Responsibly volunteering overseas

The purpose of life is not to be happy. It is to be useful, to be honorable, to be compassionate, to have it make some difference that you have lived and lived well

Ralph Waldo Emerson – American essayist, lecturer, philosopher, and poet

A perspective on healthcare volunteering

For the most part, volunteering stems from our collective humanity, altruistic passion and the fundamental desire to help others. Or that is the story we often tell ourselves. Somewhere in there volunteering also appeals to our sense of curiosity and adventure. There is little doubt that there is personal gain from volunteering, however we are not always encouraged or indeed compelled to acknowledge this personal gain.

Last September, at the European Society of Emergency Medicine (EUSEM) Conference in Glasgow, the RCEM Global Emergency Medicine Committee were invited to present a lecture and panel discussion on this important topic. We would like to use this blog post to take you through some of the details that helped inform our panel and invite you to share your thoughts and comments with us. The talk and panel discussion were recorded and are presented below.

EuSEM volunteerism talk
EuSEM volunteerism panel discussion

I’d like to acknowledge my co-authors for this post: Shweta Gidwani (@Global_EM), Hooi-ling Harrison (@DrLingHarrison), Jennifer Hulse (@coffeeheadaches), Najeeb Rahman (@NajeebR777) and the members of the RCEM global health committee (@RCEMGlobal) for proof reading.

So what does it mean to volunteer?

Healthcare volunteering is commonly romanticised in charitable campaigns: the dusty street in a remote African village, a woman carrying a baby on her back, bags on her head. And then the volunteer: smiling brightly, dressed in a white shirt and khaki trousers, walking tall whilst holding the hands of scores of children in tattered clothing (conjuring the collective grimacing of all past and present volunteers).

In reality healthcare volunteering is not limited to the economic situation of a country at all. Odd as it may seem it has little to do with racial demographics, the amount of dirt on children’s faces, or state of their local hospital’s walls.

In the simplest terms, healthcare volunteering is tied to the development stage of a health system: any health system – even within high-income countries, even the UK (you probably have volunteers in your emergency department). There are big socio-economic divides that impact health care outcomes literally anywhere. It is likely that you can think of such a setting local to you right now. In short, a need for healthcare volunteering can be found anywhere where there is a broken healthcare system.

The flawed framework of helping others

If you have come here to help me, you are wasting your time. But if you have come because your liberation is bound up with mine, then let us work together

Lilla Watson, renowned Australian activist and academic1

Experienced global health workers tell us that when it comes to volunteering, the framework of helping others can in itself be a questionable one. Lilla Watson’s words are reminiscent of the Southern African concept of Ubuntu, or the philosophy that our salvation is tied up in our togetherness2.

As an Aboriginal woman, Lilla understood the various underlying motivations used to justify volunteering. She also understood that there is really only one true motivation, and that the various other motivations can lead to various degrees of harm: harm to the volunteer, harm to the charity, harm to the setting, etc. Best intentions simply do not feed the world’s hungry.

Ling3 and the other panel members refer to a number of harms they experienced within the settings they have volunteered in. Jenn4 mentioned stories told by local doctors of well meaning volunteers woking outside their scope, Ling mentioned the walk-out by UK doctors following unethical trials during the West African Ebola crisis, and also mentioned unnecessary amputations that followed the Haiti earthquake.

Having an understanding that we can cause as much harm in a foreign setting as we can in an NHS hospital without the correct preparation, training and cultural understanding is an important takeaway here. A good starting point is Health Education England’s fantastic resource for trainees (or anyone) planning to volunteer overseas5.

It is worth noting that there are risks to volunteering which touches on safety and security of the volunteer. Being a volunteer doesn’t exclude you from potential harm; especialy if you are travelling to war-stricken areas. Do consult the foreign office’s travel advice before you travel6. If there is a travel warning, consider completing the free United Nations Basic Security In The Field course7.

Ethics of volunteerism

Often, following well-publicised disasters, healthcare professionals feel compelled to participate in a volunteer activity, despite being inexperienced in the key skills required to effectively participate. They then find themselves in poorly resourced settings; with different disease presentations; very different cultural, political, economic and social norms; where no-one speaks any English and has limited understanding of the interventions offered to them. In these confusing settings, ethical boundaries can get blurred very quickly.

Breaches of ethical codes easily occur from taking pictures of patients8 without their consent (usually for fundraising or publicising the project) or worse still, carrying out interventions without consent, or without the necessary qualifications. A simple way to determine whether you are skilled to join a volunteer mission, is to consider whether you would be sufficiently skilled to perform the same activity in your normal place of work. If not, then joining the volunteer mission is not advised.

Jen mentioned local doctors commenting negatively on volunteers practicing outside their usual scope in a busy South African emergency department, renowned for it trauma burden (despite no doubt the very best of intentions all around). It is worth being aware that if you choose to remain registered with the GMC in the UK while you are volunteering abroad, that you are expected to work within the guidance and standards provided by the GMC. You also need to comply with the local rules and guidelines of the local regulator.

Sustainability must be central to volunteering missions

Before getting involved, it is important to consider whether a volunteer activity or intervention is, or will be sustainable (even existing outfits). The easiest way to do this is to picture the affected community with the activity removed following the activity or intervention. Would it be able to continue through its own volition, funding or leadership? If not then the volunteer activity is unsustainable. Ling mentions the effect of providing free medications in a setting where nurses were dependent on the income from medication sales. This is a good example where context trumped good intentions.

Although it is easier to self-fund a short placement (less than three months), it in general does not confer a sustainable community healthcare benefit. Without the participation and engagement of local health providers, there is a significant risk of rather fulfilling the self-interests of the volunteer team, rather than the inherent needs of the local providers and communities.

Consider how long service placements are for foundation doctors and trainees in the UK. Patient safety, quality of care, and learning depend on an integrated understanding of the medical needs identified and expressed by local providers and community leaders. And this takes time. Rushing it in a foreign setting will have pretty much the same results as a slap-dash service improvement project in an NHS hospital.

Becoming embedded in a project has several reciprocal benefits for volunteers and this study describe how local healthcare staff benefit as well9. In general, when there is a long term commitment, local healthcare staff are able to develop a personal connection and appreciate the perspectives and contribution to learning that volunteers provide.

Without this sort of embedding of projects, volunteers can be perceived as aggressive, unable to relate to patients and local trainees, deficient at adapting to the setting, and self-serving. That certainly sounds familiar to some of us who have worked on both sides and it is worth being aware of this when you volunteer.

In spite of this valid criticism, short term volunteering, when embedded in more longer term, well-structured projects, do have a tremendous opportunity to help with education, training and capacity building.

Staying at home volunteering

Although it does not sound terribly exciting, you don’t need to go anywhere to be a volunteer. You do not even need to be actively involved in volunteering. You simply need a global mindset – an awareness that your situation is relatively privileged compared to the situations of the foreign patients and staff that benefit from volunteering.

Have you ever considered publishing open access? Or facilitating an exchange opportunity for foreign healthcare staff and trainees? If we benefit from the experience of working in a different healthcare system would it not stand to reason that so would they?

Capacity building is fundamental to the development of healthcare systems. And by and large can be done from anywhere with a stable internet connection. A key component to capacity building is high quality training partnerships. This is something that can be done very well off-site.

Shweta’s10 team has worked via training partnerships with organisations in India to support more than 18 local hospitals develop11 into high functioning EDs that are now centres of training themselves. The vast amount of work for this was done from an offices in Washington and London by volunteers. Fundraising is another good example. It is likely that the pound will remain a relatively strong currency compared to many low- and middle-income country currencies, irrespective of Brexit.

Creating rules of engagement in volunteerism

There have been several calls for creating an international code of ethics for medical volunteering, similar to the International ethical guidelines for biomedical research involving human subjects12.  

But in the absence of agreed standards, we can at least agree to some sensible rules of engagement for volunteers, based on the contexts described above. Here are some helpful rules of engagement13 that everyone involved in volunteering can embrace and honour. These are not so different from the rules we use in our daily work in the NHS:

  1. The safety and need of the patient should always come first.
  2. The quality of healthcare delivered within an underserved location should be the highest possible allowed by the resource constraints.
  3. Providing a service can take many forms. Well designed service projects fulfill a supporting or assisting role in partnership with local healthcare organizations and avoid the missteps of ignorance, arrogance and paternalism toward both patients and local providers within a community.
  4. Every effort should be made to adequately learn and prepare before embarking on a volunteer placement.
  5. Development of a sustainable program requires a clear identification of project goals, objectives, and systems for measuring outcomes composed within an infrastructure that enables and promotes autonomous function. The primary objective is to avoid the development of any sense of external dependency or learned helplessness.  Sustainable outcomes rely on the empowerment of local providers and the communities themselves to provide a higher quality of healthcare.
  6. Professionalism embodies the core values, goals, behaviors, and attitudes that constitute the practice of medicine. The profession of medicine has not only an inherent societal responsibility to improve the quality of health but also a responsibility to deliver the best care possible to every patient. Therefore to optimise quality healthcare, volunteers need to seek out and work with local health providers.
  7. The most basic of our medical values, primum non nocere (first do no harm), should guide our actions. Simply put, the core principles of how we practice medicine in our own hospitals and clinics, including respect for patient autonomy, privacy, dignity, and confidentiality, should be upheld.

Summary

Despite the challenges, volunteering for global emergency medical opportunities fundamentally inspire, develop and change participants. In addition, they promote a sense of common humanity. Gustavo Gutierrez, the father of liberation theology, once advised people to forget the head trip of studying the problems of the poor and to rather take a foot trip to work among them. Medical volunteering offers an opportunity for health care providers to take such a foot trip. You can find more information about the RCEM Global EM committee’s activities here or connect via FB or Twitter @RCEM_Global

Stevan

@codingbrown

Sources referred to in the blogpost

  1. Malawian impressions of expatriate physicians: A qualitative study
  2. Health Education England guidance for trainees planning to volunteer or work overseas
  3. The Ethics of Medical Volunteerism
  4. Rules of Engagement: The Principles of Underserved Global Health Volunteerism
  5. How to communicate the world (Radi-Aid and Barbie savior)

How you can support St Emlyn’s


References

  1. 1.
    Lilla Watson – Wikipedia. Wikipedia. https://en.wikipedia.org/wiki/Lilla_Watson. Published 2019. Accessed March 13, 2019.
  2. 2.
    Evans K. Annet Alenyo at #dasSMACC – How to support African EM – #badEM. #badEM. https://badem.co.za/aalenyo/. Published June 29, 2017. Accessed March 13, 2019.
  3. 3.
    Dr Ling Harrison (@DrLingHarrison) on Twitter. Twitter. https://twitter.com/DrLingHarrison. Published 2019. Accessed March 13, 2019.
  4. 4.
    Jennifer (@coffeeheadaches) on Twitter. Twitter. https://twitter.com/coffeeheadaches. Published 2019. Accessed March 13, 2019.
  5. 5.
  6. 6.
    Foreign travel advice – GOV.UK. Foreign Office. https://www.gov.uk/foreign-travel-advice. Published 2019. Accessed March 13, 2019.
  7. 7.
    Training.dss.un.org – Online courses by the United Nations Department of Safety & Security. Basic Security in the Field. https://training.dss.un.org/course/category/1. Published 2019. Accessed March 13, 2019.
  8. 8.
    The Social Media Guide — Radi-Aid. Radi-Aid. https://www.radiaid.com/social-media-guide/. Published 2018. Accessed March 13, 2019.
  9. 9.
    Parekh N, Sawatsky A, Mbata I, Muula A, Bui T. Malawian impressions of expatriate physicians: A qualitative study. Malawi Med J. 2016;28(2):43-47. https://www.ncbi.nlm.nih.gov/pubmed/27895827.
  10. 10.
    Dr Shweta Gidwani (@Global_EM) on Twitter. Twitter. https://twitter.com/Global_EM. Published 2019. Accessed March 13, 2019.
  11. 11.
    Master in Emergency Medicine- International Programs in India | The Ronald Reagan Institute. Ronald Reagan Institute of Emergency Medicine. https://smhs.gwu.edu/reaganinstitute/international/india. Published 2019. Accessed March 13, 2019.
  12. 12.
    Council for. International ethical guidelines for biomedical research involving human subjects. Bull Med Ethics. 2002;(182):17-23. https://www.ncbi.nlm.nih.gov/pubmed/14983848.
  13. 13.
    Wilson JW, Merry SP, Franz WB. Rules of Engagement: The Principles of Underserved Global Health Volunteerism. The American Journal of Medicine. June 2012:612-617. doi:10.1016/j.amjmed.2012.01.008

Posted by Stevan Bruijns

Dr Stevan Bruijns is a South African/ British emergency physician (dual trained). His interests include quality improvement, emergency care development and research access in African low-resourced settings. He is honorary associate professor of emergency medicine with the University of Cape Town and the chief editor of the African Journal of Emergency Medicine. Stevan is a person of action and like for things he does to be useful to others. He has worked in a number of settings, including resource-rich and resource-poor ones. Stevan currently works at Yeovil District Hospital in Somerset, UK. He also serves on the Royal College of Emergency Medicine's Global Emergency Medicine committee.

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