course of delivering health care to individual patients—may emerge as well.
The essays in this volume identify and analyze both types of issues and explore practices and procedures volunteers and volunteer organizations may implement to promote ethical behavior. In some cases, volunteers may not even be aware of the ethical issues they face when providing health care services in a resource poor setting because the experience is so different from their home setting. The role of context in creating, understanding, and resolving ethical issues in short-term medical volunteer work is the focus of Anji Wall’s contribution to this volume. She highlights some of the sharp contrasts between what medical volunteers from resource rich nations are likely to think of as ethical issues in the practice of medicine and the concerns they are likely to see when they volunteer in resource poor settings. These differences include extreme poverty, violence, and the existence of widespread diseases and conditions that never or only rarely are seen in resource rich settings. Moreover, medical volunteers often do not have at their disposal the resources to which they are accustomed in their home settings, such as time to follow-up, additional personnel, and top-rate medical facilities. Finally, language and cultural differences themselves as well as combined with these other factors can raise significant ethical questions and concerns. A. Wall (2011) argues that preparation for engaging in short-term medical volunteer work should include developing an understanding of the ethical issues that emerge in this setting and of the ways to resolve such issues, an argument she has expanded with practical recommendations in Ethics in International Medicine: A Practical Guide for Medical Aid Workers in Developing Countries (Wall in press).
Matthew DeCamp (2011) situates short-term medical volunteer work within the broader context of global health and global health ethics. He argues that global health work, including short-term medical volunteerism, is not an ethically neutral enterprise and that there are significant ethical concerns short-term medical volunteer work can raise. This is particularly problematic, he says, because there is very limited literature explicitly articulating the ethical concerns such work raises or how to improve practices to avoid ethical pitfalls, which is one of the reasons this number of HEC Forum was assembled. Despite significant attention to international research and the ethics of conducting clinical trials in resource poor settings, very little attention has been paid to medical mission trips aimed primarily at providing health care, including those that have significant student involvement. He argues that short-term medical volunteer endeavors should follow a robust ethical framework. In his contribution to this volume, DeCamp builds on previous discussions to identify requirements for ethical engagement in short-term medical volunteer work (see DeCamp 2007).
Barbara Ott and Robert Olson (2011) explore ethical issues that emerge in short-term medical volunteer work both for clinicians and for organizations that sponsor and organize such work. Their analysis is informed by their experience providing surgical care through Operation Smile International. In particular, Ott and Olson address some of the standard clinical ethical issues that arise in encounters between health care professionals and patients, such as informed consent, and the ways in which those issues take on a different shape when the health care professionals from developed, Western nations are working with patients and other health care professionals from resource poor settings. They also argue for the ethical obligation to develop sustainable aid programs in resource poor settings that do not impose unreasonable costs on a community rather than to provide sporadic care that fails to contribute to the long-term welfare of a community. The importance of working with local communities rather than simply imposing an agenda and plan has been recognized by others as well:
[A]ny project arising solely from our own agenda carries a certain unconscious and unrecognized arrogance that says, “I know what you need.” It is presumptuous and disempowering. When we present ourselves in a low- income country with a package of services, are its residents really free to reject our offer? It may be difficult for an under-resourced community to turn a well-intentioned intervention down, even if it doesn’t fit in with current community policies and priorities. The real challenge is to work within the established health system in a country, integrate work and research with national and local policies and priorities, and help build capacity. In fact, accepting this challenge is the only logical and sustainable form of engagement for those working in global health. Although, already practiced in many community-based public health programs, this approach would be innovative for visiting medical students and physicians (Anderson and Wansom 2009, pp. 506–507).
These observations are especially important for surgical care, which Operation Smile offers, because, as Farmer and Kim note, surgery is “the neglected stepchild of global health” (2008). Ott and Olson’s examination of an NGO providing health care services through short-term medical mission trips brings into focus the importance of ensuring that NGOs collaborate with host communities and implement sustainable programs that meet a community’s needs.2 Ott and Olson stress the importance of planning for sustainability when NGOs provide services.
Sustainability is also a major ethical issue for student GHE programs. Such programs must have substantial institutional support, including training for students and health professionals who will participate on trips and a plan for working with local communities to establish and nurture fruitful long-term relationships (see, for example, Crump and Sugarman 2008; Shah and Wu 2008).
Lewis Wall (2011) uses his experience providing surgical repair for obstetric fistulas in resource poor settings to recommend a series of ethical requirements that all medical volunteer activities should fulfill. He begins by noting the inherent power differentials that exist when health care professionals from wealthy nations provide care not only to persons who are vulnerable in multiple ways—they are poor and living in poor nations, they are women with obstetric fistulas, who often are marginalized because of their medical condition. L. Wall, like DeCamp, observes that there has been significant attention to the requirements for the ethical conduct of research in resource poor settings but that volunteer clinical care has essentially received a pass. L. Wall explores the many ways in which recipients of volunteer medical care may be vulnerable, demonstrates the importance of recognizing potential sources and types of vulnerability, and argues that medical volunteers must recognize their fiduciary obligations to all patients, including the obligation to provide appropriate medical care.
The U.S. National Library of Medicine MeSH heading defines medical missions as “travel by a group of physicians to a foreign country for the purpose of making a special study or of undertaking a special study of short term duration; not to be confused with missions and missionaries which covers permanent medical establishments and personnel maintained by religious organizations” (National Library of Medicine 2011).
There are thousands of NGOs that provide essential services in resource poor countries. Significant resources are spent annually to fund these organizations and to carry out their work. It is important that these resources are used as effectively and efficiently as possible to meet as many needs as possible. While many NGOs have been very successful in providing services, there have been some that have failed local communities in various ways. Critical examination of the work of different NGOs can improve the services they deliver and ensure that more needs are met.