Amateurs Play Doctor for World’s Poor
In 2008, NFL player Tim Tebow traveled to a Philippines orphanage run by his father Bob’s ministry. But while he was there he did more than regular missionary work—by the end of his trip, he was sporting rubber gloves and a mask while assisting with circumcisions, according to the Orlando Sentinel.
Tebow has no medical training but he’s not alone—students and volunteers from the U.S. and abroad are traveling to so-called underserved communities to offer assistance and pad their resumes, whether they’re qualified or not.
During her first year at the Ohio State University College of Medicine, Dr. Jessica Evert went to Kenya to volunteer—something many medical students and even pre-med undergraduates do to gain experience. When she was asked to perform a lumbar puncture (a spinal tap) on a child, two thoughts ran through her mind: one, if she was going to be a doctor, she had to learn to do these procedures; two, she wanted to be helpful.
“The child cried. He was held down and there was no anesthetic,” Dr. Evert told The Daily Beast. “I ended up not doing the procedure right so it delayed his diagnosis—that was 15 years ago.”
Dr. Evert, now a practicing physician and avid advocate for more comprehensive global health education, said she, like many students, went abroad with an organization that made her believe she was the “savior of Africa.” Her university praised her altruistic efforts.
This wasn’t the first time Dr. Evert was applauded for something that she now, looking back, questions—like the time she ran two free clinics as a student in medical school. Instead of being challenged, she was celebrated.
“It is not uncommon in some parts of the country to have free clinics be the safety net [of] health care, and often the free clinics are run—or at least partially staffed—by students,” she said. “I got all these awards and when I [moved] to San Francisco, where there is actually a robust public health system, I just felt like, wow, no one during my whole time in med school challenged me to say ‘wait a minute, is a free clinic by students appropriate health care for anyone?’”
Over the last 15 years, Evert has become somewhat of an expert in the area of global health education. She is the co-chair of Global Activities by Students at Pre-Health Level (GASP), a working group dedicated to advancing the best practice standards for undergraduates going abroad. The group also wants to “[grow] best practice awareness among medical and health science graduate admissions committees,” because the reason a lot of students go abroad is to better their chances of getting into medical school.
“The critique tends to be rendered toward the volunteers themselves. That is a problem because a lot of [students] wouldn’t be [doing] these kinds of things were it not for the fact that the health profession schools require experience to get into their programs,” Dr. Noelle Sullivan told The Daily Beast. “But they never actually define what they mean by ‘experience.’ On the web pages for medical admissions, for instance, they don’t define what [students] shouldn’t be doing. They never give a code of ethics.”
Dr. Sullivan is a professor at Northwestern University and runs a student program in Tanzania. Northwestern partners with the University of Dar es Salaam so that students from both universities can work collaboratively on community health projects. The specific topics are decided by local government leaders; at the end of their research, the students present their data back to the local government.
In 2008, Dr. Sullivan said volunteers tended to be medical students doing clinical rotation. Programs focused on learning rather than actual practice. But in 2011, when she returned to provide the data from her 2008 study back to the facilities where she had done her research, what she saw was very different.
“Volunteers had exploded all over [Tanzania],” she said. “There were always missionaries that were coming to the area. Loads were working in orphanages, schools, and [doing construction]. The health facilities were packed with volunteers and I got to watch a lot of stuff that was quite concerning.”
Since 2013, Dr. Sullivan has been researching clinical volunteering in six clinics in Tanzania. During her observation, Dr. Sullivan said she has seen it all.
“I’ve watched from the mundane to the absolutely atrocious,” she said. “On a mundane scale, [students] shadow doctors—but there is a linguistic problem there. The doctors might speak sufficient English to be able to translate and explain to the students, but often the nurses don’t—and certainly the patients don’t. So that can be quite tedious and boring for the students coming in.”
When it comes to the atrocious, Dr. Sullivan saw an 18-year-old aspiring orthopedic surgeon amputate the leg of a motorcycle crash victim, as well as students birthing babies and suturing wounds.
Dr. Sullivan said that volunteers come in waves. Those who have been in Tanzania for a while or are leaving soon set expectations for those coming in—which departments are most interesting, how to navigate it so you can do things like deliver babies, etc. In a way, Sullivan said, it re-socializes the incoming students.
When it comes to delivering babies, the midwifery students who have done deliveries back home will teach the pre-health students in Tanzania. Not only does this lead to unqualified volunteers birthing babies, but it also ousts the Tanzanian doctors who have this medical skill.
In response some Tanzanian health professionals have even told administrators that they will not deal with the volunteers and that they should not be sent to their departments.
Dr. Evert said allowing students to check for even a small number of things (like blood pressure or blood sugar levels) can have negative effects in more ways than one.
“Patients go to these clinics and they see these western, white people, wearing white coats. They look official—but [patients are] getting diagnosed by untrained, unlicensed students who are poorly supervised. When patients are told everything looks good, they get a false sense of security [even though] they weren’t asked about a comprehensive set of issues.”
She continued, “If students are just screening for blood pressure and weight and, for example, not asking about a 55-year-old woman’s vaginal bleeding of a woman who is 55 years old, she will leave getting kind of a blessing from these outside folks who seem like they know what they’re doing. It could turn out that she actually has endometrial cancer.”
A crucial part of what’s missing from global health education is knowing when to say “no.”
“I feel for the students,” Dr. Evert said, “because when I was a student and I was asked to put the needle in the kid’s spine, I had never been trained to say ‘no thank you,’ or told that I should even think about that. Students need to be taught how to say ‘no.’”
The University of Minnesota created the Global Ambassadors for Patient safety, a program that offers a pre-abroad workshop to provide students a safe and ethical experience. GAPS also has an oath that students must sign before going abroad, offering a way for students to refuse work they are not qualified for.
“It is really hard in that position with a lot of pain and suffering going on,” Dr. Evert said. “It can be really tough to say ‘no thank you,’ because you do want to be helpful. This contract allows students to say ‘I’d love to help you but I signed this oath here are the papers,’ so I think that is really helpful to to take the onus off the students.”
What else can be done?
After surveying organizations that send students on these trips, the students themselves, and the hosts, Dr. Laster, sociologist and author of Hoping to Help, has come up with not only a comprehensive description of how this field operates, but a list of recommendations for how it could be better.
“There is a divide between the people that think any kind of volunteering is wonderful and the people who think it is truly awful, dreadful, and exploitative,” Dr. Lasker said.
Dr. Lasker emphasizes mutuality and continuity as the two pillars of effective volunteer trips. Mutuality in its most basic sense means that both volunteers and hosts learn from each other; they both have something to be gained from the partnership. Continuity means that volunteers don’t visit sporadically—instead, they return beyond the initial visit, strengthen the local institutions, and continue to track results from a distance.
The Fair Trade Learning model developed by the global learning organization Amizade aims to do just that: achieve both mutuality and continuity for volunteering abroad.
“We got inspired by the Fair Trade Model with coffee,” said Amizade’s Executive Director, Brandon Blanche-Cohen. “If there’s this huge market place in volunteering abroad and no one is policing it and it’s is being commodified and sold to the lowest bidder, maybe we should think about creating a set of standards that people agree to and sign on to, to make sure that the communities and the very people who welcome you into an experience like this can get the most out of it. That is how all our programs have been designed for several years now.”
Amizade also is trying to flip the script on who gets to serve, and are working with low-income and minority youth in the U.S. as well as engaging Bolivian, Brazilian, Peruvian, and Northern Irish to serve in the United States.
When it comes to money spent and the commodification of volunteer work abroad, Dr. Lasker posed the question: if Americans are spending billions of dollars on short-term trips, is that a good way to be useful? The allocation of resources is another ethical concern when it comes to global health.
Dr. Sullivan explained that global health is targeted toward specific populations, ailments, and goals—for example, HIV. In the same clinic where you have top-rated HIV services, there are no pediatric antibiotics. The health professionals working in these clinics leave to work at NGOs because they will pay them better.
“The amount of money in HIV care alone in Tanzania exceeds the budget for the entire health system by a lot,” Dr. Sullivan said.
But if you work to build a primary health care system, you can’t say how many people it saved. It isn’t auditable, she said.
“The whole premise of public health is prevention, get them out of the hospital to begin with by ensuring that they live in a situation where they can create a meaningful life,” Dr. Sullivan said. “We know that works but we can’t quantify it in the way you can quantify the number of pills somebody is given.”
In terms of results we can audit, the big question is: when it comes to voluntourism and pop-up clinics, how much do they actually help, if at all? While it may be helpful for some patients with very minor health issues, ultimately the rewards don’t outweigh the risks.
“There are huge opportunity costs when you are misdirecting students to places that are not sustainable and not appropriate,” Dr. Evert said. “They’re not learning what is appropriate and they come away with a whole inaccurate world view.”