Who Benefits from my Work? The Problems with Voluntourism

Travelling gives me a tremendous amount of joy and I’m forever grateful that we’ve had resources enough that I’ve had so many opportunities to serve communities and enrich Rónán’s young life by seeing other spaces and making new friends. I’ve had the pleasure of admiring precious babies and adorable animals the countries that we’ve visited. I’ve made dear friends and maintain many of those relationships. I look back on those experiences with pride, but try to also be cautious about the ways that I engage with communities and the work that I do there. I’m careful that I’m always invited, that I provide a skill that is needed but not currently available, that I leave behind those skills in my new colleagues to perpetuate the work and its usefulness, and that I share power over our data and their dissemination with the community to which they belong.

The Barbie Savior instagram account parodies voluntourism in a painfully accurate way

That may not have always been my path, though. When I was in high school, I remember friends going on “mission trips” to teach English and build schools in far away poor countries. I was envious of the fun they had and the good work I perceived them to be doing. I saw pictures of them playing with adorable babies and eating exotic food and wished that my family would pay the thousands of dollars those trips cost. I never wondered how qualified 16 year olds really were to build schools or teach people English. It didn’t occur to me to ask myself if my family would send me to a school a group of 16 year old Nicaraguans had built. It didn’t even occur to me to wonder why we were sending teenage Catholics to teach Catholicism to a country with a higher proportion of Catholics than the United States.

In this piece, we’re going to talk about some of the real damages that voluntourism—the practice of travelling to do volunteer work—damages the very communities that we seek to serve.

Who Benefits?

Every year, approximately 1.6 million of people from wealthy nations pay for the privilege of volunteering in low and middle income countries (LMIC), fuelling a $2 billion industry. They build schools, teach English, and sometimes provide medical care, many times without the practical or language skills necessary to deliver services competently. Many medical voluntourism programs have no language requirement and even those with a recommendation to have “basic medical terminology” do not provide it themselves. Even more worryingly, many do not even have a basic requirement for medical experience. Volunteers pay a program fee to the organizing group–sometimes several thousand dollars–and spend a few weeks to a few months in communities performing “service” to the communities. Some groups, like Child Family Health International, have a stronger hierarchy of what is appropriate for a volunteer to do at their experience level (e.g., undergraduate, trainee physician, resident, etc.), but that is not universally true.

Projects Abroad invites students “from all academic backgrounds” to “care for sick or injured people and to learn new medical techniques that they would not have been exposed to until their second or third year of medical school.” While this probably makes for rewarding and exciting work for the “medical intern,” how well is the patient served by this care? Is their blood pressure being taken correctly? Is the intern skilled enough to draw blood from a dehydrated individual without “blowing out” the patient’s vein? If they do not have the skills to do a thorough exam, will they send a patient with an illness home and delay their care? Is the provider’s time used effectively when teaching an intern who arrived without prior experience? Clinics in LMIC are often much busier than US clinics because there are many fewer providers available for each patient than in wealthier countries. In these cases, the lack of public health infrastructure is exploited by the foreign volunteer, who would not be eligible to perform those tasks in their home country. A 2012 paper by Lauren Wallace correctly notes that, “if a group of untrained foreigners entered a Canadian community and set up medical practice, they would immediately be stopped.”

How Much Harm? How Much Benefit?

When medical professionals (trained or untrained) go abroad to volunteer for short periods (i.e., less than a year), does that negatively affect long-term care management for patients? Unite for Sight outlines their guidelines for programs to follow when foreign volunteers work in LMIC with 4 pathways of harm that can result from foreign good intentions:

Significant Harm - when providers operate beyond their skill level or outside of their specialty, incorrect and harmful procedures are performed on patients, potentially injuring them beyond their preexisting ailment. An already strapped health infrastructure system is left to fix whatever issues the volunteers may have caused. An example of this is discussed below.
Personal harm - Because foreign volunteers do not always leave detailed and appropriate medical records of their patient encounters, there is substantial risk of drug interactions, overdoses, and misdiagnoses. Wallace’s paper offers an example of a group of volunteers providing multivitamins to Guatemalan children and then promptly leaving.

“The next time an illness occurs, the mother drags the child down to the permanent clinic, because there is no field clinic that day, and tells the physician she needs vitamins. The physician explains that what the child really needs is metronidazole. She explains that she will give her child both. The physician writes both prescriptions, assuming that the vitamins will not harm the patient. The mother heads to the pharmacy, where she is told that the metronidazole is 14Q (queztales), and the vitamins are 50Q. She has enough for the previously suggested vitamins but decides to skip the unfamiliar drug.”

Infrastructural harm - When an untrained team of foreign medical volunteers arrives, the local clinic staff may not immediately know their (lack of) skill level and reallocate their own work, leaving patients with unacceptably poor care. Moreover, in places without socialized medicine, local doctors and midwives must receive payment for their services and cannot compete with the donated care by volunteers, which undermines the preexisting health infrastructure.
“Philanthropic colonialism” - Foreign aid is often not about helping poorer countries, but rather about exerting soft power over those that we keep oppressed with the economic structures we ourselves control. When volunteers (or paid aid workers) from wealthy and middle-income nations work in low income nations go to work in poorer countries, it's important that they help build the capacity of those communities rather than just doing the work themselves and leaving. Public health interventions are most successful (and sustainable) when they're developed and implemented by the population that should benefit.

What Happened in Haiti?

Even when the medical volunteers are trained, however, results can still be disastrous. When the 2009 Haiti earthquake caused devastation in the already impoverished island nation, US doctors and nurses joined the relief effort. The vibro cholera outbreak that UN peacekeeping troops brought from Nepal is well documented, but there were also complications from the swarm of medical volunteers who arrived to help.

Dr. Richard Gosselin of the University of California San Francisco found that almost two-thirds of the medical providers who arrived in Haiti had no prior disaster experience. Further complicating the situation, not all providers came to Haiti with formal organizations, making tracking their work and holding people accountable for medical errors more difficult than if they came with an established group (e.g., Doctors Without Borders or the Red Cross). Because these providers came and went while patient records were lacking, coordinating follow up care simply never happened for many patients and many post-operative patients were left without care at all when the volunteers went home.

While undoubtably well intentioned and motivated by a real desire to help a devastated country, far too many volunteers were unaccustomed to working in resource-constrained environments and did not think to bring even basic supplies like anesthesia for surgeries, WHO essential medicines, food, or water. Many thought that shelter would be provided for them, even though Haitians themselves were experiencing homelessness. Surgeons both performed unnecessary amputations (sometimes without anesthesia, since they had not brought it) and used procedures inappropriate to save limbs in an unsterile environment. One such procedure, an external fixation, preserves limbs by inserting a rod into the extremity, then using stabilizing pins to hold it to the bone. In environments where wounds can be kept clean, this procedure is safe and effective, but, in Haiti, patients were sleeping outdoors and often lacked access to clean water, so infections could not be controlled. Had these providers had a system of oversight and better (i.e., any) disaster training, patient outcomes may have been better.

Specialized Health Camps: Bangladesh

In some LMIC, specialized health camps (SHC) allow people who are otherwise underserved in both urban and rural settings to access medical care quickly and efficiently, often at no cost. Camps cover a range of activities like Vitamin A supplementation, vaccination, nutrition, child abuse awareness, and antenatal care.

As a case study, I’ll use the example of the Spreeha Bangladesh Foundation, with whom I’ve worked for the last 3 years. Spreeha is fairly representative of Bangladeshi NGOs, but perhaps not of all groups in other nations. My master’s research was to better understand the community’s perception of a physician’s capacity to effectively treat illness, so I spent a fair amount of time discussing the ways that camps raise the profile of formal medical care, thereby increasing the potential to improve clinical utilization rates in the communities served (if clinical care is generally available).

Spreeha is a busy clinic in an urban unplanned community (“slum”); its 2 physicians had approximately 1,600 recorded patient encounters in the first half of 2015. The Foundation both hires and recruits volunteer specialists to help at the camps, which it holds several times throughout the year in various disciplines, sometimes in Sankar where Spreeha operates, but also in other impoverished Dhaka communities. At a 2 day camp in August 2014, Spreeha served more than 400 patients with paediatric, optometry, general health, nutrition, and antenatal care. Dr. Ishtique Zahid, Spreeha Chief Medical Officer, led the camp, so the clinic’s capacity to see patients was lower for the duration of the event.

While there is the short-term opportunity cost (i.e., how many patients would have been cared for in the clinic that day by medical staff and how much good would they have done for their patients), there is potential for long-term benefit by increasing the prominence of formal medical care. Spreeha’s physical clinic was in its first year at the time, so the visibility of the camp helped to raise awareness of the services it was able to offer to patients. The first line of care for many in South Asia is to see either a traditional healer or a “pharmacist” at one of the thousands of unregulated pharmacies that line urban and rural streets. Shifting care-seeking behaviours from these “informal healthcare providers” to trained physicians, nurses, and midwives has the potential to improve health outcomes in the long-term by connecting patients with sustained care in established local clinics and introducing them to their providers.* If the camps were put on by foreign medical volunteers, the benefits would be much more limited. A large part of the good that comes from these events is a result of the community-based approach that Spreeha (and most other Bangladeshi NGOs) use.

So What Do We Do?

Foreign medical volunteers make up a growing part of a hugely profitable and hugely problematic industry that capitalizes on the lack of regulation over medical care in LMIC. The classic onion article on the white woman’s profile picture never being the same again after visiting Africa for 6 days strikes close to the heart of the issue: voluntarists gain an awful lot of nice pictures and CV padding, while the communities they “serve” gain very little.

Like the US, the health infrastructure of many LMIC is fractured, but comparisons are imperfect. In the United States, care-seeking behaviours are different (when was the last time you bought something a man on the corner told you were antibiotics?), so the costs and benefits of these pop up camps are different. Patients certainly need medical care in places where there are fewer clinicians and medical resources, but we need to be balancing the costs and benefits of untrained volunteers providing that care.

If you’re looking for ways that you can volunteer to help others, I want to thank you for your altruism. There are many people in your community who would benefit from the time and other resources. You have tremendous power to enact change right where you are and there are so many people in your community who could benefit from your help.

Clothing and food banks could use donations.
Soup kitchens always need extra hands to help serve and prepare meals.
Libraries need volunteers to help with tutoring and after school programs.
Shelters for youths who are experiencing homelessness or housing instability sometimes need adults to volunteer for their overnight shifts.
Immigration assistance organizations often need volunteers to help new neighbours learn English and navigate life in their new community.
Elementary schools love when undergraduates can come and do science lessons for their students. Education budgets are tight and children need to see adults valuing education (and them).

* I think it’s worth mentioning here that I absolutely support training people already in the workforce; it doesn’t need to be a doctor providing care for it to be good. BRAC has shown that TBAs make fantastic midwives and Dr. Stergachis in the University of Washington School of Pharmacy is a fantastic resource on the good that can be done by giving pharmacists more training.