In its present form, short-term medical trips represent a sub-optimally deployed resource. They could, however, address global health needs and issues, if we let them and if we facilitate them to do so in a socially conscious, appropriate way
Global Health and Idealism in the Age of “Voluntourism”: Matching a Workforce’s Intentions with Outcomes
by Lawrence Loh*
Adjunct lecturer at the University of Toronto’s School of Public Health, co-founder and Chief Medical Officer for The 53rd Week
In an era of social media dominated by Twitter and Facebook, it comes as no surprise that young health professionals worldwide are more aware than ever of global health issues facing our societies collectively. The idealism of youth foments individual desires to address poverty and inequality, reduce disease and disability, all while fostering wider transnational, intercultural understanding. At the same time, modern transport and communication links make it easier for them to identify opportunities and travel abroad, effectively allowing them to turn dreams into reality.
These young health professionals are deeply concerned with critical global health issues, often volunteering on a wide range of charitable activities at home and abroad. Research topics focus on various global issues, and advocacy takes place both through traditional routes as well as an ever-growing number of issue-based societies. Volunteers travel the world, providing service and skills with organizations big and small. Constantly interconnected by the web, today’s young leaders produce homemade videos to raise awareness, source donations through crowd-funding online, and lobby their leaders through the flattened world of e-mail and social media.
The impact of such efforts matches their heterogeneity, with initiatives ranging from large and readily apparent changes to potentially harmful outcomes for stakeholders. One only needs to look at the speed by which internet “memes” spread to understand how quickly information can be disseminated if the right vehicle is used. Many organizations and campaigns have successfully used the reproducibility and transferability of social media today to raise awareness of critical global health issues. At the same time, other well-meaning efforts driven by young professionals have far more questionable benefits and potential harms.
Increasing popular media coverage has focused on the impact of volunteering abroad, often called “voluntourism”, and the sometimes negative effects such well-intentioned efforts have on the receiving communities. Interested visiting volunteers from the developed world clearly gain much from these experiences, and often go with the very best of intentions. Despite this, there is growing sentiment that improperly conducted efforts come across as self-serving, given the ethical and sociocultural considerations involved, the unequal relationship between visitor and host community, and the significant draw on local resources to the resultant minimal impact of such efforts.
This growing sentiment, together with popular media anecdotes of the harms of “voluntourism”, often are simple analyses that have yet to account for a number of key considerations. Firstly, there exists a real need for skilled human resources to address critical global health issues in the developing world, which already suffers from shortages due to the outmigration of skilled workers. Secondly, global health problems continue to grow unabated in quantity and quality, and interest in addressing these problems comes from both governments and young professionals. Finally, such efforts represent huge collective investments -both in terms of finances, manpower, and intellectual effort- from volunteers, sending organisations, and local partners. It is an investment that is currently not being optimally realised.
Taking this classic puzzle in business terms, there is a clear need, a defined interest, investment and product, and suboptimal returns and outcomes. What is the market outlook? What is the context in which these operations currently occur? And finally, what are some strategies we can use to ensure these investments produce the primary and secondary outcomes we are looking for, and what are those desired outcomes?
Market outlook: need, interest, and barriers
Global health is everywhere in today’s world. Definitions abound about what constitutes a global health issue, but simply put, Koplan’s definition stands as the most simple: global health is about the issue, not where the issue is located; any health issue with transnational implications is “global” by nature. Some examples include the emerging infectious disease threats, growing non-communicable disease, climate change, the epidemic of injury, and the scourge of extreme poverty and malnutrition alongside a contemporary nadir of mental health. For young health care professionals, the need is real, and they feel a desire and capability to address challenges in the context of their diverse interests and skill sets.
Global health is valued. Experience abroad is look at favourably on resumes, institutions with global health programmes are more heavily sought after by top students, and whole local economies in the developing world rely on foreign aid and visiting team contributions to their programs. A 2011 survey of medical students in the United States found that 65% of respondents expected to participate in a global health opportunity abroad. These volunteers participate for myriad reasons; while all often intend to “do good” or “make a difference”, they often harbour personal growth goals as well.
Global health work occurs in a modern world where jet travel makes it possible to be anywhere within 36 hours; a world where a single mobile phone provides more knowledge than has ever been historically available to an ordinary citizen. At the same time, that modern world constrains the finances and times of young professionals through extensive training requirements, complex daily schedules, and limited holiday time. Short-term volunteer opportunities thus become the only viable outlet for interested young professionals looking to develop a global health interest.
The market outlook thus suggests that interest and participation in short-term global health work will continue to grow, given the continuing population health challenges coupled with expanding interest and access to various opportunities.
Context: harms, benefits, and values
Various stakeholders dictate the terms of short-term medical volunteerism’s present context. Traditional global health agencies, such as Doctors without Borders (MSF), have often attracted many global health volunteers previously. However, their extensive time and training requirements limit the ability of many young professionals to commit to their work abroad. The concept that “long term work” is the only way to do global health abroad is a holdover from a previous era, where those who wanted to “make a difference” abroad often packed up the van, moved away from the industrialised world to a less developed country for decades, and crafted a career and commitment that way.
Short-term volunteerism abroad, of which medical work is one small part, is a disruptive change that has particularly arisen in North America (but also in Australia, New Zealand, and Western Europe) since the late 1990s. Consider the proliferation of “alternative spring breaks” or “service trips” that have popped up from institutions ranging from major universities to small-sized non-governmental organisations (NGOs) and churches/community centres. A simple Google search for “medical missions” or “short-term medical trip” comes up with tens of thousands of results. These trips represent enormous numbers of volunteers being sent abroad. Leaving aside the obvious variability (particularly in their impact and ethics), the assessment of benefits and harms from these trips is critical.
Young healthcare professionals clearly benefit from going abroad. Research has documented the obvious benefits - exposure to disease entities and presentations not available at home, increased clinical acumen which feeds decreased reliance on diagnostic testing, and the development of professional networks and relationships both with the community abroad and with other members of the team they join. They also develop an awareness of global health issues and the need that is out there and are better placed to act as advocates, having experienced it first-hand.
The proliferation also reflects the benefits for sending organisations. For medical schools, many faculty and medical student candidates are looking for international connections to pursue research or advocacy work. Running short-term educational experiences abroad allows these institutions to attract top candidates, gain stature, and win funding for these efforts.
The picture is less clear for the receiving communities abroad. Many short-term volunteer efforts focus on manual labour (e.g. painting schools or building houses) or downstream interventions (e.g. clinical care or surgery.) More upstream interventions that address the underlying determinants of health are less often addressed, as the length of time these trips occur within precludes a deeper examination of the issues. Together with this limited benefit, the communities experience numerous harms; they often commit limited resources to hosting such trips, and while they are developing relationships with professionals from abroad, such relationships often occur within an unequal power dynamic. More challenging is the nature of the benefits received; there is no continuity of care or follow-up to deal with complications, and the power inequality precludes the local community from dictating what their priorities might be.
The final perspective, perhaps, is to look at what short-term volunteerism offers the world. While the power dynamic is a concern, few can argue that the carrying out of these relationships does build some form of a relationship which helps to flatten the world and build bridges between communities. Such efforts provide a vehicle to increase understanding between disparate peoples and reaffirms societal values of charity and altruism. The data that arises from these trips can also be used to support research and biosecurity efforts. The harms from a world perspective include the potential expense of resources and the carbon footprint, and the ongoing perpetuation of a colonial mentality (related to the previously described power dynamic), but one can argue that breaking down boundaries between world communities is an opportunity that we shouldnât waste.
Considering the foregoing, there seems to be a sea change in values and beliefs related to global health work. Many young physicians who are interested in pursuing work abroad describe frustration with the old models and being able to build a career that allows them to contribute to meaningful initiatives. Long-term strategies, while still valuable, are less attractive to a generation that only has short-term time and finances to offer. At the same time, however, our societal values of altruism, volunteerism, and charity remain very much in place. It would seem the question should focus less on the value of such trips - that’s clear and evident right now. Rather, our question should be how we can take these deeply personal investments and make the more impactful, allowing them to retain current benefits while mitigating harms.
There is an opportunity here to make the short-term paradigm more effective, and to ensure that all these newly proliferating alternative spring breaks and medical mission efforts are not causing harm, but are recognised as valuable human resources making a genuine impact to mitigating global health needs.
Where to from here? Strategies and perspectives
Many traditional organisations have come out and identified problems with short-term medical volunteerism. One non-profit organisation, for example, has come out and called them the “worst practices” in global health. Discussions on the issue are widespread but have not kept up with the growth in interest. A 2008 paper by Maki and others found that over a quarter of a billion dollars and 6000 volunteer hours had been invested in published efforts alone, and this has likely only grown in the years since. While many global health stakeholders are aware of the issue, few people have begun to suggest viable solutions; short of closing off the airport and preventing people from going, what can the global health community do to optimise these experiences and their outcomes?
That same community is ever acutely aware of the challenges they face in the post-Millennium Development Goal that is only under a thousand days away. There have been calls by the World Health Organization to promote universal health coverage and by the World Bank to eliminate extreme poverty by 2030. These are not simple goals. They will require significant human resource and financial commitments by governments that are cash-strapped following an economic crisis. At the same time, concomitant threats in the rise of chronic disease, mental health, injury, and emerging communicable disease threats (particularly antimicrobial resistance) threaten to set back all the progress that has been made by the global health community in the past decades.
It’s time to stop ignoring short-term volunteer trips and dismissing them as “band-aid.” They are only band-aid if we let them be. If anything, they represent an opportunity to crowd source and harness the idealism and manpower of a young generation of physicians, nurses, pharmacists, and allied health professionals, as well as professionals from other disciplines. There needs to be greater grant support and research funding to help understand this phenomenon and how it can support global health work.
Could we take short-term trips and crowd-source them towards addressing the social determinants of health? Instead of going to a community for a week and handing out pills, could twenty or thirty coordinated short-term teams instead work on building a water sanitation system or professional development that supports the development of local capacity? If people are going to put their efforts into such means anyway, can we not figure out ways to make sure the means justify the ends?
The next generation is idealistic and wants to make a difference. It falls to us to train them and come up with paradigms that allow the appropriate, ethical harnessing of their passion and involvement. Done right, these trips could retain all the benefits of breaking down global barriers, while having the added of bonus of adding genuine global impact.
The old paradigm of packing up the van and moving to Africa for twenty years is less relevant today; short-term volunteerism is here to stay. It is in our interest to not ignore it, but rather challenge and understand it. In its present form, short-term medical trips represent a sub-optimally deployed resource. They could, however, address global health needs and issues, if we let them and if we facilitate them to do so in a socially conscious, appropriate way. Taking these steps today will ensure that a new generation of global health practitioners will be at the table, not just considering the hard questions of our time, but instead actively answering them and safeguarding the future of their children and our ever-changing world.
*Dr. Lawrence Loh is a global public health and family physician based in Toronto. He serves as a medical specialist for the Public Health Agency of Canada and as an adjunct lecturer at the University of Toronto’s School of Public Health. A proud alumni of the Schulich School of Medicine at the University of Western Ontario, he completed his residency at the University of Toronto and obtained his Master of Public Health from the Johns Hopkins Bloomberg School of Public Health. He serves as co-founder and Chief Medical Officer for The 53rd Week and is committed to reducing the harms and maximising the outcomes of short-term global health experiences through awareness advocacy, innovation, and research.
To learn more about what The 53rd Week is doing to improve short-term volunteerism abroad, visit www.the53rdweek.org