Melissa Melby, assistant professor of anthropology at the University of Delaware, was pleased to hear a pre-med undergraduate excitedly describe participating in a brief medical outreach program to an impoverished Central American community. That is, until the student proudly recounted how she had performed a pelvic exam on a patients at the local clinic.
"No one here [in the United States] would allow you to perform medical procedures for which you're not licensed," says Melby. "And that should not change when you cross international boundaries to developing countries."
Well, a lot of students are crossing international boundaries. The concern is that they not go out of bounds as in the example above. The concern has come to the fore because of the growing demand for programs that bring health students from the developed world to do volunteer work in poor countries. In 2015, 36.3 percent of matriculating medical students participated in an international volunteer experience, according to the responses to the Association of American Medical Colleges' most recent student questionnaire.
Since their inception in the 1980s as volunteer helping missions, most such programs have come a long way along the culturally sensitive curve. They originally tended to parachute students or medical residents in and out of an area for one-shot medical outreach deals with little concern about the longer-term impact.
Today, it's recognized that such an approach is "just not appropriate," says Stanford University dean of global health Michele Barry, who has seen short-term experiences in global health programs (called STEGHs) evolve dramatically.
Even so, "there is such pressure for students to have these experiences to get into medical or public health schools that short-term programs are springing up all over the place," says Melby, and not all of them measure up in terms of staff experience, educational resources or cultural sensitivity.
To keep programs on the right track, as part of a consortium in 2010, Barry helped develop guidelines. The mission: to focus on what will benefit the local community, not how much the experience may mean (and often does mean) to the medical trainees. Moreover, the goals such as helping build a clinic or establish a safe water supply) should be long-term, both established and maintainable for the future by the community itself. These guidelines also reinforce the message that those group members need to respect the culture and needs of the people they hope to help.
Those are the standards that reputable programs — such as those run by members of the Consortium of Universities for Global Health — should be expected to follow, Barry says. Nonetheless, Barry (who sits on CUGH's board of directors) still knows of programs where undergraduates are invited to perform biopsies, suture lacerations or do other medical procedures for which they have no training, a situation that's both inappropriate and unethical.
That is what motivated Melby and several of her colleagues to spell out the ethics of STEGHs in a review published in the journal Academic Medicine. The report highlights the unintended consequences that poorly managed STEGHS can cause, such as undermining local health professionals or creating dependencies on the STEGH providers rather than developing and maintaining local clinics or services.
As a result, students need to know how to evaluate which ones will be in the best interest of the community and of the highest quality for their own educational benefit.
One way to do that is to check whether the organization running the STEGH has a well-established relationship with the site, Barry says. Another is to prepare beforehand by taking courses about global health. Whether or not such an on-site course is available, students can take advantage of a free curriculum that's been online since 2011.
Developed cooperatively by Barry at Stanford, Matthew DeCamp from the Johns Hopkins Berman Institute of Bioethics, and others, it includes numerous case vignettes about potential ethical pitfalls. What do you do when you're asked to perform a medical procedure beyond your training? How do you exhibit cultural sensitivity to local customs, especially when socializing with those of the opposite gender? How do you act in conjunction with local caregivers rather than overriding them?
"The course is based on real scenarios, with locations and some details changed to protect privacy," says DeCamp, who first became interested in global health after participating in a 10-day program in rural Honduras while he was a medical student at Duke in 2001. That was only the second year of the still-ongoing STEGH program designed by Duke professor of pediatrics and global health Dennis Clements. Back then, he struggled to recruit the 15 students to go on the trip, he says. Today, "we have about twice as many students applying as there are places."
In fact, the problem for many STEGH start-up programs, says Clements, is that demand has outpaced the number of experienced teachers.
Clements' success suggests lessons in how to proceed. From the get-go, he strove to develop a sustainable strategy to achieve a goal articulated by the townspeople themselves. They wanted a year-round clinic, where babies could be delivered safely, staffed by a nurse or other local medical professionals. And before students embark on the trip, they participate in a 12-week training course, with sessions devoted not only to some of the particular medical challenges common to that area (like mosquito-borne illnesses) but also to the area's history, religion and cultural practices.
His favorite session: he pretends to be a patient who is hard of hearing and can't see very well (a reminder that hearing aids and prescription eyeglasses are limited where they'll be going), and who is trying to communicate what's troubling him in a language that the students may or may not understand.
Their preparation and dedication has paid off, Clements says. "I once asked one of the ladies there, 'What is the benefit to you of our coming here?' She answered, 'because you explain things to us, and we are not afraid to go to our own doctors now.'" The response surprised Clements: "That is something I would never have guessed — that they are now also more likely to go to their own local physicians and ask questions."