Author: Rebecca Kim
Although many global volunteering programs have temporarily grinded to a halt due to the COVID-19 pandemic, the pre-pandemic popularity of global health volunteering had soared to new heights. It has been estimated that out of all Americans who volunteer internationally, around 21% designated medical care as their primary sphere of interest. This 21% translates to a staggering two hundred thousand Americans volunteering in global health annually.1
This growing popularity has caused many critics to raise questions regarding the morality and efficacy of global health volunteerism. Widespread backlash against ‘voluntourism’ is especially notable. While masquerading as benevolence, a diversity of factors – including colonial histories, incompetence, and negligence – can make such interventions problematic. This paper will attempt to open an honest conversation by challenging the popular conception of global health volunteerism as being within the sphere of indubitable virtue. It will do so by examining the imperialistic roots of global health interventions, the systematic offshoring of medical students, and the destructive ‘something-is-better-than-nothing’ narrative.
While often conceived as inherently altruistic, medicine is entangled in a complicated history of imperialism. As enumerated by John and Jean Comaroff in their aptly titled work, the toxic connections between “Medicine, Colonialism, and the Black Body” can be traced back to Social Darwinist ideology. In the early nineteenth century, for instance, Swiss anatomist George Cuvier sought to compare different races by assigning arbitrary meaning to anatomical parameters of his choosing.2 Cuvier correlated the size of the mid cranium to “degree of dependence… upon external sensations,” and came to the conclusion that “Ethiopians” (the classification he used to refer to black Africans) were more biologically rudimentary compared to “Caucasians,” whom he considered to be the original race. This pseudo-science was widely published by the British biomedical press, thus piquing the interest of Europeans who came to see Africa as a reflection of primitive humans.
Consider this excerpt from a mid-nineteenth century account detailing philanthropic work in Southern Africa, written by a founding member of the London Missionary Society:
“Africa still lies in her blood. She wants… all the machinery we possess, for ameliorating her wretched condition. Shall we, with the remedy that may safely be applied, neglect to heal her wounds? Shall we, on whom the lamp of life shines, refuse to disperse her darkness?”2
The London Missionary Society sponsored not only Christian evangelical efforts, but also combined its missionary work with medicine. For example, one of the most famous members of the London Missionary Society was David Livingstone. As a physician and evangelist to regions of southern Africa, Livingstone’s intentions were not explicitly that of colonialism. Livingstone himself is documented to have been “careful to treat patients without undermining the local doctor,” as he made it a point to “never challenge their practice in front of patients,” but offered his views privately.3 However, because his practice took place at the cusp of the Scramble for Africa, he is now better remembered as an icon of the British Empire. In addition, Livingstone himself was not immune to discriminatory thinking. For instance, he once attributed the relatively low malaria mortality among black women to their “heavy menstrual discharge” that supposedly “flushed” pathogens from the body.2 It is clear that this hypothesis originated less from any sound medical evidence, but from an unfounded conviction regarding the extreme reproductive biology of African women. This way of thinking of black women as sexually robust entities is widespread to this day. For instance, it is thought that the roots of the racial fetishization of black women can also be traced back to colonialism.4 Thus, regardless of whether or not Livingstone’s intentions were altruistic, his legacy is a prime example of how medicine can unwittingly fall into patterns of discrimination. The establishment of the image of the wretched African – which medicine played a large role in creating and perpetuating – has served time and time again as a moral justification for colonialism.
Even putting aside these racist historical roots, global medical volunteering should be scrutinized for another pivotal reason: promoting incompetence. Regulations in patient care – strictly enforced in the US since the 1990s – make it near impossible for unqualified individuals to actively practice medicine domestically. The vast majority of these hurdles, however, dematerialize overseas. Taking advantage of such dearth of regulation, some medical schools have developed programs to shuttle first-year students to the ‘third world,’ where they can apply clinical knowledge in a real-world setting in manners that would never be permitted in the US.5 Take this first-hand account of what such volunteer programs can look like in practice:
“After finishing my first year of medical school, I participated in a mission trip to Mexico… I remember vividly seeing a frail 11-year-old boy with polyuria, polydipsia, and nocturia. My lack of medical training limited my differential. With only a scattered history and no other tests, I told him to limit caffeine intake and see if that helps. Thinking back, he could have had a urinary tract infection, any number of renal abnormalities, or worse, I sent him out without ruling out diabetic ketoacidosis. And while I was seeing patients by myself, other first year medical students were performing surgeries in the other clinics and later bragging about it.”6
The outsourcing of medical education thus raises a troubling ethical question: Why is the care given by a first-year medical student deemed adequate for certain individuals and not for others? By offshoring training to other nations, we are in many ways treating foreign bodies as subjects of experimentation in an approach uncomfortably reminiscent of colonial medicine.
One widely employed justification for the differential valuation of lives across borders is the claim that the communities where students volunteer typically lack medical services. It thus follows that while the care provided by medical students may be sub-par, the mere act of offering treatment is perceived as valuable. Surely, this ‘something-is-better-than-nothing’ argument typically holds true in our daily lives. However, in regard to medical volunteering, we must accept the truth that something is not always better than nothing. While UNICEF advertisements and other nonprofits often portray the ‘third-world’ as an empty vacuum barren of medicine, most of these nations already possess basic healthcare infrastructure, albeit often lacking personnel and resources. Consequently, when expatriate medical volunteers are inserted into this already precarious system, they can actually “undermine local health infrastructure” by driving scarce “medical personnel into roles as translators and supervisors.”5 The heedless presence of expatriate volunteers can unwittingly erode health care in the very communities they aim to help.
In noting the differential standards of care of medicine that is applied domestically versus globally, this paper does not mean to insist that all people must be treated with the same standards we apply in the US. Not only is the US healthcare system far from the gold standard, but each country faces unique challenges in providing health care, necessitating the undertaking of procedures that may not be acceptable in the US. The manifestation of creativity in the face of disparity is captured by Improvising Medicine, Julie Livingston’s ethnography of a Botswana cancer ward of the early 2000s. While the ward’s expatriate doctor – referred to as “Dr. P” by Livingston – readily acknowledged that it is the ideal procedure to make cytological diagnoses after having examined at least four samples of biopsied material, Dr. P regularly made diagnoses after having examined only two or three samples.7 Dr. P also consulted cancer literature published decades prior to help guide his treatment. While US standards of care would deem Dr. P negligent, upon further investigation, his actions seem to have been justified. Dr. P’s work at the hospital regularly stretched past eleven hours. Thus, a more time-efficient method of diagnosis was demanded. In addition, the equipment available in the cancer ward was so obsolete that new cancer literature simply did not apply. Certainly, in unique circumstances, it is unfortunately necessary to “improvise medicine.” However, it is important to note that such improvisations should stem not from the dismissal of patients’ humanities, but rather a respect for them. Another critical detail to note is that the differentiation of standards should not be carried out solely through the will of expatriate doctors. In the oncology ward, Botswana nurses were integral in making decisions upon which the life of patients depended on.7 While standards of care may look different world-wide, efforts can still be made to achieve maximum quality that complements specific contexts in a collaborative manner.
Even after considering the aforementioned consequences of medical volunteering, critics argue that such excursions can help foster a spirit of idealism within students. Some may claim that early exposure to global health volunteering makes students more inclined to seek out similar opportunities once they have become fully fledged physicians. Even if this theory could be proven, the implications of volunteering when under-qualified are still problematic. If educational institutions are to actively support the haphazard funneling of students across borders, a dangerous precedent can be instilled in the minds of participating physicians-in-training. Students may come to accept the popular subconscious understanding of certain people being more worthy of quality treatment over others – possibly perpetuating discriminatory practices that have plagued medicine for centuries. Thus, even if individuals do choose to engage in global health volunteering after having become licensed physicians, it still considers the patients they encounter as satisfiable by lower standards of care compared to those in the US. We may very well be training the kind of doctors that would readily boast about performing medical procedures they have never been properly trained for.6
This unsettling mindset among some physicians has manifested time and time again. One health trend that has been drawing scrutiny is “fistula tourism” in the Horn of Africa. Genitourinary fistulas are extremely uncommon among women in developed nations. Despite this fact, gynecological surgeons will travel to Africa in order to “try their hand” at such fistula operations.5 While for these surgeons, their volunteer experience may merely be an exciting story with which to enamor fellow colleagues, for the women who are operated on, an improper procedure could lead to lifelong incontinence and social ostracization. A certain short-term intervention in Sololá, Guatemala serves as another example of the irresponsible nonchalance of expatriate doctors whilst lowering standards of care. There, physicians were overseeing the distribution of lice-shampoo containing the potent insecticide Lindane. Lindane is extremely toxic and can lead to death when applied incorrectly. However, even though the village residents did not have access to a reliable source of running water or possess latex gloves necessary to use the shampoo safely, physicians demonstrated a disturbing lack of discretion through their gifting of this dangerous product. This action seems even more problematic when considering head lice are endemic to Sololá. Thus “the dispensation of Lindane to an individual, without comprehensive education on how to rid… entire famil[ies] of lice,” would achieve nothing but the introduction of toxins into the community.8 Chronic lice is not a critical health threat, a fact that even the physicians of this intervention readily acknowledged. Rather, the primary impetus behind Lindane distribution stemmed from the physicians’ perception of lice as repulsive. It can therefore be concluded that the expatriate doctors deliberately endangered their patients in order to satisfy a fantasy of sterilization. In this manner, while it is critical for a global health volunteer to possess competence in medical treatment, such knowledge is meaningless if not complemented with proper awareness.
Unfortunately, exactly what this proper awareness entails is not clear. While this paper has heavily critiqued existing volunteering structures, it is much more challenging to design a quality volunteer program. What we should focus on, however, is not the construction of a perfect, universally applicable procedure for volunteering. As a matter of fact, the existence of a perfect, universally applicable framework is impossible, as the ideal volunteer intervention would be adaptive by-nature. An intervention that was successful in one community may not be successful in another. Even the act of scaling up a program within the same community comes with a new and unique set of challenges.9
Instead, this paper aims to suggest actions and ideas that should be taken into consideration when composing such interventions. The notion of ‘alternative summer breaks’ consisting of international volunteering must be abandoned. Volunteering is most meaningful when carried out with a long-term vision, something that is very unlikely to be achieved if it is contextualized along with vacation as inherently ephemeral. In addition, such programs help perpetuate the subconscious understanding of volunteerism as a quick-fix method to satisfy a craving for moral validation – a problematic mindset that carries the potential to undermine communities. Language barriers are also a critical hurdle in global health volunteering that must be kept in mind. When seeking out opportunities, volunteers should opt to offer their services in communities where they either speak the language or possess sufficient clinical skill to justify the allocation of local human capital towards translation.
Individuals wishing to engage in global health volunteering should critically examine the effects they will have on the communities they aim to serve. They must consider their interventions in the context of colonial histories. They must candidly evaluate the services they are qualified to administer. Perhaps most importantly, they must possess genuine conviction regarding the humanity of all patients and be willing to collaborate with community members when shifting procedures of care. Certainly, limitations in access to funds, resources, and equipment make it difficult to perfectly recreate domestic standards of care. However, even the mere proliferation of this understanding will mark a significant improvement in global health volunteering.
References
- Lasker, Judith. (2016). Hoping to Help: The Promises and Pitfalls of Global Health Volunteering. ILR Press, an Imprint of Cornell University Press.
- Comaroff, J., & Comaroff, J. (1992). Medicine, colonialism, and the black body. In Ethnography and the historical imagination (pp. 215–233). essay, Westview Press.
- Barrett, M. P. (2013). Defining Dr Livingstone. The Lancet, 382(9900). https://doi.org/10.1016/s0140-6736(13)62100-5
- Holmes, Caren M. (2016). “The Colonial Roots of the Racial Fetishization of Black Women,” Black & Gold: Vol. 2. Available at: https://openworks.wooster.edu/blackandgold/vol2/iss1/2
- Wendland, C., Erikson, S. L., & Sullivan, N. (2016). Beneath the Spin: Moral Complexity & Rhetorical Simplicity in ‘Global Health’ Volunteering. In R. Prince, & H. Brown (Eds.), Volunteer Economies: The Politics and Ethics of Voluntary Labour in Africa (pp. 164-182). James Currey Publishers.
- Bauer I. (2017). More harm than good? The questionable ethics of medical volunteering and international student placements. Tropical diseases, travel medicine and vaccines, 3, 5. https://doi.org/10.1186/s40794-017-0048-y
- Livingston, J. (2012). Improvising Medicine: an African oncology ward in an emerging cancer epidemic. Durham, NC: Duke University Press.
- Berry N. S. (2014). Did we do good? NGOs, conflicts of interest and the evaluation of short-term medical missions in Sololá, Guatemala. Social science & medicine (1982), 120, 344–351. https://doi.org/10.1016/j.socscimed.2014.05.006
- Biehl João, & Petryna, A. (2013). When people come First: Critical studies in global health. Princeton University Press.