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Altruism or Tourism

Hidden Ethics of Overseas Electives

The New Physician December 2007
Call it the Albert Schweitzer syndrome. It affects the brightest and best—the most caring and compassionate of both present and future physicians. And it can have real health consequences.



According to data collected by the Association of American Medical Colleges, 27 percent of medical school graduates had some international experience during their four years of medical school. Twenty years ago, the number was closer to 6 percent. And the trend doesn’t seem to be letting up. Sangeetha Reddy, a second-year at the University of California, Los Angeles, School of Medicine, coordinates med students who want to work with LIGA International, a group of volunteer physicians and medical students who make monthly trips to clinics in Mexico to provide medical services and supplies. According to Reddy, this year she had places for 36 medical student volunteers—and twice as many applicants.


Médecins Sans Frontières’ receipt of the 1999 Nobel Peace Prize may have added a little cachet to global health care, as has publicity of work like Dr. Paul Farmer’s in Haiti and elsewhere. Literature such as John le Carré’s novel, The Constant Gardener, has fueled many a romantic notion. And even now, the image of Dr. Albert Schweitzer devoting himself to the patients in his African clinic is as powerful as ever. But when it comes down to it, the impulse to go overseas, to take one’s nascent skills and use them in some small way to make the world a better place can be seen simply as the impulse to practice medicine in its purest form.


Or it can be seen as a way to build an impressive résumé and a reputation as an international adventurer. Not everyone is Schweitzer at heart.


To be fair, students’ motivations seem most often to be genuine compassion, and the students who choose overseas rotations, or do volunteer work in their off-time, gain more than medical experience and exposure to foreign cultures. “Students come away [from international volunteer experiences] excited by the broadening of their views,” says
Mary Terrell White, director of the Division of Medical Humanities at Wright State University’s Boonshoft School of Medicine. Dr. Marc Kahn, professor of medicine and a dean at Tulane University School of Medicine, goes so far as to say that the experience is “life changing” for the students who participate. Much of the change, no doubt, is personal and immeasurable.


Newly inspired career choices, however, can be tracked. Child Family Health International (CFHI), an organization that provides volunteer opportunities in global health care to medical students, has begun surveying its former volunteers to see what kind of effect the experience has on them. This research is still in its early days, but so far 38 percent of volunteers have replied that working overseas with CFHI influenced their choice of medical specialty, presumably leading them into primary care, pediatrics, tropical medicine or another field that will allow them to work with underserved populations in developing nations.


When Bad Things Happen to Good Intentions


The experience is life changing for the students, but what about the communities and individuals they go to serve? Does visiting another country with the intent of sharing medical knowledge and services always do more good than harm for the intended beneficiaries? Not all experts are sure that it does. The ethics of this kind of medical altruism are anything but straightforward. In the “Personal Views” section of an April 2000 issue of the British Medical Journal, Drs. Rachel Bishop and James Litch, co-directors of the Kunde Hospital in Nepal, write:


It is inappropriate arrogance to assume that anything that a Western doctor has to offer his less developed neighbor is progress.… [Visiting Western physicians] frequently don’t understand local illness presentation, culture or language. They often offer inappropriate treatment because they think they “must give something.” The consultations are often one off, with little possibility for follow-up, and the local health providers are left to pick up the pieces with no record of the consultation. If an unregistered Nepali doctor on holiday in the United Kingdom offered general medical consultations in a shopping centre, there would be a public and professional outcry. The problem is extended when applied to nurses, paramedical staff and medical students.


This complaint is not an isolated one. And physicians on the ground in underserved areas aren’t the only ones who are concerned.


Rachel True, program director of CFHI, sees similar problems with students eager to volunteer in under-served communities on the other side of the planet. “We have a challenge in shaping students’ expectations,” says True. “Some students think they’ll go overseas and try out clinical skills they can’t use here in the United States,” she explains, “when more often they go as observers on a learning mission.”


The ethical problems that arise are not always the result of unrealistic expectations, however. When medical care of any kind is scarce, students are often asked to do things they aren’t qualified to do or aren’t comfortable doing, such as suturing wounds or delivering babies. As much as one wants to help, and believes that any care is better than none, students should never feel pressured to do things they aren’t comfortable and prepared to do, says White.


“Programs can actually be a burden on a community if they are not set up correctly,” she says. Dropping in for
a few weeks with humanitarian gestures might help a few, but the long-term effects are not so obvious. A visiting doctor cannot provide ongoing care, and those who are left behind after the volunteers have departed may have to deal with more problems than they had before “help” arrived. For example, local health workers may not know what drugs were given by the volunteers. Local health care providers may be using traditional treatments that are effective on their own but interfere with the medications given by visiting physicians.


More likely, though, problems arise when volunteers simply do not understand the cultural and political complexities of the areas they visit. In most cases, health problems in underserved areas, including those in the United States, are so complex that providing a few weeks of medication and consultation will be of relatively little benefit even if it causes no direct harm.


In a recent editorial in the New York Times, Uzodinma Iweala, an American novelist whose parents are from Nigeria and who spent his childhood in both Nigeria and the United States, criticizes the approach, if not the intent, of much American aid to Africa. “There is not an African, myself included, who does not appreciate the help of the wider world, but we do question whether aid is genuine or given in the spirit of affirming one’s cultural superiority,” Iweala writes. “Africans, real people though we may be, are used as props in the West’s fantasy of itself.” He goes on to explain that in our zeal to do good and to feel good about doing good, the West often ignores the work Africans themselves have done to fix their problems. The ethical complexities, many obvious, others subtle, of playing Schweitzer is enough to give the most dedicated do-gooder pause. And pause they should.


Getting It Right


Arrogance, cultural ignorance, and that American tendency to barge right in and “do something even if it is wrong” is not a reason to turn away from the world’s health crises. It is a reason to do it right. “The burgeoning interest in global health is very positive for heath care as a whole,” says White. Problems can be avoided, she says, by thorough preparation and a knowledge of your limits.


“I went on an [international health care] program as an undergraduate with the best intentions,” recalls Alexis Armenakis, a fourth-year at the University of California, San Francisco, School of Medicine, who is spending a year as the global health intern at CFHI. “I soon learned that it is more important to sit back and learn than to think that [the local people] will benefit from what you have to offer,” she says. For those still in the preclinical years, that is the best attitude. Being a sensitive, strong listener is essential, White says. Even though an area may be lacking health care services and technologies, they are not necessarily lacking knowledge and tradition. Listening to and learning from the locals can be as important as sharing the information and supplies that you have brought, she adds.


What students can actually do is very situation-specific. “Some students have had nursing experience, EMT experience, or some other kind of clinical experience at home,” White explains, “and they will obviously be able to do more.”


Reddy points out that in her first trip to the San Blas clinic in Mexico, she worked as a translator for some of the doctors who spoke little or no Spanish. Other students, further along in their training, were able to assist with surgeries. “Be sure that you go with a clear idea of what your limits are, [and] what you will and will not do,” says White.


Avoiding the more subtle ethical dilemmas is a bit trickier. But again, preparation is key. Gaining a better cultural perspective is one of the benefits of this kind of experience, says Tulane’s Kahn. White agrees, but stresses that you shouldn’t wait until you get there to start learning. She offers advice familiar to medical students: Do your homework. Most experts recommend spending at least six months studying the culture and politics of the area you are planning to visit. A year is even better. If you don’t already know the language, learn at least some, urges True.


It is also crucial to choose a good program (see “Checklist: Picking a Program,” p. 15). Flying in with a few skills, a box of medicines and flying out a few days or weeks later does little or no lasting good. A good program has close ties with the people in the communities they are serving and offers continuity of care. Even if many of the workers are there for only a short time, there are others who stay long-term, and local people are ultimately in charge. Building relationships with the communities CFHI serves is essential to the group. “We try very hard to be socially responsible and financially just,” says True. “We feel that it is important that the hosts be compensated for their time and effort [in teaching students].” In addition, when students take supplies, CFHI takes care to make sure the materials are necessary for that particular community. This kind of care is only possible when a program is based on a long-term relationship with the local community. For example, the LIGA program, of which UCLA is one of many partners, makes monthly weekend trips to three clinics in Mexico. The clinics are open only when the U.S. doctors are there. At worst, this sounds like medical tourism and, at best, like weekend warrior training missions for students who can’t afford the time for a longer program. On the ground, however, the program is well organized and staffed by a consistent group of doctors, says Reddy. They are able to give follow-up care to the patients they see, and local residents can come to one of the three clinics for ongoing treatment of chronic illnesses and elective surgeries, knowing that they will get continuity of care by physicians who know their medical history. Evaluating a program requires paying close attention to this kind of detail.


But perhaps the key to successful global health care is as much a matter of having the right attitude as having the right system. “When they go on these trips,” says White, “students are ambassadors of Western nations, Western medicine, Western people.” And, as such, there is much more than giving vaccinations that needs to be done.


“We can make an impact by not being so aggressive, by listening, forming relationships, being collaborative and humble,” says Armenakis. Being collaborative and
humble, in particular, are not traits that come easy to most physicians here in the United States. But it is essential that we develop these skills if our humanitarian impulses are to do more good than harm.


And we must get it right, because the ultimate ethical issue is our responsibility to the rest of the world, a responsibility White believes stems from our drain on their resources. “We owe these underserved nations something,” White says. “We must pay them back for what we’ve taken.” When viewed that way, humility quickly replaces arrogance.
Avery Hurt is a freelance writer in Birmingham, Alabama. Direct comments about this article to tnp@amsa.org.