Weve mentioned this before, but we really like the simple and free information available from the Global Health University of Unite for Sight. Here is one of our favorite passages (uniteforsight.org/global-health-course/module8) Overview: Good Intentions Can Be Harmful(1),(2) Despite having good intentions, international health workers who do not follow global health best practice principles can be wasteful, unethical, and harmful. Worst practices are serious public health concerns that create new and often more substantial barriers to patient care, thereby reinforcing health disparities and perpetuating the cycle of poverty. Furthermore, these worst practices violate concepts of social justice and human rights. Due to high costs, schedule constraints and complicated logistics, many global health endeavors take the form of short-term medical missions, which undermine the local health care system, cause significant harm, and reinforce poverty.(3) These missions are often labeled as medical tourism or volunteer vacations – “short-term overseas work in poor countries by clinical people from rich countries”(4) – and can be seen as: Self-serving: providing value for visitors without benefitting the local community Raising unmet expectations: sending volunteers who do not have appropriate language or medical training or accountability Ineffective: providing temporary, short-term therapies that fail to address root causes Imposing burdens on local health facilities: providing culturally irrelevant or disparaging care and leaving behind medical waste Inappropriate: failing to follow current standards of healthcare delivery (such as continuity and access) or public health programs (like equity and sustainability)(5) Worst Practice: Short-Term Interventions Minimal Benefits: Though few would question the honorable intentions behind most global health interventions, short-term missions rarely produce tangible medical benefits in local communities. Organizers often fail to sufficiently research the communities they are entering, and without preventive and follow-up care, they cannot provide enduring health improvements. A course of mebendazole, for example, will rid patients of certain parasites, but without a sustained effort at water purification, it is only a matter of time before the patients become re-infested. A multivitamin might supplement a child’s diet for 30 days, but it cannot attack the persistent underlying issue of malnutrition. Temporary benefits that do not address the root of the problem are characteristic of short-term “band-aid” international medical programs. Even the impact of surgical intervention, often considered an immediate and permanent fix, is questionable. “While surgeries and dental treatment repair some of the consequences of poor health conditions, little, if any, preventive care is given that would affect the incidence or prevalence of these conditions or, in some cases, would prevent them from occurring or recurring. Thus, according to medical anthropologist Patricia Townsend, much of the curative efforts in both cases merely delay morbidity or mortality rather than reduce them.”(6) The evidence suggests that the visiting volunteers and the sending institutions gain much more from short-term international medical interventions than do the local communities. “Sending institutions clearly stand to benefit in multiple ways from developing sound global health programs that include short-term service and training opportunities. First, the institution may help attract attention to global health disparities. Second, for some trainees, the opportunity may form the foundation of a career working in resource-poor settings or on related issues. Third, the training experience may strengthen the position of a university to recruit the most talented trainees who are interested in a global health experience. Fourth, the training experience may provide trainees with an opportunity to learn about health and culture in ways that may be impossible in their home countries. Fifth, sending institutions may benefit financially from some short-term training programs because of the appeal of global health programs to philanthropists or the collection of tuition while trainees are abroad.”(7) Significant Harm: One misconception behind some of the worst practices in global health is the idea that providing some care is better than providing none at all. Drs. Rachel Bishop and James Litch, co-directors of the Kunde Hospital in Nepal, explain why this philosophy is misguided: “It is inappropriate arrogance to assume that anything that a Western doctor has to offer his less developed neighbor is progress. These [Western physician] tourists are often working outside their trained specialty or have little concept of how that specialty applies to Nepal. They 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.”(8) Indeed, short-term interventions often do more harm than good, in several ways. Personal Harm: As Bishop and Litch mentioned, local healthcare providers often have no records of medical care administered by visiting doctors, which can lead to potentially dangerous drug interactions, overdoses, or misdiagnoses. There are countless other examples of the harmful aftermath of short-term medical missions with no follow-up care: “Consider the following scenarios: After the team leaves, someone develops a stomach ulcer from taking too much ibuprofen on too little food and water. Someone receives an antibiotic and experiences an unrecognized first-exposure reaction that indicates a second exposure could be deadly. Children take too many multivitamins and become temporarily ill; when food is scarce, the sweet tablets are candy too tempting to resist.”(9) Infrastructural Harm: Short-term interventions often fail to work in conjunction with local partners and disrupt local healthcare patterns by subverting or burdening existing healthcare delivery services.(10) When a visiting medical team arrives, overburdened local staff may see an opportunity for a break, or they may reallocate their efforts, leaving patients “without a trained clinician familiar with the local spectrum of disease and in local diagnostic and management algorithms”(11) Patients also tend to view Western physicians as superior, compromising the status of local doctors.(12) After observing Honduran women preferentially seeking prenatal care from an American student over a local physician, Matthew Decamp of the Duke Global Health Institute suggested that medical outreach may “contribute to a sense of false hope in Western medicine… [and] foster dependency on foreign aid or disenfranchisement with the local health system.”(13) On the other hand, if impaired communication or a lack of follow-up care leads to a patient’s health deteriorating, a new barrier to healthcare has been established: fear of doctors. Dr. Laura Montgomery points out other ways in which short-term medical missions harm a communitys health infrastructure: “While [Western medical] teams provide temporary but sporadic access to health care, overall, they do not improve long-term access and they may, in fact, undermine existing services. It is unclear whether the short-term projects are treating only individuals who under current circumstances would have absolutely no access to medical care because of an inability to pay for it, or if they are diverting some otherwise paying or potentially paying patients from local practitioners and facilities. Local practitioners who must earn a living in the community cannot compete with the volunteers who donate their services. Furthermore, they cannot provide the same volume of free care over sustained periods and remain financially viable. Because the patient population… has not been closely analyzed, it is difficult to assess the precise impact on the local health care delivery system. If these groups actually do compete with local providers, the possibility exists that they could be put out of business, further restricting access to health care.”(14) Philanthropic Colonialism: When teams from affluent countries visit the developing world, they risk engaging in “philanthropic colonialism.” Global health organizations should aim to build local capacity without violating cultural norms, but most short-term medical missions fail to adequately research the demographics, current events, and culture of the communities they enter. Montgomery summarizes some of the risks of cultural ignorance in medical missions: “Short-term missions [have] both naïve realism and ethnocentrism which assumes that approaches suitable in one setting are appropriate in another…These attitudes also manifest themselves through an assumption that no special planning or localized knowledge is needed and participants frequently have a lack of awareness and training regarding other medical systems, beliefs, or practices. Sometimes local beliefs and practices are ridiculed and, therefore, discounted and not taken seriously. Since the projects are present for such a short period of time, participants are often ignorant of the possible conflicts between health beliefs and practices that may result in miscommunication or noncompliance.”(15) Montgomery goes on to point out that because of Americans’ predilection to explain behavior and circumstances in terms of personal qualities of individuals rather than in terms of larger cultural patterns and structural issues, there is an “inattention to or a discounting of the impact of social structural issues of injustice or inequality as being critical factors determining health and poverty... This orientation also tends to obscure for participants the inherently political nature of their activities.”(16) Worst Practice: Untrained Volunteers and Practicing Beyond Ones Abilities Whereas well-trained volunteers can contribute significantly to global health endeavors, untrained volunteers detract from them. It is the responsibility of global health organizations to train and oversee their volunteers. The lack of health resources has been cited in the past as encouragement for students to go and operate in these underserved areas. The operative principle seems to be that some surgery, however expert, is better than none. Raja and Levin disagree and counter that the lack of available resources in a society makes a greater imperative for getting surgery done right the first time. Poor surgical outcomes will burden the health system with increased iatrogenic morbidity.(17) Practicing beyond one’s abilities: The trend of allowing medical providers to practice beyond their abilities is one of the worst practices in global health. All too often, medical students and residents see medical missions to developing countries as opportunities to gain unbarred exposure to techniques and procedures that they could not perform in their home countries. Other times, visiting physicians feel compelled to treat patients outside of their specialty, simply because there is no specialist available. In the developed world, internists do not treat children, and general surgeons do not prescribe eyeglasses – why should this be different in the developing world? Lowering the standard of medical care for those in developing communities is unprofessional, unsafe, unethical, and often illegal.(18) The following account of a first-year medical student’s mission experience illustrates the dangers of relying on untrained medical volunteers: “After finishing my first year of medical school, I participated in a mission trip to Mexico. Before flying to Mexico, I was not given any cultural, medical, or other training, nor could I speak Spanish. Upon arriving, I was assigned to a clinic where there were hundreds of patients seen by only one physician. I remember vividly seeing a frail 11-year-old boy with polyuria, polydipsia, and nocturia. My lack of medical training limited my differential. With only a scattered history and no other tests, I told him to limit caffeine intake and see if that helps. Thinking back, he could have had a urinary tract infection, any number of renal abnormalities, or worse, I sent him out without ruling out diabetic ketoacidosis. And while I was seeing patients by myself, other first year medical students were performing surgeries in the other clinics and later bragging about it.”(19) In newspaper articles, on blogs, and on the websites of NGOs and other organizations, there are countless descriptions of frightening and dangerous instances of non-medical professionals reveling in the unauthorized opportunity to practice medicine. A business management major...creates his own adventures to help the less fortunate in the world. During the last two summers, with no medical training, he has gone down to El Salvador to work in medical clinics to help the people there in any way he can and is planning his third trip for this summer. I had always wanted to go do something like this...There was only one doctor, and the nurses werent very qualified, so I helped them out, he said. He had the opportunity to do what he had seen on television to really assist the people. He vaccinated children, sutured wounds and even delivered two babies.(20) In addition to causing individual harm to patients, these dangerous practices can also cause permanent infrastructural harm to healthcare systems. A young medical student, referring to himself as Dr. Jones arrived in a village in a Central American country during an unsupervised elective course. He greeted the villagers with bags of candies, quickly winning over the interest and affections of the children. He was able to move easily among them, taking photographs and earning their trust. He was summoned one day to the bedside of an extremely ill baby and was asked by some of the villagers to help her get better. After an exam during which he used his stethoscope and otoscope, both of which were unfamiliar to the family, Dr. Jones recognized that the child was extremely dehydrated with a high fever. Without access to the kinds of diagnostic tools--laboratory tests and radiological examinations--on which he usually relied for information--he was unable to determine the cause of the childs illness. He told the family to give her fluids and acetaminophen to keep the fever down. He was unfamiliar with the familys usual dietary habits and never inquired if the child was being breastfed or if the family had a source of potable water that would provide a suitable alternative. Unfortunately, the child died within a few days of Dr. Jones bedside visit. The families of the village became convinced that his ministrations were the cause of the babys death. His instruments and the medications that he gave her aroused suspicions that he may have introduced the evil eye or mal de ojo, a potential source of illness, or even death. Because he had taken many pictures of the children in the village, others became concerned that he had used the images of the children to inflict future suffering. After the death of the child that Dr. Jones saw, subsequent visits by white American medical personnel were prohibited by the villagers, even though a need developed for immunizations when a measles epidemic swept the country.(21) Medical Context: Even the highly trained western physicians face challenges adapting to a new medical environment. Bioethicist Ross Upshur and Andrew Pinto of the University of Toronto Faculty of Medicine point out that “medical training in a developed world context does not translate to competence in all settings. Rather, one should recognize that being in a different setting puts one at a disadvantage, especially in clinical medicine.”(22) Furthermore, culturally incompetent medical providers “may want to recommend certain things to patients that are not culturally appropriate... Conversely, [they] may observe traditional or local health practices that they perceive to be harmful.”(23) These challenges are compounded by linguistic and cultural communication barriers.(24) Lastly, all volunteers should be aware of the medical landscape of the communities they are entering, not only to assess need and outline goals but also for the volunteers’ own safety.(25) Non-Medical Volunteers: Just as medical providers who practice beyond their abilities can cause harm, incompetent non-medical volunteers can be equally counterproductive. Volunteers involved in local education, for example, risk propagating incorrect public health information if trained improperly. In general, volunteers who have not been prepared cannot contribute productively, and they become a logistical burden on the host organization and local community.
Posted on: Wed, 12 Nov 2014 21:21:32 +0000
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