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On a Mission

Created 04.18.12 by Alison Hayward, MD
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Global health: it’s a vast topic, one that spans everything from tropical and neglected diseases, to humanitarian aid, to disaster relief, to public policy, to public health campaigns for disease prevention, and health promotion. In our increasingly globalized world, students training for careers in the health professions have become increasingly interested and engaged in health issues outside the borders of their own country.

The precise definition of ‘global health’ is elusive. It is sometimes used interchangeably with ‘international health’, however, in recent years, international health has fallen out of favor. The reasoning behind the terminology change was that ‘international health’ is felt to emphasize the differences between nations, and to imply a unilateral movement of aid from one nation to another, whereas the term global health has a more inclusive connotation and underscores the importance of a collective approach to addressing health issues.

More and more, students are seeking out opportunities for voluntary service either prior to starting their graduate studies, or during the studies. In fact, the American Association of Medical Colleges Graduation Questionnaire from 2010 revealed that 30% of students had participated in at least one global health experience. The phenomenon speaks to the commitment towards service and spirit of altruism in this generation, but it also provides unprecedented exposure for untrained volunteers in culturally and ethically complex health situations.

Students may take part in opportunities ranging from spending a day or a weekend volunteering at a clinic or providing disaster relief to taking a year or multiple years to work abroad and gain in-depth experience in a developing country. Health professionals also frequently take part in such efforts, from the young physician who flies to Haiti with the idea of providing disaster relief, to the retired surgeon who travels abroad to provide surgical care free of charge in a developing country. This is in addition to a vibrant and growing community of health professionals and researchers who have been trained in global health or humanitarian aid through formal channels, such as international fellowship programs, humanitarian studies programs, or diplomas in tropical medicine and hygiene.

These experiences have amazing potential to change careers, change hearts and passions, and ideally, to improve health on a global level. In the best cases, all of these objectives are achieved. In the worst cases, not only can such projects be uninspiring and frustrating, they can even be harmful to those they purport to serve. Sadly, potentially harmful “medical missions” and global health projects might even be in the majority. This fact is not apparent to most of the general public or those who participate in the projects. The lack of dialogue at all levels about global health ethics is a major obstacle to allowing budding humanitarians to serve others in a way that is empowering, respectful, sustainable, and compassionate.

Part of the reason for this lack of dialogue is that the questions are very difficult. In many cases, there are serious disagreements about what the right answers are. The questions involve how to prioritize one life over another, how to spend resources when there is a limit to what you can spend. Americans are not used to dealing with resource constraints in health, as the outrage whenever a politician mentions healthcare ‘rationing’ illustrates. So what happens when Americans get involved in global health and find themselves stuck in an ethical quagmire? Stay tuned – we’ll explore this question further in future columns.

Alison Schroth Hayward, MD, is a board certified emergency medicine physician currently on the faculty at the Mayo Clinic in Rochester, Minnesota. In 2003, she co-founded a nonprofit called Uganda Village Project, and currently serves as the Executive Director. Her expertise in global health ethics has mainly resulted from making all the mistakes already herself, and trying to learn from them.

References
Association of American Medical Colleges. 2010 Medical School Graduation Questionnaire: All Schools Summary Report. Washington, DC: Association of American Medical Colleges. Found at: https://www.aamc.org/download/140716/data/2010_gq_all_schools.pdf

Dyer, O. et al. What Is Global Health? Journal of Global Health, Spring 2011 online edition.

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  1. Natalie says:

    I am looking forward to more articles especially your perspective on the ethical situations that arise in this type of work! And as a vet student, I would love to see an article about the veterinarian’s role in global and public health – both preventing zoonotic disease and keeping the animal food source healthy and able to feed people. I’m also interested in hearing about any collaborative projects with MD’s and vets.

  2. Alice says:

    Throughout my own volunteering experience abroad, I found myself sharing many of the sentiments you expressed in this article. While my experience had a very positive influence on my decision to enter medicine, I found myself struggling with the ultimate outcome of medical missions and global health services. While many individuals enter “underdeveloped” countries with altruistic intentions, I feel the outcomes are often temporary. There is a lack of effort and awareness in evaluating a community’s resources and needs, and then working together toward a feasible and sustainable solution. For example, multiple service organizations have build hospital and medical infrastructure throughout the country I volunteered in. However, without a constant supply of resources that we have established in the US as the current “standard of care” (i.e. a method for sterilizing equipment before procedures, a reliable water supply for hand washing, a constant supply of new gloves), these medical infrastructures often fail to provide the long term solution these countries need. At the same time, it also interferes (for better or for worse) the traditional healing systems that are sometimes already in place.

    I appreciate the attention to this topic and look forward to reading more!

  3. Freesia88 says:

    As an African with a future medicine, I can understand the sentiments and questions raised in the article and in the comments above. While the efforts of international agencies and foreign countries are appreciated and do some good, ultimately, they do not address the real issues which plague health care in poorer regions.

    First, there is the already mentioned issue of limited resources. Quite frankly, healthcare is often not high on the priority list of the governments of these pooer countries, and I am sorry to say it, but if we are not willing to help ourselves, the west will not save us.

    This lack of interest is evident in the fact that health care education and training , for example, is very exclusive ( you have to be rich or smart or connected to make the cut ). I have a better chance of entering a medical school in the US than i did of entering one in my own country. This is not to say there are no brilliant students who got into these medical schools by their own merit , but you would think that for a region which sufferes from a paucity of doctors and qualified medical professionals, emphasis will be placed on ensuring that the students who show promise and interest but are not necessarily rich or connected have chances as well.

    The doctors who do graduate seem to have little or no interest in practising in rural areas and or starting initiatives which can provide medical care to rural areas for compensation in forms other than money. Often the emphasis is to open a private practise in the city and get rich by taking care of those who can afford the care. Some others do opt to work for the government hospitals which are cheaper but again, you have to be able to pay for care to receive it. Many people in my country for example are farmers in rural areas. They have food and can take good enough care of their families, but when disease hits, the doctors do not want to be paid in bags of corn…

    Furthermore, there is the often ignored issue of local health and wellness practises. Western medicine was introduced to sub-saharan Africa only within the last hundred years or so. We have cared for our sick in other ways which have worked for us. They may not be as effective or based on hard science as western medicine can be but these are our methods and we have come to trust and rely on them. When some one from abroad who had no clue how our local practises work comes pushing little white ( and often expensive) pills at us and telling us our methods do not work for shit…guess what happens? Personally I think an effor should be made not to erase the local practises but to see how they can be refined and made to work in harmony with western ideas. We might never achieve the standards of western medical care as they are, but this does not mean we can not establish standards that work for our societies.

    It is a complex situation and I am sure I do not even have a full grasp of it, still I think the resolution is to be found not with external forces of change but from within. We the poorer people, the underdeveloped people have to step up to the plate for our selves and revolutionize out health care from within.

    (And in case you are wondering, what i intend to do about this situation, I plan to pursue research and teaching back home in my own country, after I get my medical degree in the US .)

    1. Robert says:

      It’s complex and the entire problem won’t be fixed by one organization…. so what!?

      I’m sure the family that got clean water is happier, I’m sure the patient who had their disease cured is happy. If you don’t help 10,000,000 people are you doing good? Yes.

      You help one person at a time, maybe it only makes a difference for that day, month or year BUT it’s about doing what good you can do each day. The rest works itself out.

      I always see this response, “It’s complex, you’re doing little good.” It depends on whose perspective you have, for the individual being helped, it makes all the difference in the world.

      1. Freesia88 says:

        Understood.

        My point however is that more good could be done and more impact be had if the local people who needed help worked with local medical professionals who understood their backgorunds and the contexts of their lives, to look for workable solutions rather than remain the eternal beggar at the mercy of others.

        Why is there such a shortage of qualified medical professionals in African nations?

        Medical education is expensive and very elitist to begin with. All over the world it is and even more so for pooper countries. It needs to be opened up to those who have interest and potential. instead of sponsoring interminable projects, why are some of the billions of dollars funneled into “Aid Projects” not funneled into improving the education of indigenous medical professionals? Why not enable the people to take care of themselves?

        Why are so many of the trained and qualified medical professionals leaving the continent? Because they feel it is hopeless. The task is too big, the needy too many. The ones who stay are hardly able to or even interested in serving the people who cannot afford the care but need it the most.

        Lets switch places for a second, if the US was in the state that African nations are in, would you be ok with being foever dependent on international aid? I think not.

        The rest does NOT work itself out. Trust me, I know. I spent the first 21 years of my life in these conditions after all didn’t I? I have seen young children die from simple ignorance and misinformation. I have seen people go from door to door begging strangers to come have their blood tested to see if they can donate blood for an emergency surgery. I have had a sister die from an easily curable disease after being paraded from doctor to doctor with no two of them agreeing on a diagnosis. I have seen children with Down’s syndrome mocked and reviled for being products of witchcraft. I have seen people with schizophrenia abandoned to the streets by their families because they had no idea how to take care of them.

        The individual being helped might be grateful and happier but do not tell me the rest works itself out when there is so much that could be done if we stopped seeing ourselves as dependent on others for help and started trying to find solutions for ourselves.

  4. Xethan says:

    Dr. James Orbinski wrote a fantastic book, “An Imperfect Offering,” in which he explores the realities of global humanitarian efforts. He discusses his experiences with MSF and the difficulties of navigating limited resources, and the often oppositional political forces at work. I highly recommend this book to anyone interested in the topic of humanitarian action. I look forward to the future articles on global health.

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