art by Cara Ocampo
Worlds Apart: The Divide Between International Medical Brigades & the Communities They Serve
by Cara Ocampo
It’s been an exciting few days at the clinic that your medical brigade set up in a village just south of Tena, Ecuador. Despite your limited Spanish, you’ve impressed the importance of frequent teeth brushing on many children, filled dozens of bottles of prescription medications and learned how to take blood pressure readings like a professional—an experience you’ll likely never forget.
When the group tears down the clinic tents on the last day of the trip, however, something changes. You watch the stream of patients walking down the path away from the clinic. You wonder what will happen if their hypertension medication runs out before the next brigade arrives, leaving them with pill bottles as empty as they were before you filled them this morning. Or what will happen if they have unexpected medical complications, but are too far away from the nearest hospital to get help.
As your group boards the rented school bus one last time, you have difficulty summoning the same altruistic enthusiasm that you started with. In its place, a new thought takes over, a doubt that will stay with you long after you’ve returned home.
What happens now? What if, in the next few weeks, these same patients find their health problems reappearing, with no one to call on for help?
“It is a life changing experience to see how poor the health care system can be in other countries,” reads the testimonial of one student who volunteered in Lima, Peru last year. Another student who volunteered in Honduras recalls learning how “basic things that we take for granted go a long way over there.”
These are common attitudes about medical volunteerism, an increasingly popular endeavor that accounts for roughly 162 million hours of Americans’ lives each year, according to Judith Lasker, PhD, NEH Distinguished Professor of Sociology and Anthropology at Lehigh University. The programs that facilitate volunteer health services abroad have many names, including “medical brigades,” “medical missions,” “volunteer trips” and “medical voluntourism.” They are managed by a variety of entities, including universities, private companies and nongovernmental organizations (NGOs).
What they share in common is the recruitment of volunteers (often students) to participate in temporary clinics that offer medical services to communities in developing countries. Most volunteers come from the United States, Canada, Australia or the United Kingdom, according to Alexandra Martiniuk, PhD, and Mitra Manouchehrian in BMC Health Services Research. They flock in greatest numbers to Honduras and Papua New Guinea, but many countries in Latin America, Asia and Africa receive a large number of volunteers as well.
Students’ reasons for volunteering run along fairly unified themes. Those who plan to go into health care professions view the brigades as an opportunity to see clinical care up close, learn about different health care systems and, of course, “make a difference” in the lives of patients in developing countries. International medical experiences are also often used as résumé boosters for medical school applicants, signaling the applicants’ “humanitarian qualities and unique perspective,” writes Lauren Wallace in the Journal of Global Health Perspectives.
Increasing the cultural competency of future health care providers is perhaps the most touted benefit of medical brigades. Being exposed to medicine within the context of poverty provides volunteers with an increased awareness of the social and cultural factors that shape patients’ and caregivers’ attitudes. Interacting with residents of low-income countries may also encourage brigade members to dedicate their efforts towards helping underserved communities in their home country. For example, John Bui, a third year medical student at the University of Pittsburgh, cites his undergraduate experience in a medical brigade as an influence on his subsequent dedication to researching HIV treatments.
Additionally, some researchers, such as Dr. Alex Campbell and Maura Sullivan, PhD, from the University of Southern California, point to the benefits of the cultural exchange between volunteers and the patient communities they serve. Receiving aid from citizens of better-developed countries can help patients feel that their struggles are being recognized on a global level, with the added benefit of local and visiting physicians appreciating the opportunity to learn from each other.
Critics, however, question the extent to which medical experiences abroad genuinely change participants’ outlook on their professions. A survey of medical mission volunteers who traveled to Honduras in 1998 found that, despite participants' claims that the experience had significantly changed their lives, including their desire to donate to charity, most participants did not significantly increase their charitable donations. In addition, as Dr. Lauren Taggart Wasson notes in the American Medical Association Journal of Ethics, the data suggesting that volunteers are more likely to later work with underserved populations comes largely from self-report surveys. As a result, it is possible that medical brigade volunteers consider themselves more attentive to the underserved after their volunteer experience, though in reality the experience may not have had a significant, lasting impact on their behavior.
Detractors of medical brigades criticize not only the lack of permanent change effected on returning volunteers, but also the shortsighted nature of most medical missions. For all their good intentions, visiting volunteers and medical personnel often provide only temporary treatments that fail to address the underlying causes of illness and poor health. Unite for Sight, a global health organization that provides eye care, cites an example of a group of medical volunteers who conducted a campaign to eliminate parasites plaguing the patients in a rural community. If the parasitic infections were propagated by a lack of clean drinking water, Unite for Sight cautions that those in the community will likely find themselves infested again once the medical brigade leaves after having completed their week of altruism. Patients requiring further medical attention are often left without access to the necessary follow-up care.
Volunteers should be cautious even when providing non-medical or non-invasive care, and take precautions to guard against miscommunication. As an illustration, Wallace uses the story of a medical brigade that distributed multivitamins to families in rural Guatemala. The volunteers stressed to parents that vitamins make children healthy and strong, departing afterwards “when their ‘good’ work [was] complete.” This initiative, however, had unintended consequences for the community. Some parents came to regard the vitamins as a panacea for all their children’s health problems, subsequently declining to purchase other necessary medications and instead treating only with vitamins.
In other cases, due to the prevalence of injectable vitamins in Guatemala, communities observed a rise in complications from non-sterile injections. Since the medical brigade neglected to consider the cultural context of the community they had entered, their efforts had unintended consequences that potentially did more damage than good. In the journal Missiology: An International Review, Laura Montgomery, PhD, argues that there is an arrogance underlying the belief that one can meaningfully address the needs of a population without understanding the community’s cultural context and living conditions.
Lack of coordination between the volunteer brigade and local health care providers may also disrupt the structure of the existing health care system. Offering free treatments that would otherwise be administered by local professionals in a permanent medical institution funnels business away from nearby providers. Patients in the community often mistakenly believe that the foreign medical personnel brings superior care to that offered by domestic providers, further disenfranchising local medical practitioners.
In some cases, volunteers may be called upon to offer treatments that they are not qualified to provide in their home country. Patients, whose knowledge regarding the foreign care providers is already impeded by language barriers, may not realize that the student volunteers are not yet full-fledged physicians. Juli Buchwald, Co-Lead of the Medical Brigades division of Pitt’s Global Brigades chapter, noted this outlook in the patients she served during a trip to Honduras.
“What struck me the first time I went,” Buchwald says, “is you’re doing this triage with [a patient] and they look at you as if you’re a doctor. But here [in the U.S.], if you have a student taking blood pressure, people are like, ‘What are you doing? Are you qualified?’” When asked to perform procedures outside the scope of their training, students may debate whether it is more ethical to offer less expert care or to deny service entirely.
“Well-intentioned volunteers may be overcome by a moral imperative to help,” writes Wallace. She cautions, however, against viewing lower quality medical care as acceptable in the setting of a developing country, when such treatment would not be tolerated in more affluent regions of the world. The idea that some care is better than none at all, Wallace argues, “can legitimize a value system in which the lives of some people are considered more important than the lives of others and create a double standard for medical care.” Good intentions are not enough, particularly when the patient’s well-being is at stake. It is better to give no care at all than provide sub-par care that can endanger.
Perhaps the most uncomfortable aspect of medical volunteerism is the ethnocentric undertone of the brigade philosophy. As pointed out by Lasker, some critics view short-term medical brigades as “a new form of colonialism, in which the wealthier continue to extract benefits (e.g. satisfying experiences, career building credentials) from the poor, all the while believing that it is in the best interests of the latter and a demonstration of the humanitarianism of the former.” In its online global health course, titled “Ethics, Quality, and Equality,” Unite for Sight derides medical brigades as self-serving, “short-term overseas work in poor countries by clinical people from rich countries.”
With this perspective in mind, the question arises: Who really benefits from medical brigades—the community receiving temporary medical care or the visiting “voluntourists”?
Certainly, in low-income areas where lack of infrastructure hinders access to even basic health care, the services provided by visiting medical brigades are much-needed and of great help, given that the aid supplied and the method of delivery is tailored to the needs of the specific community. Ultimately, those considering medical brigades should participate responsibly, taking care to be culturally sensitive and avoid imbalanced power dynamics between patients and medical volunteers.
As a starting point, one should research the missions and operating models of various brigade programs to find organizations that empower underserved communities rather than imposing damaging or insufficient services. “Something that we urge our brigaders to think about,” says Julia Zheng, Co-Lead of Pitt Medical Brigades, “[is] if they’re OK with the structure [of the medical brigades].”
Every approach to health care has its drawbacks, and international volunteer programs are no exception. Until all communities worldwide have permanent, reliable access to health care, medical volunteer programs will continue to fly around the world in service to the underserved. For now, you can still go to that clinic in Ecuador. You can still feel accomplished when you take blood pressure readings like a professional. You can still look with pride at the bottles of prescriptions that you fill. But when you leave, don’t be ashamed to ask yourself: What happens now?