Not long after finishing my residency in internal medicine I took a trip to Thailand where, after being a tourist for several days, I visited a leprosy colony run by the Anglican church near the city of Chiang Mai, spending a week there watching and trying to help out. It was profoundly educational. Not only did I learn about the disease but also about all of the creative approaches the hospital there used to manage anything from chronic wounds to physical disability and patients' need to have meaningful work. The patients had illnesses that took years to heal, and they had workshops where they made beautiful wood boxes, prosthetic limbs and a variety of wheeled chairs or carts for getting around. Fishing line was sterilized to be used as suture material. Many things we throw away in the US were sterilized and re-used. Care was excellent and there was mutual respect between doctors and patients. That week was more important to my becoming a real doctor than many months I spent in medical school. My skills at that time were basic and I doubt I was of any real help, but I always hoped to go back when I had more time and more competence to offer.
Decades passed. In the spring of 2010 I began a series of trips to Haiti, Tanzania and South Sudan primarily to educate and be educated in medical programs of various descriptions. This included being involved in projects to do with sanitation and nutrition, teaching bedside ultrasound, helping out with research and occasionally providing direct care to patients. These projects have been wonderful in so many ways. They all have their own blog posts, scattered throughout whyisamericanhealthcaresoexpensive. They have also allowed me to make a myriad of mistakes that I can never undo and learn a great deal about how global health projects can have unexpected bad consequences.
There are a couple of root causes of the badness that comes of trying to do good. The first is ignorance. When we go to places that are exotic and unfamiliar we don't understand their culture or their diseases, how they deal with them, how systems that appear to be chaotic and just plain wrong are actually delicately balanced. We don't know their languages or customs. The second is resource inequity. We are rich and they are poor. This fact and the processes that caused it to be true and perpetuate it have created the need that draws us to help but also sets us up to fail.
We start with hurdles that stand between us and our goals. Sometimes we find that our important gizmos and doohickeys have been stolen because we don't understand the risks of where we stowed them. We then find that there are rules or regulations that govern what we intend to do which we were not aware of before leaving home. Solving those problems puts us in long lines and costs us unexpected fees and delays that were not part of our calculations. We offend people who we expected to work with due to misunderstandings. We find that despite the fact that we spend large amounts of money on our carefully designed plans, everyone seems to want something else, something we don't think we can provide. We become tired, frustrated and sometimes demoralized. Often we are resilient, though, and pop back, ready to face insoluble ethical quandaries.
We face ethical problems in the three main functions that we take on when we are doing global medicine: research, donations and volunteering.
Research:
Scientists in developed countries use the informed consent process as a way to protect our patients from possible harm. The idea is that we will explain what we are doing, why we are doing it, and what harms can arise from our research protocol. Our subjects will listen and judge for themselves if they are willing to take on the risk. This works fine if our subjects really understand what we are saying. In the US, with a population that generally shares our language and values, it's a pretty good strategy. In rural Africa, an informed consent form is nearly useless. A few years ago we did a research project in a small impoverished island in Tanzania. Our consent form informed one of our subjects that we would not be reimbursing her for parking. Since there were no parking lots in her village and she didn't own a car or even know anyone who owned a car, this was hard to understand. The form was pages long and had been painstakingly translated into Swahili, which she spoke far less fluently than her tribal language. She was also used to making decisions based on the judgment of a male leader or relative, so the very concept of giving consent was foreign to her. Our translators were hurried and most likely told her that if she wanted the mzungu (foreigner) to do this thing she should sign her name on the line. Explaining the whole thing would probably have taken an hour or more.
We also do research into techniques or treatments which are impractical or unnecessary. My group researched using ultrasound to diagnose malaria. Although it was definitely interesting to look at the ultrasound findings in patients with malaria, there is a perfectly good fingerstick test for malaria widely available where we were which was much easier to do than an ultrasound. Patients might have seen us doing an ultrasound for malaria and then believed that their own doctors who did not use ultrasound for this were giving them substandard treatment. We may have been unintentionally undermining perfectly adequate care. In helping us with our research, physicians who normally saw 100 patients in a day were slowed by helping us, leaving their patients in the lurch.
These are only our well-meaning mistakes. Sometimes research projects are truly harmful, offering treatments that have unacceptable side effects or comparing active drugs to placebo thus denying sick patients access to proven therapy. Well publicized harms caused by research projects have soured many African countries on any research which involves human subjects.
If we avoid all of these errors, we still take our data home for processing and submission and don't necessarily inform our subjects or local collaborators of the results. We take (from a poor country) and don't give back.
Donations:
I have enjoyed donating medical goods of various description when I travel, but I'm not entirely sure it was the right thing to do. Often we donate what we have, which has for some reason ended up un-used in our hospitals. I've seen specialized bone suture at a hospital in South Sudan, which had taken up space in a transport plane to get all that way so was by no means free. It was completely useless, as were boxes of plastic vaginal specula in a place where speculum exams were almost never done and where metal ones which could be sterilized and re-used were much more useful. We are often asked to donate ultrasound machines, but when we do, the machines are not under warranty and the companies that make them have no obligation to fix them should they fail. The machines we give are often far more expensive than the models African hospitals would normally buy from China and have unfamiliar buttons and knobs. If they had the money we spend on a machine to donate, they could buy several ultrasound machines. When we donate machines, the health authorities don't know which hospitals have functional ultrasound machines and which do not. Our good intentions may be slowing the development of sustainable local health systems.
Often when we donate some piece of equipment we do so with the agreement that the receiving hospital will use it free of charge to patients. This obliges the recipient to budget time to a procedure that gives them no profit. The providers may decide to charge for the procedure after we are gone, limiting its use to those who can afford it. Either of these arrangements can take time away from other obligations.
Volunteering:
Potentially the greatest gift of all that we can give in ourselves. As doctors or nurses we have trained for years in our fields and have added wisdom from our years of practice. Most of the countries where we go to volunteer don't have nearly enough skilled medical practitioners so you would think that they could use our help. Unfortunately it isn't quite that simple.
Often the places we go to volunteer are in disarray. This can be due to some horrendous natural disaster, but more often is caused or exacerbated by bad and corrupt leadership. As humanitarians we may need to help, but we must understand that our support may be propping up a bad regime or allowing a government which does have resources to shirk responsibility for creating a functional health care system. In less catastrophic times our help may be competing with a new and fragile homegrown capability and may cause it to fail. It seems benign to come to a place a provide free dental care, for instance, but in some of the places we serve there are trained dentists. If we come once or twice a year, patients will wait for us. We have fancier machines and don't charge for our services. Any potential local dentist will be wise to establish his or her practice in a place where volunteers don't visit.
Some projects have been categorized as "drop and run." Specialized surgeries may be unavailable in remote areas and it makes sense to try to deliver this care with a specialized team. This can, however, disrupt regular services if a project is set up to happen at a functioning hospital or clinic. Also there can be complications of our surgeries which fall on already overworked and not-specialty-trained local providers after we leave. Such projects work best if these issues are taken into consideration and if we focus on training local providers to do what we do.
Even training local doctors or nurses to provide specialty services can have unintended consequences. People trained to provide a technically difficult or much-needed procedure will be able to find a higher paying job in a different area, maybe a place that has less need and so is less stressful. Training is a gift to the provider but may place an intolerable strain on the clinic that they leave behind. In Tanzania we introduced a clinical officer with a busy obstetrics practice to ultrasound. He easily learned basic obstetrical ultrasound allowing him to improve his care of mothers and babies. He fell in love with ultrasound, though, and I believe he left the over-stretched health center to pursue a career in radiology.
Working in resource poor communities can be an opportunity to do things that we would never get to do in our own settings. Medical students have found themselves delivering babies or taking the lead in performing some procedure with which they have little familiarity. I do many more procedures in Africa than I do at home, making me more capable when I get back but potentially putting African patients at risk from my lack of expertise. We do these things because we are convinced that we are "better than nothing." Sometimes we are, but sometimes we do things that would much better have been left undone. When we make catastrophic errors, not only do we risk patients' lives but we undermine the trust of the communities we are trying to serve.
And we are so expensive. It costs about $2000 for me to fly in and out of Juba, South Sudan. The small plane that will be chartered to take me to the village will cost someone a fortune, but will also transport supplies. Still, I am part of that cargo and I add a cost. While in Juba I will stay in a safe hotel which will cost $100 a night and there will be a capable person assigned to me to make sure I don't die, since robberies and carjacking are common. If I do get robbed or injured, other costs will pile up quickly. Is there a better way to use those resources?
So am I saying that we just shouldn't go?
No, not at all. There are many good reasons for healthcare providers from wealthy countries to offer their services to places and people in need. We must do research to find out what works and what does not in resource poor countries where diseases and problems are different from our own. Doing global health projects creates bonds of caring and makes us into better people. The vast majority of global health projects succeed in building compassion, empathy and perspective. That, in itself, probably achieves far reaching benefits. It's just that we should pay attention to the details and try to follow Hippocrates' advice to "do no harm." I emphasize "try." It is not possible to do absolutely no harm, but if we're careful we can minimize it.
Advice:
- Find out about a trip or project before committing to go. Ask lots of questions and make sure you are satisfied with the answers.
- Partner with local people. Listen to them. Ask them about etiquette and politics. Find out what they think about the impacts of a project.
- Don't be too set on your own agenda. After all of your good planning ahead of time, you may still find out that what you had planned to do is wrong or needs tweaking.
- Find out as much as you can about the health systems already in place in the area you plan to visit.
- Step out of your doctor suit and think about social justice. Figure out how you can contribute to the health of the community you serve rather than just your patients.
- Forgive yourself for your inevitable mistakes and try not to take yourself too seriously.
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