I’ve been doing Global Health work since 2007. What that initially meant was I joined a university-based project, flew to a low income country, and functioned as a teacher in a clinical setting, where I didn’t know the context, or even the biophysiology of the majority of the infectious disease that I was seeing. I did not speak the language. While I tried to manifest cultural humility, I didn’t know what I didn’t know.
A couple of months ago, I posted a TikTok about medical voluntourism. It was cheeky and irreverent, but it led to a lot of great discussion. And I’ve had lots of medical students and even premed students sliding into my DM’s since, asking me how they can determine whether an opportunity they’ve been exploring is propagating colonialism, racism, and classism. I think it’s great we’re having these conversations. Here are my thoughts.
Medical students working outside of their scope of practice, and this also applies to physicians and non-clinical volunteers, is one of the most dangerous things that can transpire. Not just dangerous, for the locals on whom experimentation and dehumanization is taking place, but also dangerous for the volunteer, who is learning how to take advantage of their privilege in such an overt way. These kinds of life lessons are part of what creates such a dramatic inequity in society. When we dehumanize others and feel that they don’t deserve the same things that we would deserve, it deepens polarities and inequities that harm all of us.
In my perspective, the point of going overseas is to learn and not teach. There might be some academic consulting around medical education or residency programs, capacity building around a particular skill set like the use of bedside ultrasound or advanced cardiac life support. But local knowledge should not be underestimated. in my experience, working in Africa, the Ugandan and Ethiopian doctors had equal if not greater medical knowledge than anyone I’ve worked with in Canada. Part of the issue is that the Human Health Resources is such that, in many nations, there is one physician or health professional for 10,000 or even 100,000 people. They simply don’t have time to hold the hands and teach a bright-eyed Westerner.
One main discrepancy around knowledge base is tropical infections, which still cause about 50% of illnesses in equatorial settings. I studied at the London School of Hygiene and Tropical Medicine (DTM&H, iykyk). Once I recognize that, working in Laos, I didn’t know the first thing about the lung fluke or the Schistosomiasis that was harming so many patients. Even things like tuberculosis, we had such a rudimentary understanding of it. Some awareness of epidemiology and public health interventions is also key.
The scope of practice of a generalist physician in many of these places is far beyond what we would do, because there simply isn’t the same level of resources. In terms of radiology, surgical subspecialty availability, accessibility to tertiary care centers - a family doctor in Africa does a lot of surgical and obstetrical interventions that I would never dream of.
Cultural humility is so imperative. I know of one student who saw a gathering that she thought was special and wanted to emulate it for her birthday. So she asked her fellow students to celebrate in the same way, in a special process reserved for… funerals. Still other students would wear bikinis to suntan in very conservative environments. Some places that I’ve worked, it was really important to know that you would not point your feet at anybody while you were sitting in a chair. Or that you had to accept the food offered by a host. Having some understanding of the culture where you’re arriving, and some basic language skills, is important.
This humility should be the underlying tone of the presence. So often, I would see white saviorism - showing up with a project plan, and a binder plopped down on the table. They would call it collaboration. Or partnership. Without an understanding that there should be mutual benefit, participatory activities, and profound respect for the relationship. I don’t think that western nations understand just how extractive we continue to be in resource-poor environments. They are only facing poor resources because we are stealing them. Trained humans, products of the earth, food, and so much more. We also steal their financial security through the debt programs, and their political potential through the enforcing of the policies surrounding debt. Like they aren’t allowed to spend sufficient money on health or education as a part of their contract.
I have now worked in Laos, Tanzania, Kenya, Uganda, Ethiopia, Myanmar, and Nepal. I have learned far more than I have contributed. And when I ran the Residency Program in Global Health, I tried to instill these values in my students.
With my nonprofit work through Global Familymed Foundation, we are very focused on capacity building. We support resident tuition and just finished collaborating with our local partner to construct a housing facility for residents who will live in the rural area while they are training. Studying in smaller communities makes them more prone to feel comfortable and competent to work in them upon graduation, where they are most needed
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Considerations for people wanting to work overseas:
1. Local leadership in the accepting organization - beyond just tokenism, is it truly led by the people on the ground who will ensure there is local benefit and decision-making
2. Redundancy - could your money go further helping locals be hired or trained to do the same activities?
3. Sustainability - is there a plan for capacity building, for maintaining the services beyond the short-term?
4. Inadvertent harms - many don’t realize that bringing donations or a service might take the place of a local resource
5. Self-reflect - is your intention to save? To teach? Or to learn? Humble yourself first. Go with curiosity and listen.
6. Awareness - if you’re a student, you are taking time of a busy professional, likely a translator, and maybe others for your benefit. What are you doing in return? Is it worth their time?
7. Home - could you gain the same skill set locally working with newcomers, with special populations, or with other resource-limited communities?
8. Ethics - what are the ethical implications of this choice?
9. Trauma - students often come back from these experiences, desensitized to loss of life and significantly equitable determinants of health. When you start to think of these scenarios as expected, you don’t tend to advocate for change.
Here are some recommendations, from me and the TikTok community - please comment to suggest more!
Article: Scientific American - the problem with medical voluntourism
Resources: book When Helping Hurts
Documentary: First, Do No Harm - a qualitative Research documentary
Narratives - All of us in our own Lives
- The Spirit Catches You and You Fall Down (more about cultural humility even at home)