Monthly Archives: August 2011

Social Justice, Medical Aid, and Acupuncture Part 2: Sustainability.

How does acupuncture fit into the medical voluntourism spectrum? I would argue that some of the problems posed by Part One of this topic can be eliminated or adequately addressed by the use of acupuncture and associated therapeutic modalities. The nature of this medicine allows greater mobility, ease of information sharing, and lower overhead cost than allopathic medicine. I also argue that it can be more easily integrated into the social structures of diverse cultures than the technology-heavy and iconized allopathic medicine. This is not to say that acupuncture and associated modalities can completely replace allopathic medicine, but its practical application may create a more positive cost-benefit picture.

From the Acupuncture Without Borders (AWB) website:

While modern medical treatment remains indispensable in a great number of the conditions encountered in developing countries, the cost of medication and the lack of medical supplies mean that any efficient way of replacing prescriptions provides a welcome element in healthcare management.

AWB is therefore dedicated to offering a complementary therapeutic tool for existing local medical practice, whether modern or traditional. Acupuncture very often makes the prescription of drugs redundant, and only indispensable medications need be paid for.

Statistical data collected by AWB have shown that acupuncture could efficiently treat some 60% of the pathologies seen in dispensaries (this figure does not include minor surgery or dressing of wounds).

All Acupuncture Without Borders Centers are thus committed to collaborating and promoting exchanges with any organization sharing similar objectives. The benefits of collaboration and complementary actions in the field of humanitarian work are self-evident.

AWB aims to contribute to the development of greater self-reliance in the field of healthcare for disadvantaged peoples, by offering healthcare practitioners training and therapeutic practice in acupuncture. AWB acts in a spirit of solidarity, respecting the culture and the dignity of the populations concerned, and is committed to a policy of non-interference.

Acupuncture Without Borders in Burkina Faso

To this end, AWB sponsors missions in developing countries by volunteer acupuncture practitioners, with the aims of:

– sharing their knowledge with local medical practitioners (doctors, nurses, midwives, medical assistants, and so on), by imparting a theoretical and practical grounding in acupuncture.
– providing teaching media: books, manuals, acupuncture charts, etc.
– providing essential acupuncture equipment: needles, moxas, sterilizers, etc.
– ensuring delivery and correct use of the equipment.
– maintaining a long-term follow-up and evaluation of the training as part of a primary healthcare program.

Acupuncture Without Borders works solidly within the recommended guidelines for creating socially just and ethical medical aid. Acupuncture presents several areas in which it can excel as compared to allopathic medical aid, and a few areas which face the same problems as allopathic medical aid. I will outline my understanding of these below, using the guidelines set forth in Perceptions of short-term medical volunteer work: a qualitative study in Guatemala.

Danger areas in which acupuncture excels as complementary medical aid abroad:

1. The risk of medical interns and volunteers practicing beyond their scope of practice, which can occur for a variety of reasons (lack of proper oversight, lack of communication, initiative on the part of the volunteer, medical research):
Acupuncture poses very little risk of being used in a way that is beyond the practitioner’s scope of practice. The main types of risk management involved in acupuncture training include how to recognize emergencies that should be referred to a surgeon or ICU, and how to prevent a pneumothorax or syncope from acupuncture. Acupuncture is understood to be a low-risk profession, as evidenced by our relatively low rate for malpractice insurance in the U.S.

2. Lack of follow-up care:
Acupuncture for long-term, chronic illnesses can be taught to family members in many countries, so they can treat the patient over a long period of time for a very low cost.

Certificate of Completion for Acupuncture Training Course in Burkina Faso

Acupuncture protocols can be taught for particular diseases or afflictions that may be prevalent in one region (such as arthritis or asthma). Many types of self-care can be transmitted easily, involving the use of hydrotherapy, herbal teas and poultices, moxibustion, cupping, and simple self-acupuncture protocols. Most organizations include some kind of training certification that local community members can participate in, to further the care when they leave.

3. Volunteers taking advantage of lax laws or absence of supervision to experiment with procedures or medicines rather than simply provide necessary health care:
Since acupuncture has been practiced in a very similar way for over a thousand years, there is very little concern with using dangerous or new procedures.

The National Acupuncture Detoxification Association (NADA) expresses their intent to aid Gaza civilians concisely, in Guidepoints January 2011 by Greg Schnabel:


The NADA Gaza Strip project was designed to help civilian residents cope psychologically with the traumas of war and everyday life. For this project, teams of local health care professionals are trained in the NADA protocol for a period of 2 weeks.  After receiving training, members of these teams provide ongoing care within their communities.  This model empowers members of a community to help themselves and their neighbours and provides continuity of care in a region that is often difficult or impossible for international medical aid to access.

5 Needle Detox Protocol

…The potential for the application of the NADA protocol within Gaza is vast. The NADA Gaza group hopes to collaborate with other clinics inside Gaza that offer more traditional psychological support services. If they succeed in doing so there will be a need for more trainings and more needles in clinics throughout Gaza.

In a country that has seen war and conflict for so many decades, the incidence of trauma can span generations. It is the sincere hope of all members of the NADA Gaza group that the relief NADA brings to individuals may have a ripple effect, helping to ease the burden of care placed upon families and society. We hope that by easing these burdens we contribute, in some small way, to peace.

NADA practitioners are clearly positioning themselves within a collaborative care framework, with the stated goal of helping to aid in the creation of peace and autonomy of the Gaza community. The simple, clear, transparent process of this organization shows how acupuncture can be used to enhance the quality of life of a community without creating any burden or disadvantageous power dynamic. However I’m not trying to say that acupuncture is completely free from the problems that plague any medical aid organization. For the rest of the article I will explore the aspects of acupuncture that may be slightly better or no different from those of allopathic medicine in a foreign aid setting.

Dangers of medical voluntourism that pose less of a problem for acupuncturists than for allopathic practitioners:

4. Cultural assumptions and values inherent in the type of medical care provided may affect the recipients in a negative way (i.e. colonial mindset).
Acupuncture and its effectiveness as a healing modality can be seen through several lenses (see similarities with traditional Native American, Mayan, Tibetan, and Ayurvedic medicine among others) and does not necessarily reflect the traditional colonialist religion-affiliated-hospital association. Acupuncture could be practiced in a religious setting, but the medicine itself doesn’t currently create an imperialist dynamic in the same way that “Western” medicine sometimes does. The closest association may be that of the communist “barefoot doctors” of Maoist China, but interestingly when practiced by people from other countries than China, this association becomes diluted or dispelled.

Health worker in Liberia, from Merlin's Hands Up For Health Workers website

5. Language and cultural barriers leading to less effective treatment and medical errors.
Acupuncture uses a sophisticated system of objective and subjective diagnosis to understand the condition of the entire body. This theoretically does not require the patient to say anything, although a clear patient history is preferred. Acupuncture also does not usually require the removal of clothing other than socks. The patient maintains a fairly high level of autonomy during the treatments, easing the power dynamic between doctor/patient and allowing a more open and comfortable environment.

Challenges that all foreign medical aid NGOs face:

6.Understanding local medical needs.
Acupuncturists fortunately don’t rely on a set of specific and limited medicines; rather, this flexible medicine can respond easily and in a similar way to a large spectrum of medical needs as they are presented. However, local medicine needs must be clearly understood, since there may be times when a different type of medicine would benefit the majority of the local population. The knowledge may already be in the community but the technology might not be available. Possibly a broader structural change in the society or economy would solve the health crisis more thoroughly than any kind of health care aid. Acupuncture still has the potential to delay a crisis in such a way as to prevent real structural change from being spurred into action.

7. Identifying all stakeholders.
Acupuncture aid organizations function in a less institutional and more individualized way than many allopathic medical organizations at the grassroots level, and consequently they have greater ability to be flexible in practice. This leads to the possibility for closer communication with the full spectrum of social structures, from government offices to religious centers and schools to local business owners associations and individual community members. Hopefully this flexibility and communication translates to higher level of awareness of the stakeholders, but each organization differs. This is the responsibility of the personnel involved in the organization rather than something inherent to the medicine.

Moxafrica's Health Care Worker Trainees

8. Undermining the livelihood of local medical providers.
This may be unavoidable, but this prospect is hopefully offset by the opportunity for those local medical providers to learn acupuncture themselves if the clinic becomes threatening to their practice. Acupuncture is a complementary therapy in general, and it is generally seen as a way to help prevent illness. Specialists may not be undermined by acupuncture, since more serious illnesses requiring surgery or pharmaceuticals will be referred out of the acupuncture clinic. At the same time, a tendency to use acupuncturists as a general practitioner could emerge and undermine local health care providers.

9. Brain drain due to training and new opportunities abroad.
Training preference is usually given to community members that already provide health care to their community in some way and are looking to expand their current practice. However, the opportunities available for trainees would undoubtedly expand as their knowledge base and exposure to English improves. The aid organization has no control over what the trainees ultimately do with their knowledge. Hopefully the organization would keep track of the long-term effects of their training program and take steps to encourage the stability of the community.

Image credit Image Focus Australia on Flickr

Well that concludes my long-winded two cents regarding the challenges of creating sustainable acupuncture aid abroad. Much more research and documentation needs to be done as these projects mature and expand their reach. I am excited about the potential for sustainable aid using acupuncture and Chinese herbalism.

A few focused NGO Non-Profits are already providing effective and sustainable health care abroad using acupuncture and Traditional Chinese Medicine. The Acupuncture Relief Project is one outstanding foreign medical aid organization which uses Traditional Chinese Medicine and Massage to bring free health care to people in Nepal. They also summarize the above points nicely:

“Community acupuncture is a highly effective and efficient way of treating a variety of individual and community conditions in areas of conflict, disaster or devastation. Clients are treated in a group, sitting up in chairs, fully clothed. Acupuncture does not rely on the availability of expensive medications and can be extremely effective in treating pain, anxiety, depression and post traumatic stress disorders in areas of disaster or conflict.

  • Acupuncture addresses physical and mental health conditions simultaneously.
  • Effects are immediate, but can also be long lasting, well beyond the time the treatment is being given.
  • While the treatment alleviates symptoms, it is also a general balancing treatment, which treats not only symptoms, but also the root cause of the symptoms. It addresses the whole person and has a comprehensive effect.
  • There are almost no side effects or contraindications. It is non-addictive.
  • Equally effective when there are language or cultural barriers.
  • Healing in a community environment is especially beneficial when a disaster, trauma, or conflict has affected the whole community.
  • Acupuncture in a group setting allows the community as well as the individuals to experience healing.

In addition to providing aid to this besieged community abroad our practitioners will gain valuable experience that will aid in their personal development and compassionate treatment of their patients back home.”

In a similar vein, Mindful Medicine Worldwide provides acupuncture and massage in three clinics in Nepal, including more rural areas. They provide a stronger year-round presence and are also collaborating with a hospital in the Thai-Burmese border region to provide integrative care to refugees using acupuncture, naturopathy, and other healing modalities to address trauma, drug use, and communicable diseases such as HIV and tuberculosis.

Another inspiring international NGO/NP is Moxafrica, an organization that teaches people in Uganda and South Africa to use moxibustion for the treatment of symptoms associated with Tuberculosis:

MOXAfrica

“Are we seeing moxa as being an alternative to existing drugs?

No.
We seriously see it, however, as being potentially helpful when drugs are available, particularly so if they are in inadequate supply as is currently the case.

We also seriously see possible benefits in connection with any one of the following: reduced periods of infection if moxa supports the patient to enable the drugs to work more effectively; possible resultant reduction in disease spread; shorter drug regimes resulting in improved rates of overall recovery; potential reduced rates of mortality; better tolerance to drugs and reduced side effects; possibleimproved results with DR-TB when appropriate diagnostics are absent; consequent possible reduction in the growing incidence of drug resistance; indications for innovative possible approaches to treat patients co-infected with TB and HIV/AIDS.
However, in circumstances in which drugs are unavailable (as is also often currently the case) we also speculate that moxa may be helpful and may even provide the possibility of an emergency “barefoot” treatment when nothing else is available.

Why aren’t we proposing conducting our investigation in the UK in premier research establishments?

We’ve tried.
We have been asked why such an investigation as we propose is necessary given that effective treatments already exist. Whilst this is true for those of us living in the affluent world, for most of those living in Africa where this disease is so dangerous this is obviously far from the case.
Individual responses from the medical status quo have varied. In some cases they have been basically dismissive. In some cases they have been cautiously encouraging, this encouragement often being accompanied by what might best be described as a kind of worried pat on the back. In some cases we have received simple honest encouragement. Institutionally, however, in every case to date there has been clear and consistent disassociation from direct support for any investigation we might suggest.
The bottom line, of course, is that conducting research on any disease like TB which is out of control in one particular environment (the develoiping world), but doing this in another discrete environment (the “first” world) in which it is basically already controlled tends to point towards relevant research results.

Do we think moxa offers an answer to TB?

No, no and no.
We do believe that it just might have a part to play, however, in the campaign against this dreadful disease, particularly in those environments where the might of scientific medicine is as remote as a clean supply of drinking water.
The TB plague has been identified by Dr Paul Farmer of Partners in Health as a symptom of a global blind spot towards one particular human right – the universal right to decent health care. This is such an important concept, and our proposals do nothing to challenge it. It has become perhaps an even more challenging idea in a world which is now engulfed in economic recession, and the last thing we would wish to offer in association with our project is an idea that TB can be controlled by moxa “on the cheap”.

TB cannot be controlled on the cheap, it can only be controlled by concerted effort and investment .
In the meantime we wonder whether moxa may offer at least a much needed rest-stop on the roadmap to better global health care.”

Video of personal testimony from South African hospice workers collaborating with Moxafrica.

As further proof that acupuncture can be very useful in resource-scarce regions, acupuncture is being used to relieve anxiety, pain, depression, stress, and reduce the amount of medications required in Intensive Care Units in the US. This shows that not only can acupuncture flexibly respond to various conditions on the ground, but it can also help mitigate emergency situations which will then be treated by allopathic practitioners.

From the American College of Chest Physicians website:Integrative Oncology and the Memorial Sloan-Kettering Cancer Center Critical Care Experience:

Acupuncture reduces many symptoms experienced by cancer patients in all stages of treatment, including dyspnea, fatigue, hot flashes, sexual dysfunction, urinary problems, osteoarthritis, neuropathy, xerostomia, and more. Most relevant to patients in the ICU, acupuncture can relieve anxiety, depression, stress, and pain, and it can reduce the amount of opioids required to maintain patient comfort. Randomized clinical trials show that relief offered by acupuncture is not a placebo effect. A phase III MSKCC trial reported that acupuncture reduced pain and dysfunction in cancer patients with a history of neck dissection. In addition, acupuncture relieved xerostomia in this population (Pfister et al. J Clin Oncol. 2010;28[15]:2565). A companion functional MRI (fMRI) study illustrated that true vs sham acupuncture produced neuronal activation associated with increased saliva production. Signal changes on neuroimaging were correlated with changes in the appropriate cortical areas (Deng et al. BMC Complement Altern Med. 2008; 8:37).

-Barrie R. Cassileth, PhD. Chief, Integrative Medicine Service, Laurance S. Rockefeller Chair in Integrative Medicine, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY

As usual, since you’ve made it this far, I would like to end with a video…

Social Justice, Medical Aid, and Acupuncture. Part 1: Voluntourism

Since I will be taking a four month trip to learn about traditional Thai and Chinese medicine in Thailand next year, I have been pondering the significance of medical volunteer work abroad. What is the goal of medical service in other countries? Why do we volunteer in other areas when there are certainly people in need of free medical services in our own countries, states, cities and communities? It can seem like the flight of fancy of a privileged class of practitioners, or an extension of the colonial or missionary mindset, but on the ground what does it offer to the travelers and to the communities they work with? 

Travel can teach people about different cultures and can open their minds to new ways of acting in the world, but traveling is a privilege and should be recognized as such. In the case of medical-practice-based traveling, at least the traveler can offer something in return for the opportunity to live in a new place for a short period of time. What kind of “return” does this look like in practice?

This thorough 2009 qualitative study summarizes some of the conundrums of global health and international medical volunteer work: Perceptions of short-term medical volunteer work: a qualitative study in Guatemala(1). The entire article is worth a thorough working-over, but here I provide the general background, minor discussion and conclusions:

…..There is growing interest among healthcare providers in the field of global health; over 25% of all 2008 United States (US) medical school graduates participated in global health experiences during medical school. Beyond medical school, there are countless opportunities for physicians to volunteer their services abroad in resource poor countries, frequently in the form of medical missions that last for a week or two at a time. Several editorials in the medical and social sciences literature have raised important questions about potential unintended consequences of such short-term medical volunteer work [1-9]. Editorials such as these raise concern about the ability of short-term volunteers to provide safe and effective medical services in the setting of language and cultural barriers that impair clear communication between patients and healthcare providers. They also raise concerns about a lack of follow-up care for patients who receive treatment from groups with a short-term presence. They raise ethical concerns about people without formal medical training participating in these groups, or medical professionals practicing beyond the scope of their expertise and practice at home, in a setting where they are not held accountable for the consequences of medical interventions made.

In addition to basic questions pertaining to patient safety, these editorials raise important questions about the impact of short-term medical missions on the larger medical systems in the countries they visit. For example, it is suggested that short-term medical groups that are not integrated with local medical systems do not understand local medical needs, and consequently, their efforts will be misguided.

Furthermore, there is suggestion that groups providing free medical care in other countries undermine the livelihood of medical providers who depend on payment from patients in those countries. The literature in medical anthropology is filled with examples of unintended consequences of medical programs that pay insufficient attention to local conditions and culture and, perhaps more importantly, fail to consider the potentially incompatible and harmful cultural assumptions and values embedded in those programs [10,11].

With countless groups from wealthy countries participating in shortterm medical volunteer work abroad, it is critical that we evaluate the safety and effectiveness of these interventions for patients, as well as the larger implications and consequences of such work on the development of medical systems and the health of communities where this work takes place. The editorials summarized above were written by medical professionals from wealthy countries with an interest in global health, and these writings serve as an important starting point in this discussion. Even more important, however, are the opinions and perspectives of those who live and work in the countries where this work takes place, and thus far, their voices have not been heard.

…Short-term medical volunteer work may be seen as one extension of those interests in the post colonial era. As such, short-term medical volunteers often bring with them, albeit unconsciously, attitudes that foster dependence and lack respect for local practitioners and local knowledge and practices related to health. Understanding how short-term medical volunteer work is perceived by those living and working in receiving communities is a critical first step in designing and implementing healthcare programs that provide needed healthcare services to supplement and complement local healthcare systems without undermining their efforts. Specifically, we sought to explore the perceived utility and perceived impact (positive and negative) of short-term medical volunteer work in Guatemala from the perspective of healthcare providers and health authorities in Guatemala. Because of the short time available for the research, this study focuses on the perceptions of these individuals and not on the impact of short-term volunteer programs. Its purpose is to identify and describe the range of perceived issues surrounding short-term medical volunteer work as a basis for future indepth studies.

…Our study, although small in scope, is one of the first to systematically and critically examine the effects of shortterm medical volunteer work. All major thematic areas in our results underline the challenges of outside groups working as equal partners. Is it paternalism or cooperation? Is it charity or aid? Is it experimentation or quality care? Have all stakeholders been properly identified? Let us say that a recipient community has been appropriately consulted and involved to develop the most suitable intervention with strong community ownership. Omitting other healthcare providers, organizations, and the Ministry of Health may nevertheless jeopardize the long-term success and sustainability of any effort. The very real power and wealth differential between short-term medical groups and their host communities make trust, understanding, and true partnership difficult.

…According to our results, recipient communities may perceive very tangible benefits from short-term volunteer groups: Free or discounted care, improved access to healthcare overall, access to highly-trained specialists, and access to procedures not always possible within the local infrastructure. Local providers enjoy exchanging experiences and knowledge with foreign visitors, and appreciate the influx of supplies that accompany volunteer groups.

White Coat = Authority

On the negative side, it appears some of the least sophisticated groups offer services or treatment that are seen to be at best duplicative, and at worst, harmful. For example, though some drugs may remain effective 1–2 years past their expiration date, the perception of harm may arise from using drugs that are no longer considered safe, legal, or effective in the US. Similarly, a surgical group not planning for appropriate local follow-up could also be seen as acting recklessly and creating the potential for harm. Such issues may be easily solved with proper planning and supplies. On the other hand, many situations described by our respondents do not present the opportunity for an easy fix. Well-intentioned, well-prepared groups provide services that may help many but may harm others though unforeseen externalities. For example, free care from outsiders improves access in the short-run, but may undermine local healthcare providers, and in the long-run may reduce access: The government might close public clinics with patient volumes that are dropping, and private physicians might leave for areas without competitors providing free care. This could only further increase the dependence on external assistance.

…Finally, it is our hope that this paper will stimulate studies into the economic, political, and health outcomes of short-term volunteer programs to critically assess their quality and effectiveness. What is the effect of the concentration of such services on the government investment in healthcare infrastructure and services in those areas? Do free or very low cost services provided by short-term volunteers truly draw patients away from private practitioners or state services? Are outcomes for procedures (e.g., cataract removal) or conditions (e.g., diabetes) different when care is provided by the regular healthcare system versus by short-term medical volunteers?

The above article brings up so many good points that have only begun to be addressed in a systemic way over the past few years. As recently as March 2011, a narrative article was published in Health Affairs which succinctly illustrates the challenges of participating in (much less creating and operating) a short-term medical volunteer program. Dr. Teeb Al-Samarrai, an MD with a strong interest in international health and development, wrote this article as a 2nd year resident who traveled to Uganda with Yale’s medical study abroad program to work in a hospital in Mulago. Here are some key excerpts from Adrift In Africa: A US Medical Resident On An Elective Abroad. (2):

“Virtually on her own and unsupervised in a Ugandan hospital, a young doctor develops suggestions for improving overseas medical training.

…“This wasn’t part of my orientation,” I thought. I’d prepared to work alongside senior Ugandan physicians, not to become a senior physician at the country’s major hospital before the end of my first day. But I’d trained in a medical culture of multitasking efficiency and realized there was no time to waste.

So we began making the medical rounds on forty-some patients, in a hospital I did not know, in a country I’d just arrived in, and in a language in which all I could muster were, “Hello, how are you?” and “Thank you.” My hours of studying Luganda, the complexities of Uganda’s colonial history, and the subtleties of HIV care seemed irrelevant.

Patients’ “vital signs” were only occasionally measured or noted. The medicine ward contained no blood pressure cuffs or thermometers, unless an intern happened to have one in his pocket. The interns’ responsibilities were dizzying, and their knowledge base varied. The economic and technological limitations of the medical care they could deliver verged on paralyzing.

…Inside, I was numbed by the realization that Mulago wasn’t an isolated rural clinic in the middle of nowhere: It was the premier referral hospital in a crowded metropolis in a country heralded as an HIV/AIDS success story. If this was success, I wondered, what did failure look like? My mind whirred, trying to calculate the incalculable other Mulagos, the smaller Mulagos throughout Africa, in more remote regions and poorer countries. It continued to whir as I tried to count the uncounted, the patients who never made it through Mulago’s doors, who never made it to any hospital at all.

Before the end of my third week at the hospital, I asked to work on an infectious disease ward. After all, that was the work I’d come for. I was told that it was still exam time at Mulago, and there’d still be no one to supervise me. I insisted. Although no expectations were laid out for me, I tried to set realistic ones for myself. Feeling more comfortable and familiar with Mulago, I began on the men’s infectious disease ward. Each day the ward intern and I did rounds on nearly sixty patients. I let him lead the way, both of us having growing confidence in what I knew and had to offer.

Interns from adjacent wards began to wander over, asking questions, wanting to present challenging cases. I didn’t always know the answers. But I taught the importance of performing a careful exam, listening to a patient’s medical history and personal story, and then creating a differential diagnosis (weighing the probability of one disease versus other diseases) while remaining willing to reassess it. Each day I was humbled by the dedication of the interns I worked with, who were eager to learn as much as possible. I was also humbled by the patients we treated and by those whom we could not treat, and by the caring and patience of their families. Day by day, we lived Mulago together

When I returned to my residency program in the United States, I asked faculty members what their expectations were of the role of visiting medical students and residents at Mulago. Although they were devoted to Mulago and to the experience of residents there, I didn’t get a clear answer.

Nor did I find clear guidance when I reviewed the medical education literature. There appears to be no standard for medical schools in the United States that outlines the necessary supervision for medical trainees—or delineates their roles, responsibilities, and expectations while they are working abroad. Moreover, many medical trainees go abroad with little more than a naïve desire to help and find themselves unprepared for the academic, emotional, and cultural challenges, not to mention the morally ambiguous situations, they might face.

Like many medical trainees, I went abroad to learn, to serve, and to be challenged. I and others want to be pushed out of our comfort zones and see the realities and necessities of medical care in resource-poor settings. We are drawn to this work because it helps us appreciate the dedication and skills of colleagues abroad as well as giving us a sobering perspective on health care disparities and priorities in countries that differ from our own. We can see diseases we’ve only read about, and we can hone diagnostic skills that atrophy in the technology-driven American health care system.

Even more, it is a form of service. We want to help. Ideally, we work with the guidance of seasoned physicians from our host country, home institution, or both.

Although I had ideas I could have tucked into the Mulago suggestion box, the most important recommendations I have now pertain to medical schools on this side of the Atlantic:

Suggestion:Determine the roles of US medical trainees and their responsibilities for patients during an international elective.

Suggestion:Determine who is responsible for supervising the trainees.

Suggestion:Define what kind of supervision the host institution is to provide for the trainees.

Suggestion:Determine how trainees’ home institutions can support host institutions in defining responsibilities for teaching and patient care.

As those of us in the United States consider our continuing role in international health and medical education, I hope we can do so realistically and creatively. Perhaps a portion of tuition fees at US medical schools could be devoted to helping host countries and institutions hire local physicians to deliver patient care and also to teach US trainees. Such a system would provide a sort of counterweight to the brain drain that both drives and is driven by the global hierarchy of medical care. Or, as my residency program now does, perhaps an adviser from the home institution could spend part of his or her time at the host institution, both to advise US students and to offer targeted instruction for students at the host institution.

Although my experience in Uganda was not what I expected it to be, it was incredibly valuable. I realize that many medical educators would maintain that this means “living Mulago” was a successful international elective. Well, yes and no. In the absence of guidance and supervision, I initially struggled to define my role and responsibilities, yet I ultimately gained a clinical and ethical foothold that gave me one of my most meaningful clinical and learning experiences. In the process, I acquired a lens that allowed me to glimpse some of the gaps in our approach to international medical education.

As medical schools continue the process of shaping and fine-tuning international medical curricula, I hope many of us will ask how much more students and residents could benefit clinically, culturally, and emotionally if they had more guidance and supervision. Separating the difficult from the impossible is something that can be accomplished. We need to continue to heighten our skills in distinguishing between the two when shaping global health programs. Surely, when future doctors benefit, their future patients—wherever they might be—will benefit, too.”

Al-Samarrai’s experience sounds disconcerting, as the mechanisms of “aid” and the failures of communication between host and guest institution were laid bare before her eyes during her time in Mulago. Significantly, she lands solidly in favor of such a medical service endeavor, especially when organized with a clearer set of responsibilities and expectations for the guest institution as well as greater investment by the guest institution in training members of the host institution.

The way Al-Samarrai describes this medical program reveals an imbalance of benefit. Providing this form of medical service gives the volunteer a significant learning experience, while the patients of the host institution may be receiving more limited care due to the limitations of not only the host institution but also the lack of efficient usage of guest institution expertise. Assumptions or ignorance of the hospital’s clinical reality, in combination with a lack of accountability on the part of the guest institution’s leadership, created a fragmented experience for the intern. These kinds of assumptions and lack of accountability leave the door open for abuse by interns who might have more self-interest than social responsibility. Luckily Al-Samarrai exhibited a true commitment to the spirit of her profession and took further steps to help bring more effective exchange of knowledge to the program in which she took part.

However, when left unstructured, this kind of medical aid project has the potential for reproducing the more imperialist leanings of some development projects which bring in foreign “experts” that consequently pack up and don’t leave any knowledge behind when they complete their volunteer time period. Or even worse, some medical aid projects bring much-needed medication to the area or begin to vaccinate parts of the population but run out of resources and leave the remaining population high and dry. Although the Ugandan medical endeavor is not overtly imperialistic in the way that some pharmaceutical-based “aid” projects have been, Al-Samarrai’s experience on the ground reaffirmed the heavy responsibility of the guest to create a clear exchange of services, in a well-defined and accountable way.

Another article outlines the concept of “voluntourism” as it is practiced in the allopathic medical community.

The excerpt below is taken from the article: Fly-By medical care: Conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists (3). It provides further recommendations for the practice of culturally and socially aware medical volunteering.

The Association of American Medical Colleges’ (AAMC’s) offers four foundational ethical considerations prior to embarking on global health voluntourism: (1) ensuring high ethical and moral standards, (2) developing a social contract with the communities served, (3) subordinating self-interest to the interest of the communities served, and (4) ensure that core humanistic values (honesty and integrity, caring and compassion, altruism and empathy, respect for self and others) are at the forefront of all activities [23]. These ethical considerations point to a number of specific social responsibilities that physicians involved in voluntourism hold, such as ensuring that compassionate and respectful care is provided that meets the highest ethical and moral standards that the context allows for. What these guidelines lack are specific, concrete strategies for enacting ethical, socially responsible care. The 4Rs that were developed by Aboriginal leaders in Canada to guide researchers in working with their communities, which are summarized in Table 1, offer some suggestions for specific strategies [63].

Generally, socially responsible medical voluntourism is a collaborative process that considers the full participation of local communities, local healthcare workers, and local health authorities [54]. It complements principles of international solidarity and social capital within the context of civil society, where voluntourists act voluntarily and without seeking personal profit to share benefits. Physician volunteers are encouraged to develop a sense of professional and personal growth, and to examine critically what it means to be a socially responsible practitioner [93]. For example, many voluntourists seem to believe that being socially responsible means charity [60]. But charity can create dependency relationships whereas social responsibility aims at social justice, understood as developing sustainable relationships based on mutual respect. It involves working with and for communities to enable what they feel is best for them rather than using a paternalistic approach. Dickson and Dickson [60], identify a list of personal attributes that physicians need to develop as part of their professionalization and to act responsibly that include: a concern with global equity; a commitment to redressing injustices in healthcare; respect for diversity; openness to mutual learning; and embracing ethical values like human rights and social justice. The professionalization of physicians gives them norms by which their social responsibilities as voluntourists are increasingly clearly stated. It also gives physicians the information and expertise with which they may act on these norms.

The 4Rs of Ethically Sound Research
Ethical, Principle, Strategy.
1. Respect: Valuing cultures’ and communities’ diverse knowledges regarding health matters and developing knowledge that contributes to communities’ and cultures’ health and wellbeing
2. Relevance: Ensuring that research (or practice) is relevant to the culture and community
3. Reciprocity: Incorporating a two-way process of knowledge exchange and learning, where all parties benefit from these opportunities and the development of relationships
4. Responsibility: Fostering empowerment through allowing for active participation and rigorous engagement by all parties.

These guidelines seem reasonable on paper. Any thorough international medical organization can meet the first two R’s, but it seems like the second two R’s pose the biggest challenge. Those two R’s also represent what is missing from health care in general in the U.S.- so how do we expect to be able to accomplish them abroad? Or is medical voluntourism an opportunity to hone these personal and organizational skills abroad and then bring them home to create a more just health care system in the U.S.? Please feel free to share your opinion, since this type of debate is currently raging and unresolved.

Two excellent talks regarding these issues:


TEDx Talk Rainier: Dr. Wendy Johnson – A New Paradigm for Global Health: Solidarity

Through her national and international health advocacy work, Johnson believes that the key to overcoming disease burdens in both developed and developing countries is to strengthen and rebuild public health care systems. And that is exactly what she is doing. As clinical faculty in University of Washington’s School of Public Health and Director of New Initiatives for Health Alliance International (HAI), Johnson develops projects to strengthen public primary health services and advocates for universal health care access in low-income countries.


TEDx Talk Rainier: Dr. Stephen Bezruchka

Dr. Stephen Bezruchka seeks to expose why health disparities among nations around the globe are at record highs and empowers people to address the socioeconomic inequities that have most impact on the health of populations. He is especially interested in how people in the USA don’t live very long or healthy lives. Bezruchka’s work takes him from teaching at the University of Washington’s Department of Global Health to remote regions of Nepal, where he wrote the first guidebook to travel there, set up a community health project, organized a rural hospital for the Generalist Doctor Training Program, worked with Nepali doctors to improve surgical services in district hospitals, and now consults on population health issues.

Bezruchka worked in clinical medicine for 35 years. He received the UW School of Public Health’s 2002 Outstanding Teacher Award and the 2008 Faculty Community Service Award. He founded the Population Health Forum to raise awareness of, promote dialogue about, and explore how political, economic and social inequalities interact to reduce the overall health status of our society.

To see some aspects of the debate regarding humanitarian aid and medical voluntourism, you can check out Nassim Assefi’s TED Talk page. The question below prompted an interesting discussion.

What’s the most effective model of global health aid/development, given interventions can have complex, unpredictable and longterm impacts?
A debate is raging between those who believe humanitarian aid is corrupt, ineffective, and harmful (eg Dambisa Moyos of the world) and those who believe it is the moral imperative of wealthier nations to help the poor (Bill Gates, Nick Kristof, Paul Farmer, etc). As an idealistic young doctor with a privileged life and education, I wanted to give back to the world, starting some 20 years ago when I joined my first NGO. Since then, I’ve seen many different models of global health with variable effectiveness–Doctors Without Borders approach of relieving suffering but not building infrastructure, more standard NGOs that combine the two, large UN agencies (eg UNICEF, WHO, UNFPA, ICRC), medical diplomacy (free exportation of Cuban health workers), social entrepreneurship (eg Acumen Fund), missionaries, Gates Foundation/Global Fund/World Bank, international medical research posing as aid, etc. While objective successmetrics and monitoring and evaluation plans are now the standard part of most health interventions, what do we really know about the longterm, complex outcomes of our well-intentioned health interventions? Have we propped up an illegitimate government or strengthened a democratically-oriented one? Have we destroyed local economies or sustained them? Have we exacerbated brain drain or created jobs for internationals who want to return home? Weakened local infrastructure or strengthened it? Educated or misled? Oppressed the people we were supposed to help or empowered them? Please help me figure out the most effective way to use my medical and public health skills to improve health in a global context, and in doing so, help many others who are struggling with these issues. I would love to hear your experiences, perspectives, and ideas about how to do global health work right and how you might measure the complex, longterm impacts of what you propose. (Meanwhile, ironically, the US still lacks a decent, universal, and cost-effective health care system.)

The next post here will investigate how Traditional Chinese Medicine fits into this framework for socially responsible medical voluntourism.

Meanwhile, enjoy the excellent music of radical Portland folk-punk-hardcore band Adelitas! The lyrics for the song in English can be found at the end of the article.


Adelitas: Hay Que Luchar

 
References:

1. Green T, Green H, Scandlyn J & Kestler A. (2009 Feb) Perceptions of short-term medical volunteer work: a qualitative study in Guatemala. Globalization and Health. 5:4. Retrieved from: http://www.fresno.ucsf.edu/global_health/downloads/PerceptionsGuatemala.pdf

2. Teeb Al-Samarrai.(2011 March) Adrift In Africa: A US Medical Resident On An Elective Abroad. Health Affairs. (30)3:525-528

3. Snyder J, Dharamsi S & Crook V. 2011. Fly-By medical care: Conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists. Globalization and Health. 7:6. Retrieved from: http://www.globalizationandhealth.com/content/pdf/1744-8603-7-6.pdf

Hay Que Luchar:

Get up, raise your voice- Can’t you see that so many silences wound us? Time goes by, there seems to be no solution. And when you lose hope, know that I understand you.

Wake up!

It’s not the time for remorse, bitter pasts. Let’s not let this suffering detain us. Our thoughts torment us, and knowing what to do, we end up paralyzed. And what if our hands had the power to break down the old walls, and nothing could stop us?

The future remains unwritten, in spite of the illusion of control- If we want anarchy, we have to fight for it – with militancy and love. It’s coming to end, this cruel empire. centuries of dementia, oppression, extermination. Let the storm rain down, drown this hell and we will know how to swim..

Organizing resistance with strategy and persistence- For freedom, for humanity never giving up. I know how easy it is to lose hope in this world of war and fear but come on we have one life nothing more- let’s fight for a better world. And you’ll see that our hands do have the power to make our dreams real, to build a new reality.

The future remains unwritten, in spite of the illusion of control. If we want anarchy we have to fight for it – with militancy and Love.