Ambulatory Pediatrics
Volume 7, Issue 4 , Pages 317-320, July 2007

A Model for Sustainable Short-Term International Medical Trips

  • Parminder Suchdev, MD, MPH

      Affiliations

    • Department of Pediatrics, University of Washington, Seattle, Wash
    • Corresponding Author InformationAddress correspondence to Parminder Suchdev, MD, MPH, Maternal & Child Nutrition Branch, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, MS-K25, Atlanta, GA 30341.
    • ,
  • Kym Ahrens, MD

      Affiliations

    • Department of Pediatrics, University of Washington, Seattle, Wash
    • ,
  • Eleanor Click, MD, PhD

      Affiliations

    • Baylor College of Medicine-Abbott Fund Children’s Clinical Center of Excellence-Malawi, Lilongwe, Malawi.
    • ,
  • Lori Macklin, BA

      Affiliations

    • ENLACE, Abelines, El Salvador
    • ,
  • Doris Evangelista, LCSW

      Affiliations

    • ENLACE, Abelines, El Salvador
    • ,
  • Elinor Graham, MD, MPH

      Affiliations

    • Department of Pediatrics, University of Washington, Seattle, Wash

Received 12 December 2006; accepted 11 April 2007.

Article Outline

The health status of many people in developing countries is often dismal compared with the norms in industrialized countries. Increasingly, medical practitioners in the United States and other industrialized countries have become interested in global health issues, an interest that often takes the form of short-term international medical trips. We discuss several ethical issues associated with participation in such trips and use our experiences in developing the Children’s Health International Medical Project of Seattle (CHIMPS) to outline and illustrate a set of 7 guiding principles for making these trips. CHIMPS is a resident-run, faculty-supported international medical program founded in 2002 by pediatric residents at the University of Washington in Seattle. Members of CHIMPS work with a rural community in El Salvador to support ongoing public health interventions there and provide sustainable medical care in collaboration with the community and a local nongovernmental organization. The 7 principles developed as a result of this work—mission, collaboration, education, service, teamwork, sustainability, and evaluation—can be used as a model for health practitioners as they develop or select international medical trips. The importance of partnering with the community and working within the existing medical and public health infrastructure is emphasized. Many of the challenges of doing international medical work can be overcome when efforts are guided by a few specific principles, such as those we have outlined.

Key Words: medical education, pediatrics, professional ethics, world health

 

Worldwide, nearly 11 million children under the age of 5 years die annually, mostly from preventable or treatable causes.1 In 2003, the average life expectancy for inhabitants of one developing country, Botswana, was less than half that of persons in the United States.1 The increasing interest of American physicians in the health care of populations in the rest of the world is almost self-evident if one judges by the many recent articles on the subject of working overseas.2, 3, 4, 5 One reason is that US physicians take care of many patients from developing countries; a second is that in the intimately intertwined sociopolitical and economic web of today’s world, we understand that our actions have significant effect on the forces that determine global health. Finally, as pediatricians, we are taught that social justice is part of our mission, as exemplified by the motto of the American Academy of Pediatrics declaring that we are “dedicated to the health of all children.”6

In recent years, interest has grown among physicians from wealthy nations in understanding and remedying disparities in global health. As one indicator, in 2004, over 22% of graduating US and Canadian medical students had participated in an international health elective, compared with 6% of 1984 graduates.7, 8 Trainees who participate in international electives are more likely than their peers to report commitment to underserved populations and interest in careers in international medicine.9, 10, 11

Back to Article Outline

Ethical Challenges of International Health Work 

Despite its good intentions, international health work is not without significant ethical challenges. Given the cost, time, and logistics involved in working overseas, most international medical work is short term, in the form of volunteer brigades or training electives. Labeled by critics as “medical tourism”—“short-term overseas work in poor countries by clinical people from rich countries”12—these trips can be seen as:

Self-serving: provide value for visitors without meeting the local community’s needs.

Raising unmet expectations: send volunteer practitioners and trainees who do not have appropriate language or medical training or accountability.

Ineffective: provide temporary, short-term therapies that fail to address the root causes.

Imposing burdens on local health facilities: provide culturally irrelevant or disparaging care and leave behind medical waste.

Inappropriate: fail to follow current standards of health care delivery (continuity, access) or public health programs (equity, sustainability).

We believe that with foresight and collaboration, it is possible to carry out a short-term international health trip that has a positive impact. Given the lack of published principles to guide international trips, we use our experience in founding a resident-run international medical project to develop guiding principles for other practitioners. These principles can serve as a framework for others who seek to participate in international work.

Back to Article Outline

Guiding Principles 

The Children’s Health International Medical Project of Seattle (CHIMPS), founded in 2002 by 2 pediatrics residents at the University of Washington, consists of residents, faculty, nurses, medical students, and other health professionals. Although CHIMPS has had moral support from the residency program, no faculty or administrative time has been provided, and residents have raised all supporting funds; faculty members have consistently volunteered to give stability to the program. Growing interest in CHIMPS (nearly 30% of interns participated in 2006) was a major factor in the hospital’s deciding to develop a global health pathway for residents.

CHIMPS organizes annual 1-week outreach trips during intern vacation to Los Abelines, a community in rural El Salvador, and collaborates with a local nongovernmental organization (NGO) to support ongoing public health interventions throughout the year. In addition, residents take 1-month electives in El Salvador to work on specific projects with the NGO. In this way, although our presence in-country is short-term, our collaboration with the community of Los Abelines is not. To direct our work there, we have developed 7 guiding principles, which are discussed below.

Back to Article Outline

Mission: A Common and Specific Sense of Purpose 

The mission statement is a tool to communicate the group’s collective beliefs. Our mission statement is:

“To ethically address underlying health issues and to provide sustainable public health interventions and medical assistance for underserved communities in developing countries.”

We regularly refer to our mission to keep us on course, even as the project grows and changes. It is important that the mission statement emphasizes addressing the public health needs of the community.

Back to Article Outline

Collaboration: A Relationship with a Community and its Infrastructure 

Partnership with an NGO, government agency, or other local organization determines the type and extent of work that can be done. Organizations that understand and work within the infrastructure of a community can facilitate the integration of medical and public health projects and assure their continuity.

The name of our partner organization, ENLACE, means “to link” in Spanish. Its mission is to collaborate with communities to develop integrated and sustainable solutions to poverty in El Salvador. In Los Abelines it has developed a health committee consisting of local community members who provide health education and simple health interventions. ENLACE also employs a local physician who makes weekly visits to the community. Accordingly, there is a continued medical presence in Los Abelines that goes beyond visits by CHIMPS.

Back to Article Outline

Education: For Ourselves, the Community and our Peers 

Educating Ourselves 

The process of educating participants in the trip about the community, its medical problems, and effective interventions for these problems should start well before each trip begins.

The first step is to understand how the sociopolitical context of a partner community affects its predominant medical problems and to identify evidence-based solutions so that resources can be focused appropriately. El Salvador, a small country in Central America, has high rates of poverty and infant mortality. Of every 1000 children, 24 will die within the first year of life.13 Los Abelines is among the most isolated communities in the Morazán Department, the focal point for El Salvador’s 12-year civil war. Community members have little or no access to safe water, electricity, or sanitation systems. Surveys during CHIMPS trips in 2005 and 2006 found that 47% used untreated water from the polluted river, and 50% did not have a latrine.

After a literature review and consultation with ENLACE staff, we have developed a series of public health initiatives that address the needs of the community’s most vulnerable populations—women and children. We have worked with the health committee to identify and address 3 major health priorities: dental health, intestinal parasites, and nutrition. A brief description of the 9 interventions developed (on the basis of existing evidence and international guidelines and in collaboration with the community) is presented in the Table.

Table. Examples From the CHIMPS Program of Evidence-Based Public Health Interventions Developed in Collaboration With the Target Community
Health ProblemPublic Health Interventions
No access to dental care or fluorideDevelopment of dental health charlas (educational talks) for use by health committee members throughout the year.
Provision of toothbrushes.
Provision of fluoride varnish for application 3 times a year by health committee members for children younger than 13 years.15
Parasitic infectionDevelopment of basic hygiene charlas for use by health committee members.
Provision of anthelminthic treatment for administration by local health care provider and health committee to all children younger than 12 years twice a year.16, 17, 20
Nutritional deficiencies, including anemiaDevelopment of nutrition charlas that include information on preparing an iron-fortified beverage with local ingredients.
Identification of persons at risk for or with iron deficiency by dietary histories and laboratory techniques.19
Provision of iron supplementation for administration by local health care provider to prevent and treat iron deficiency anemia in young children and women of childbearing age.18, 19, 20
Development of a community garden to increase availability of iron-rich foods.

We require that a majority of group members traveling to Los Abelines have Spanish skills, and we have developed a medical Spanish class at our hospital to promote proficiency.

Educating the Community 

Teaching the teachers allows the community to be an integral part of the process of improving health. We have developed educational materials (charlas) that include lectures and demonstrations on important health messages. We teach these interventions to the local health committee for ongoing use in public health work (Table).

Educating Our Peers 

We facilitate increased understanding of international health issues in our home community through presentations, publications, lectures, and language classes.

Back to Article Outline

Service: Commitment to Doing Work the Community Needs and Wants 

In a short-term international trip, service involves providing a combination of public health interventions and sustainable clinical care that address the community’s priorities. The positive effect of short-term trips can be maximized by designing interventions that target conditions for which the traveling group has adequate supplies and that use the existing infrastructure for ongoing care. To determine the needs of the population and follow individual persons, it is important to gather basic statistics, including anthropometric, demographic, and dietary data, which we collect annually, analyze, and share with the health committee. We obtain (through purchase or donation) medications and supplies from philanthropic organizations, pharmaceutical companies, and our university hospital for common conditions in accordance with guidelines of the World Health Organization.14 Our formulary is created by using input from the local physician (employed by ENLACE) and our records from previous trips. When indicated, patients are referred for more comprehensive care with the local physician.

Ongoing community-based participatory research is being planned for future trips. Discussion of the ethics of conducting research in international settings is beyond the scope of this article but is well reviewed elsewhere.21, 22

Back to Article Outline

Teamwork: Building on Each Team Member’s Skills and Experiences 

An ethical international trip involves appropriate supervision of all junior team members in a manner consistent with policies of patient care in the United States. In addition, it is important to bring team members with diverse specialties (ie, physicians, nurses, physical therapists, dentists, health educators) so that volunteers can use their specific strengths to address the community’s prevailing needs. Upon our arrival in Los Abelines, the local physician orients the team to the common health conditions, the treatments provided in the clinic, and the health beliefs of the residents. Working with this physician and the health committee has allowed us to learn about tropical medicine and provide better care for patients abroad and back at home.

Back to Article Outline

Sustainability: Building Capacity for Ongoing Interventions 

Building a sustainable project involves working in a single location so that efforts can be augmented during successive trips. This approach demonstrates a commitment to an ongoing relationship and allows for a greater effect on the community’s health. Working within existing systems of care to teach the teachers allows the group to work with the community rather than providing care to them. In our example, this shifts the responsibility for community health improvement towards the year-long work of the local NGO, physician, and health committee and away from our intensive 1-week trip and the 1-month resident electives.

Back to Article Outline

Evaluation: A Mechanism to Determine Whether Goals are Being Reached 

Conducting periodic evaluation is important for measuring a project’s effects and improving its design and implementation. By use of the structure-process-outcome model, we evaluate our program regularly.23 After consultation with our institutional review board, we have developed a database of clinical and laboratory data collected during annual visits and use this information to determine the effectiveness of our interventions and the changes needed. For example, in a convenience sample of patients presenting to the Los Abelines clinic in 2005, 30% showed evidence of iron deficiency on the basis of an elevated zinc protoporphyrin/heme ratio (ZPPH), and only 28% ate meat once or more a week. The prevalence of malnutrition in children under 5 years of age, defined as a z score less than −2 for height-for-age or weight-for-height according to the 2005 World Health Organization Child Growth Standards (http://www.who.int/childgrowth/en/), was 44% and 6%, respectively, compared with national estimates of 18.9% and 1.4% in 2003.24 We have used this data to initiate interventions such as iron supplementation and development of a community garden (Table).

In addition, we obtain regular feedback from members of ENLACE, the local physician and health committee, and program participants through qualitative interviews and written evaluations. According to one ENLACE staff member, “Not only has the health committee members’ confidence increased, as they have become the local ‘experts’ on public health issues through their collaboration with the CHIMPS and ENLACE staff, but the experience has allowed them to take ownership of their own and their community’s health issues.” We present the yearly data from patient surveys to the health committee to focus the community’s public health work and our annual intensive trips and resident electives.

Back to Article Outline

Conclusions 

International work requires intensive logistical planning, financial support, enough skilled personnel, and institutional support for practitioners. Even with the best intentions and thoughtful planning, there are patients for whom adequate care cannot be given, and well-meaning interventions can have unexpected effects. Even so, we assert that the health of people around the world and of their communities is a global responsibility, one we as physicians in the United States share. Despite the challenges posed by short-term medical trips, when they are directed by guiding principles they can be a means of effecting meaningful improvement in the health of communities around the globe.

Back to Article Outline

Acknowledgments 

The authors report no relevant financial relationship with the manufacturers of any commercial products and/or provider of commercial services in preparation of this report. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. We thank the members of the health committee as well as the entire community of Los Abelines, El Salvador. We thank the staff members at ENLACE and the physicians working in Los Abelines, particularly Mirna García Rivera and Mireia Salazar, for their ongoing collaboration with CHIMPS. Thanks to Cornelius Van Niel, Margaret Wheeler, Nancy Danoff, and Christina Pease for their sponsorship of the CHIMPS program and to all of the current and former members of CHIMPS for their commitment to the ethical practice of international medicine. Finally, we thank the administrations of the Children’s Hospital and Regional Medical Center and University of Washington Medical Center for their support of our project.

Back to Article Outline

References 

  1. World Health Organization. The world health report 2005—making every child count. Geneva, Switzerland: WHO Press; 2005;Available at: http://www.who.int/whr/2005/en/. Accessed May 11, 2007.
  2. Wolfberg AJ. Volunteering overseas—lessons from surgical brigades. N Engl J Med. 2006;354:443–445
  3. Federico SG, Zachar PA, Oravec CM, et al. A successful international child health elective: the University of Colorado Department of Pediatrics’ experience. Arch Pediatr Adolesc Med. 2006;160:191–196
  4. Roberts M. A piece of my mind: duffle bag medicine. JAMA. 2006;295:1491–1492
  5. Panosian C, Coates TJ. The new medical “missionaries”—grooming the next generation of global health workers. N Engl J Med. 2006;354:1771–1773
  6. American Academy of Pediatrics. Available at http://www.aap.org/. Accessed May 11, 2007.
  7. 2004 Medical School Graduation Questionnaire: all schools report. Washington, DC: Association of American Medical Colleges; 2004;Available at http://www.aamc.org/data/gq/allschoolsreports/2004.pdf. Accessed October 2, 2006.
  8. Association of American Medical Colleges. 1984 Medical School Graduation Questionnaire: summary report for all schools. Washington, DC: Association of American Medical Colleges; 1984;
  9. Thompson MJ, Huntington MK, Hunt DD, et al. Educational effects of international health electives on US and Canadian medical students and residents: a literature review. Acad Med. 2003;78:342–347
  10. Miller WC, Corey GR, Lallinger GJ, Durack DT. International health and internal medicine residency training: the Duke University experience. Am J Med. 1995;99:291–297
  11. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Program: the fifteen-year experience with Yale University’s Internal Medicine Residency Program. Am J Trop Med Hyg. 1999;61:1019–1023
  12. Bezruchka S. Medical tourism as medical harm to the third world: why? (For whom?). Wilderness Environ Med. 2000;11:77–78
  13. UNICEF. The state of the world’s children 2006 (Official summary). New York, NY: UNICEF; 2004;Available at: http://www.unicef.org/publications/. Accessed May 11, 2007.
  14. World Health Organization. WHO Guidelines for Drug Donations. 2nd ed.. Geneva, Switzerland: World Health Organization; 1999;Available at http://whqlibdoc.who.int/hq/1999/WHO_EDM_PAR_99.4.pdf. Accessed May 11, 2007.
  15. Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;CD002782
  16. World Health Organization. Deworming for health and development: report of the third global meeting of the partners for parasite control. Geneva: World Health Organization; 2004;Available at http://www.who.int/wormcontrol/en/. Accessed May 11, 2007.
  17. Albonico M, Crompton DW, Savioli L. Control strategies for human intestinal nematode infections. Adv Parasitol. 1998;42:277–341
  18. Yip R. Iron supplementation: country level experiences and lessons learned. J Nutr. 2002;132(4 suppl):859S–861S
  19. World Health Organization. In: Iron Deficiency Anaemia Assessment, Prevention and Control: A Guide to Programme Managers. Geneva: World Health Organization; 2001;p. 8
  20. Stoltzfus RJ, Dreyfuss ML. Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia. Washington, DC: International Nutritional Anemia Consultative Group; 1998;Available at http://inacg.ilsi.org/file/b2_VUHUQ8AK.pdf. Accessed May 11, 2007.
  21. Council for International Organizations of Medical Sciences. International Ethical Guidelines for Biomedical Research Involving Human Subjects. Geneva, Switzerland: Council for International Organizations of Medical Sciences; 2002;
  22. World Health Organization. Guidelines for Good Clinical Practice (GCP) for Trials on Pharmaceutical Products. Geneva: World Health Organization; 1995;WHO Technical Report Series 850
  23. Baker F. Quality assurance and program evaluation. Eval Health Prof. 1983;6:149–160
  24. World Health Organization. Global database on child growth and malnutrition. Geneva: World Health Organization; 2005;Avaliable at: http://www.who.int/gdgm/p-child_pdf/. Accessed May 11, 2007.

PII: S1530-1567(07)00059-7

doi:10.1016/j.ambp.2007.04.003

Ambulatory Pediatrics
Volume 7, Issue 4 , Pages 317-320, July 2007

Article Tools