When I saw a publication by Irmgard Bauer titled “More Harm Than Good? The Questionable Ethics of Medical Volunteering and International Student Placements” posted on Canvas, I was both interested (and a bit apprehensive, as I will explain) about the information I was going to be reading. From as far back as I can remember, my desire to be a physician was synonymous with participating in some sort of international medicine program upon earning my MD; the information Bauer presented could not be more pertinent and timely to my endeavors, as I recently traveled to Perú and participated in a student health training program which strongly affirmed my desire to work as a physician and pursue international health. I read the publication with a strong obligation to be informed on current issues that might exist within international medicine. I also read it with some degree of apprehension, thinking that it was possible I would learn that I had unknowingly participated in well-meaning but detrimental practices. Bauer’s work identified a wide array of problems that need to be addressed in international health initiatives, and as I read I compared the examples listed in Bauer’s publication to my real-life experiences and observations during my program. I was also somewhat relieved to find that some programs, like the one I participated in, have already acknowledged and taken steps in order to avoid these issues. In my post I hope to both highlight what these problems are and demonstrate possible solutions that I saw during my own experience.
One of the first things Bauer mentions in her work is the difficulty international health programs have in determining the duration of their presence. On one hand she mentions that a long-term presence in other countries is often maintained in order to keep a steady flow of volunteers, student training, and profits instead of allowing health systems to become independent; on the other hand, Bauer points out that short-term disaster relief often fails to make long-term improvements to healthcare infrastructure as well. On a smaller scale, Bauer also brings to light that on occasions volunteers can exhibit a dangerous hubris towards both the people they meet and the procedures they perform (especially in terms of surgical procedures). A large amount of these volunteers, as Bauer mentions, are students. Having students come to help establish, improve, and work in international healthcare systems can be of immense benefit to both students and people in the community– if done right. In order to do this, Bauer mentions that students must be aware of cultural components that may play into treatment plans: such language barriers or prescribing medications that are incompatible with the lifestyle of people in the area (such as avoiding certain medications in an areas with limited water access). Additionally, it is stressed that only necessary procedures be performed, as it is clearly unethical to carry out risky procedures solely for the sake of practice (as we understand very well from our experiences in this class). All of the points mentioned are extremely important, and although I am unsure about how popular Bauer’s publication is among those who practice medicine, I am happy to say that it must have had some sort of influence (or people in general are starting to realize these issues). I say this from my own experience with an international health program that worked very hard to strengthen its community’s health system in an ethical manner instead of the practice of “fistula tourism” described by Bauer.
In January 2019 I studied abroad for several weeks in Ollantaytambo, Perú: the purpose of this trip was for students to gain clinical experience, learn basic Spanish, and most importantly assist the workers of an organization, called Sacred Valley Health, in their daily duties. During the trip, our first task was to learn some basic Spanish and culture of the surrounding region. Following this, we were taught and expected to reteach a wilderness course to local tour guides and hotel owners: who often have clients exploring the area’s many trails during the day. The organization has been around since 2012 and currently trains members of surrounding communities about medicine: these trained individuals are referred to as promatoras (or promatoras de salud). These people are chosen by their communities, and they are responsible for rendering medical care (such as first aid and prenatal care) and training to their communities. Furthermore, around 95 percent of promatoras are women. The effect that these women (and men) have had on their communities are far-reaching. I recall being told during my trip, that before the program there was an extremely high infant mortality rate in the mountainous, isolated communities of rural Perú. Now promatoras are responsible for distributing prenatal supplements and accompanying pregnant women to regular appointments. The effect of this initiative has been far reaching, and we were told that infant mortality rates have dropped drastically since. Additionally, we were told that the program has facilitated the empowerment of many local women through holding roles of leadership within their communities.
Both the mission of Sacred Valley Health, and their method of selecting and training individuals is a prime example of how organizations can be utilized to deliver better healthcare and improve health systems’ infrastructures while still respecting the culture of those in the area. They employ people from the communities that are being served, which is of immense benefit in terms of the influence and accessibility of these individuals to the public. Furthermore, all skills are taught by those in the organization in either Spanish, or the area’s native language of Quenchua, and all posters made by the organization also have universal symbols and graphics so that everybody can access and understand this important information. This respect and acknowledgement of the local culture allows for any language barriers to be avoided when delivering care. Furthermore, as students our job during the trip was not to solely practice procedures on others, but to work to extend the reach of these women’s expertise to the community. We were taught several skills such as how to make and apply life saving supplies (such as tourniquets or cervical collars to stabilize neck injuries) out of materials we may encounter on the local hiking trails. Upon learning and practicing these skills, we taught the class alongside the promatoras in order to teach as many locals as possible these skills. This process is a prime example of how students can learn and practice skills in medicine alongside others in the community while improving local health systems and respecting the culture.
In her writing, Bauer states: “Without a doubt, there may be many collaborations between western and local health professionals who work together in a mutually beneficial and respectful way to improve local health within the context of the local infrastructure”. This was what I experienced on my trip to Perú, and I find it motivating to hear similar stories from students I know who participated in different international health programs. I sincerely hope that organizers become more aware of possible ethical concerns as they develop their future programs and that these efforts will continue to improve and accomplish their goals of promoting better healthcare for the international community.