Many Tools to Fix the Problem
Short-term experiences in global health (STEGHs) have rightly been the subject of
increased scrutiny [1], and many scholars have provided critiques and recommendations
as to how they might be improved [2
3]. Rowthorn and colleagues present the most robust analysis of where STEGHs move
beyond being unethical to also being illegal [4]. Raising awareness of how STEGHs
can violate the law is an important approach to correcting unethical behaviors. Another
tool, as the authors also suggest, is the soft power of professional norms and global
standards, which may involve “naming and shaming” violators or creating accreditation
programs to STEGHs. In addition, I would suggest that those who wish to change behavior
must directly engage with those who may not entirely agree that these experiences
need significant changes.
Engagement with Skeptics of Change
Despite the fact that many will be horrified by the anecdotes shared by Rowthorn and
colleagues, for many, the solution is not immediately obvious. This is because skeptics
of change hold competing interests that create, in their minds, genuine dilemmas.
Below, I raise common objections to the idea that STEGHs need wholesale change and
offer a very brief response to each.
(1) Some care is better than no care. Although it is not ideal to have people performing
outside the scope of their formal training, patients and the community are better
off than they otherwise would be.
This is the most common defense of STEGHs in their current form. And it relies on
a narrow utilitarian calculation that negative patient outcomes are outweighed by
the positive ones. I have never seen a credible empirical assessment of this claim
[5]. And the often-hidden negative outcomes, such as creating a belief among host
communities that local providers are not effective or providing short-term solutions
to long-term health problems, are difficult to calculate. But even if the net utility
was positive, such a position fails to consider other values we hold dear in health
care. For example, this approach conditions providers and teaches students that unequal
treatment of patients is acceptable and that the poor are fortunate to get whatever
they can, even if it violates standards of care. That cannot help but shape the way
they see the world.
On the other hand, the above claim is ethically acceptable in times of emergency.
Natural or other disasters create situations wherein those without proper training
do whatever good they can, even if it causes some harm along the way. Some may claim
that the lack of health care in areas visited by STEGHs is equivalent to an emergency
situation, thus justifying extraordinary action. However, most STEGHs have long-term,
established relationships with local communities. If they had invested in public health
infrastructure, health education, and health profession training, the emergency conditions
would have long ago been resolved.
(2) If host communities did not want STEGHs acting as they do, they would enforce
different standards. Since host communities accept actions of STEGHs, that should
be enough.
I am sympathetic to this argument because I believe host communities should generally
be given the power to deem what is acceptable and what is not. However, this position
generally ignores two things. First, as Rowthorn and colleagues observe, many countries
have already stated what is acceptable and what is not. Many of them have licensure
laws that volunteers ignore. A country’s lack of the capacity to enforce its laws
does not mean its will should be dismissed. Second, this claim ignores the power differential
that prevails between volunteers and host organizations. Many communities rely on
the funds spent by volunteers – on lodging, transportation, food, souvenirs, and more.
And many host organization’s employees are dependent upon a steady stream of volunteers
for their livelihood. Even more, in many cultures, being good hosts is a central value
and so it would be anathema to critique a guest, even when their actions are harmful.
Therefore, this argument can only be credible in situations where we are confident
that power and cultural norms are not shaping the dynamic between volunteers and host
organizations.
(3) These are important experiences for volunteers and often lead to life-long commitments
to service in the global south. If we make it less attractive, we reduce the connections
that lead to long-term relationships.
We should provide opportunities that engender solidarity across communities. Yet instead
of solidarity, many STEGHs establish a disposition of volunteer as savior or tourist.
This is especially true when medical professionals model unethical or illegal behavior
for students. We should ensure volunteer experiences are creating the habits that
we want replicated over the long-term, which includes following best practices even
when they seem inconvenient [6]. Otherwise, we might be encouraging life-long commitments,
but they will not be the kind of commitments that help transform the communities in
need.
Many of these experiences provide greater benefit to the volunteers than to the communities
served. Ignoring that reality is, in part, what makes these experiences so troubling.
In my opinion, STEGHs would have far less to prove if they confronted the false narrative
that they are primarily altruistic.
Conclusion
Many people agree with the three statements above and critics of STEGHs dismiss them
at the expense of making change more likely. The simple fact that so many organizations
and individuals continue to behave in defiance of the law and in violation of ethical
norms means that there are countervailing values that must be dislodged. Engaging
with these skeptics is an important tool, alongside those suggested by Rowthorn and
colleagues, to making STEGHs not only comply with legal standards, but also align
with the ethical norms of health care practice.