As interest in global health continues to increase, many questions have been raised regarding the appropriateness of well-meaning but sometimes misguided attempts to help in underserved areas, particularly with short-term medical teams. The longer I’ve been involved in global health, the more I cringe when people talk about their trips like they have cured world hunger and lack of health care by handing out a few bags of rice and a month supply of Tylenol. The longer you spend in these areas, the more you realize how little you have actually impacted the great needs in these communities. So, should we ever participate in this type of trip?
NPR recently spotlighted an article by Joanne Silberner titled “Why surgeons are rethinking the fly-in medical mission.” She raises the question of whether bringing in a foreign team is the most cost-effective way to provide care in the developing world and highlighted the change in approach by ReSurge, who moved away from fly-in teams to training and equipping local surgeons to do the work. The advantages of this are obvious. A trained local team can perform many more surgeries and provide skilled follow-up care for complications. I have been pondering many of these questions in my mind for several years as I have struggled to determine the best way to help internationally as an attending surgeon.
My first international trip was to Honduras as an EMT. I fell in love with the people, the culture, and the beauty of this country. My involvement has continued to this day because of that trip. I have also had the opportunity to work in several other ways, including a specialty surgical team in the Dominican Republic, working in a local hospital in Papua New Guinea, and supporting our academic teaching partnership in Kenya. This last year, I was invited by a friend to travel with his team, and I really struggled with this decision. This was the type of trip under criticism- fly-in team, majority unskilled, lots of tourist activities on the itinerary. However, I knew he needed physicians, and I eventually decided to go. Unfortunately, the translators were not great, leaving me worried about whether I understood the problem and gave the right medications. Additionally, after asking one of the local physicians to help me explain a diagnosis to a patient, she instead gave me a lecture on how these people were poor and uneducated and would not be able to understand any medical information. I tried as politely as I could to counter that any condition can be explained in simple terms and that failure to explain the reasons for treatment leads to noncompliance. I definitely did not convince her to abandon paternalistic medicine and had to find another translator to help. Additionally, each person on this 50-person team spent $3500, with less than a quarter of the team being medical professionals. If we apply the doctrine of utilitarianism to this question, the one-off trip does not do the most good for the most number of people. The amount of money spent on travel could be donated to a local organization with more measurable benefit.
So, with all of my negative commentary, what are the benefits? First, to figure out how to make a long-term difference, you have to start by discovering what the needs are by interacting with local stakeholders and building relationships. Second, the experience changes and inspires the participants. Often people who do a short-term trip continue to support worthy efforts with advocacy and donations. Third, it is impossible to adequately estimate the value of the good accomplished at the individual level. I treated a young family whose baby had a congenital heart defect. They were being treated at the local hospital but were only given a limited supply of medication and told they would have to pay for the rest. We bought the baby a year of medication, meeting their needs until he was old enough for surgery. Similarly, I recognized a gait abnormality that had been worked up with the wrong imaging. I wrote down for him exactly what MRI he needed. This MRI identified his spinal tumor, and he has now had a successful surgery. Even a short trip may accomplish something significant for individuals, even if not cost-effective in the larger sense.
So, what factors can help you decide whether or not to go?
- Is there a strong local partnership, and do they do more than just hand out meds once a year? The group I continue to support in Honduras is now an independent NGO. What started as an annual church trip has expanded into a scholarship program, providing water filters, and building a factory to increase jobs in the region. They also partner with local physicians to improve care in a mutually beneficial way.
- Is there an opportunity to provide education or expand the skills/resources of the local medical community? The best programs are the ones who hope to make themselves obsolete. By finding ways to equip local providers and charities, we will be able to provide care in the long term.
- Does the local community want you there? Surgical teams may be intrusive to the local surgeon’s schedules and devalue them if providing services available locally. Also be careful of the sending organization. A friend of mine went on a medical trip not realizing it was sponsored by an oil company who was trying to repair their relationship with the local population.
- Are there quality translators available? Sometimes you can’t answer this question ahead of time. However, it is not safe to provide medical care without proper communication. The potential for misunderstanding, providing the wrong drug, or causing an unintentional overdose are very real.
- Are people doing things appropriate to their experience and training? Residents, medical students, and untrained people should not be doing anything outside their scope of practice. Adequate supervision is important.
We will undoubtedly continue to wrestle with the question of how to help for decades to come. However, for now, we can continue to do our best to act professionally and responsibly wherever we may work.