Friday, January 14, 2011

Student humanitarian aid?

Photo courtesy of Doctor of Record
Here is a question: do medical student trips to developing nations do any good?

Although this has been on my mind for some time, it was brought into focus by an article by Crystal Hayling from The Center for Effective Philanthropy (I actually read it on Saundra Schimmelpfennig's blog Good Intentions Are Not Enough - highly recommended). The post in question was about a family who travelled to Cambodia to build a library and some houses. They were disgruntled when their project was taken out of their hands and directed by the local folk. Ms. Hayling astutely asks "Whose Volunteer Experience Is This Anyway?"

This reminded me of applicants I interview for medical school. Many of these undergraduates have served on similar "build a house/school/latrine" missions in Mexico. I have always wondered, and sometimes ask, if the applicant's manual labor was the best use of the time and money involved.
Could their airfare / living expenses have been donated to local NGOs, or used to pay local (and probably more skilled) laborers to build the same houses?
If the aim of the mission is to create new homes for a community that is under-housed and under-funded, then using local unemployed labor would (albeit temporarily) boost the local economy.
Or is the goal to expose impressionable young Anglos to the cause of humanitarian aid, so that when they are in a position, or have a skill-set to do something effective, they will? Is that potential investment worth the loss of local economic stimulation? I'm going to say no - youth, altruism and enthusiasm are not enough justification.
If you have a skill-set that is needed, then go for it ( have a great model where they try to match your skills to needs). If you don't have a skill-set, go get one. In the meantime explore your motivations and other opportunities for volunteerism and/or donate money (advice for donations here and here and here).
(It is interesting to note that between 2007 and 2008, the number of Peace Corps volunteer applicants over 50 years old increased by 44%.)

With medical students I think the con argument is weaker, and the recruitment counter-argument stronger. Medical students are often used on these missions as relatively knowledgeable labor for large projects. Oftentimes they are used as "physician extenders" e.g. taking blood pressures or histories and physicals. While there may be local practitioners who could easily fulfill these roles, we all know they are terribly over-extended. They can ill-afford to spend time on a visitors' project at the expense of their own patients.
The globalization of health (e.g. the H1N1 pandemic; the global trend toward obesity and other chronic non-communicable diseases) and the recognition by the Canadian and US governments that global health is a political issue, all justify medical student education in global health. Houpt et al maintain that there are three aspects of global health that North American medical students need to know - the global burden of disease, traveler’s medicine, and immigrant health. A medical trip to a developing country facilitates learning in at least two of those areas. In addition, Gillian suggests that humanitarian aid participants can acquire "critical 'higher order' skills for tackling the complexity of modernising and transforming health services for the benefit of patients. They are also critical for personal career development" e.g. adaptability, interpersonal skills, self-assurance, problem-solving and strategic thinking.

Furthermore, is there an argument that exposing these young professionals to the reality of this work while they are still (relatively) ego-free is beneficial in the long-run in avoiding the ego-drive madness of so many 'humanitarian' missions.

All of the arguments for medical student trips apply equally to resident physician trips. Moreover, residents have a greater skill-set (i.e. can offer more to the host region), and gain more relevant insight into the novel diseases and presentations encountered abroad.
The positive effects of such rotations last. Two years after their experience, participants have reported a positive influence on clinical and language skills, awareness of cultural and socioeconomic factors, and greater recognition of the importance of communication skills.
In addition, medical students and residents who participate in international clinical rotations are more likely to pursue primary care medicine, obtain public health degrees, and practice medicine among under served and multicultural populations in the US [1, 2].

And what about recruitment for future humanitarian missions? When residency is over, do these enthused young doctors run back to the under-served world with their newly-minted board certifications? Yes, they do (or at least they plan to). Studies of international rotation participants from Yale and Duke revealed that they were more likely to consider or plan future work overseas [2, 3]. Do they have a better idea of what is needed and how to provide it? If the rotation is well-designed and implemented they should. I leave the actual design, implementation and improvement of these rotations to brighter minds and another post. However, the problems and mistakes that beset many humanitarian missions must be studiously avoided in those projects intended to educate and encourage future care-givers and educators.

So, do I have an answer to my question? In the process of writing this post I have become more convinced that medical humanitarian missions are of utility for medical students. But, I think the rotations have to be carefully designed to maximize benefit for the host region while minimizing disruption/distraction; and the student participants must be carefully chosen to minimize ego and maximize impact.

What do you think ?

[P.S. Here's a really nice post by Jeff Raderstrong on how to talk to / educate people about this issue.
P.P.S. And here's an equally nice post by Eric Hartman arguing that we should "accept international volunteering and advance it in the context of established best practices".]

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1. Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global health in medical education: A call for more training and opportunities. Acad Med. 2007;82:226 –230. 
Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The international health program: The 15-year experience with Yale University’s internal medicine residency program. Am J Trop Med Hyg. 1999;61:1019 –1023.
Miller WC, Corey GR, Lallinger GJ, Durack DT. International health and internal medicine residency training: The Duke University experience. Am J Med. 1995;99:291–297.