Everyone knows at least one these days: medical providers who travel to developing countries to provide medical care to communities with little access to healthcare otherwise. “Medical missions” have become commonplace for students, residents, and practicing physicians. Allied health professionals are also frequently involved, with everyone from pharmacists to alternative medicine practitioners joining these trips. Many such trips are organized on an informal basis through networking, nonprofits, or church groups, and as such, involve little to no pre-departure training on practicing medicine in resource limited tropical settings. Participants may be expected to educate themselves on an ad hoc basis, or may be provided with some limited resources for study prior to the trip.
It has become clear that just being a doctor (or a physical therapist, or a pharmacist) does not qualify a person to practice in a developing country. And yet, there are physicians traveling from industrialized nations who are retired, have lapsed specialty certification, or are no longer licensed to practice medicine even in their own country. These people are administering medical care or even performing surgery on people living in poverty. Typically, they are lauded as humanitarians instead of questioned for such practices. This is not just an ethical issue, this is a social justice issue. Caring for patients in such scenarios requires a highly specialized body of knowledge and skills that American healthcare professionals simply do not possess without global health-specific education. We need to ensure that healthcare workers are not only licensed and qualified to work in their home areas, but any areas where they travel with the intention of providing medical care.
In the United States, we require all international physicians to go through an arduous course of USMLE exams and additional years of residency to be able to practice in our country. Yet we presumptuously believe that we can parachute in to settings completely different from those we trained in and immediately start treating patients. Despite the fact that we trained with ample availability of CT scanners, a panoply of lab testing options, and ready availability of consulting services, in an environment where tropical infectious diseases are rarely, if ever seen, we believe we can quickly translate our skill set to a location with no physician, minimal lab or radiology resources, perhaps without even running water or electricity. Yes, we do it because we want to help, but well-intentioned arrogance is still arrogance.
A typical justification for this practice is that in a resource limited setting, any provision of medical care is helpful because “it’s better than nothing.” That position is difficult to defend, since substandard care can end up harming patients. Healthcare providers who arrive in a resource-limited setting without proper preparation may end up monopolizing precious resources themselves, leaving less for the local population. Also, provision of free medical care by medical missions undermines what little local health system already exists. The healthcare worker who typically services the area now has his small income cut in half for the month, because his customers all decided to go get free care from the visiting medical mission. The pharmacist who sells medications can’t pay his child’s school fees because the medical mission gave away free medication to his customers. Finally, provision of free care by visiting health workers helps to create a ‘donor culture’ or ‘culture of helplessness’. It reinforces the belief of local community members that they are dependent on external aid, and undermines local self-efficacy.
Although it will be difficult to set and maintain standards for qualification to practice medicine in resource limited, global health settings, it must be done. Standards for qualification are ethically necessary. Academic medical centers, particularly those with offices of global health, should be at the forefront of creating and enforcing institutional adherence to these standards. Global health practitioners must prioritize the publication and dissemination of such standards in such a way that physicians in all specialties across the nation will be aware of them. Such standards will go a long way towards creating a culture of professionalism and respect for the challenges of practice in the global health field.
Have you ever considered or participated in a medical mission trip? Let me ask you – how much time did you spend considering how to get licensed to practice in that country before arrival? How many of you are taken aback that I suggest you need to be licensed to practice in a developing country, even if you are going as a volunteer on a brief medical mission? Why did you think it was acceptable to practice unlicensed in that location? Was it because of the remoteness and degree of medical need? Would you consider traveling to a rural area of the USA and hanging out a shingle as a physician if you had no American medical license or DEA number?
All right, I’m almost done grilling you now. But I do want your opinions. What makes us think we are qualified?
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.
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