Module 8: The Significant Harm of Worst Practices

Unite For Sight's priority is to instill in our volunteers and the general public a thorough understanding of the sustainable best practice principles on which Unite For Sight is founded. We believe that it is very important to raise awareness and understand that "worst practice" principles employed by some organizations can do significant harm.

Overview: Good Intentions Can Be Harmful

Despite having good intentions, international health workers who do not follow global health best practice principles can be wasteful, unethical, and harmful. Worst practices are serious public health concerns that create new and often more substantial barriers to patient care, thereby reinforcing health disparities and perpetuating the cycle of poverty. Furthermore, these worst practices violate concepts of social justice and human rights.(1)(2)

Due to high costs, schedule constraints and complicated logistics, many global health endeavors take the form of short-term medical missions, which undermine the local health care system, cause significant harm, and reinforce poverty.(3) These missions are often labeled as medical tourism or "volunteer vacations" – “short-term overseas work in poor countries by clinical people from rich countries”(4) – and can be seen as:

• Self-serving: providing value for visitors without benefitting the local community

• Raising unmet expectations: sending volunteers who do not have appropriate language skills, medical training, or accountability

• Ineffective: providing temporary, short-term therapies that fail to address root causes

• Imposing burdens on local health facilities: providing culturally irrelevant or disparaging care and leaving behind medical waste

• Inappropriate: failing to follow current standards of healthcare delivery (such as continuity and access) or public health programs (like equity and sustainability)(5)

Worst Practice: Short-Term Interventions

Minimal Benefits: Though few would question the honorable intentions behind most global health interventions, short-term missions rarely produce tangible medical benefits in local communities. Organizers often fail to sufficiently research the communities they are entering, and without preventive and follow-up care, they cannot provide enduring health improvements. A course of mebendazole, for example, will rid patients of certain parasites, but without a sustained effort at water purification, it is only a matter of time before the patients become re-infested. A multivitamin might supplement a child’s diet for 30 days, but it cannot attack the persistent underlying issue of malnutrition. Temporary benefits that do not address the root of the problem are characteristic of short-term “band-aid” international medical programs. Even the impact of surgical intervention, often considered an immediate and permanent fix, is questionable.

“While surgeries and dental treatment repair some of the consequences of poor health conditions, little, if any, preventive care is given that would affect the incidence or prevalence of these conditions or, in some cases, would prevent them from occurring or recurring. Thus, according to medical anthropologist Patricia Townsend, much of the curative efforts in both cases merely delay morbidity or mortality rather than reduce them.”(6)

The evidence suggests that the visiting volunteers and the sending institutions gain much more from short-term international medical interventions than do the local communities.“

Sending institutions clearly stand to benefit in multiple ways from developing sound global health programs that include short-term service and training opportunities. First, the institution may help attract attention to global health disparities. Second, for some trainees, the opportunity may form the foundation of a career working in resource-poor settings or on related issues. Third, the training experience may strengthen the position of a university to recruit the most talented trainees who are interested in a global health experience. Fourth, the training experience may provide trainees with an opportunity to learn about health and culture in ways that may be impossible in their home countries. Fifth, sending institutions may benefit financially from some short-term training programs because of the appeal of global health programs to philanthropists or the collection of tuition while trainees are abroad.”(7)

Significant Harm: One misconception behind some of the worst practices in global health is the idea that providing some care is better than providing none at all. Drs. Rachel Bishop and James Litch, co-directors of the Kunde Hospital in Nepal, explain why this philosophy is misguided:

“It is inappropriate arrogance to assume that anything that a Western doctor has to offer his less developed neighbor is progress. These [Western physician] tourists are often working outside their trained specialty or have little concept of how that specialty applies to Nepal. They frequently don’t understand local illness presentation, culture, or language. They often offer inappropriate treatment because they think they ‘must give something.’ The consultations are often one off, with little possibility for follow up and the local health providers are left to pick up the pieces with no record of the consultation. If an unregistered Nepali doctor on holiday in the United Kingdom offered general medical consultations in a shopping centre there would be a public and professional outcry.”(8)

Indeed, short-term interventions often do more harm than good, in several ways.

Personal Harm: As Bishop and Litch mentioned, local healthcare providers often have no records of medical care administered by visiting doctors, which can lead to potentially dangerous drug interactions, overdoses, or misdiagnoses. There are countless other examples of the harmful aftermath of short-term medical missions with no follow-up care:

“Consider the following scenarios: After the team leaves, someone develops a stomach ulcer from taking too much ibuprofen on too little food and water. Someone receives an antibiotic and experiences an unrecognized first-exposure reaction that indicates a second exposure could be deadly. Children take too many multivitamins and become temporarily ill; when food is scarce, the sweet tablets are candy too tempting to resist.”(9)

Infrastructural Harm: Short-term interventions often fail to work in conjunction with local partners and disrupt local healthcare patterns by subverting or burdening existing healthcare delivery services.(10)

When a visiting medical team arrives, overburdened local staff may see an opportunity for a break, or they may reallocate their efforts, leaving patients “without a trained clinician familiar with the local spectrum of disease and in local diagnostic and management algorithms.”(11) Patients also tend to view Western physicians as superior, compromising the status of local doctors.(12) After observing Honduran women preferentially seeking prenatal care from an American student over a local physician, Matthew Decamp of the Duke Global Health Institute suggested that medical outreach may “contribute to a sense of false hope in Western medicine… [and] foster dependency on foreign aid or disenfranchisement with the local health system.”(13) On the other hand, if impaired communication or a lack of follow-up care leads to a patient’s health deteriorating, a new barrier to healthcare has been established: fear of doctors. Dr. Laura Montgomery points out other ways in which short-term medical missions harm a community's health infrastructure:

“While [Western medical] teams provide temporary but sporadic access to health care, overall, they do not improve long-term access and they may, in fact, undermine existing services. It is unclear whether the short-term projects are treating only individuals who under current circumstances would have absolutely no access to medical care because of an inability to pay for it, or if they are diverting some otherwise paying or potentially paying patients from local practitioners and facilities. Local practitioners who must earn a living in the community cannot compete with the volunteers who donate their services. Furthermore, they cannot provide the same volume of free care over sustained periods and remain financially viable. Because the patient population… has not been closely analyzed, it is difficult to assess the precise impact on the local health care delivery system. If these groups actually do compete with local providers, the possibility exists that they could be put out of business, further restricting access to health care.”(14)

Philanthropic Colonialism: When teams from affluent countries visit low- and middle-income countries, they risk engaging in “philanthropic colonialism.” Global health organizations should aim to build local capacity without violating cultural norms, but most short-term medical missions fail to adequately research the demographics, current events, and culture of the communities they enter. Montgomery summarizes some of the risks of cultural ignorance in medical missions:

“Short-term missions [have] both naïve realism and ethnocentrism which assumes that approaches suitable in one setting are appropriate in another…These attitudes also manifest themselves through an assumption that no special planning or localized knowledge is needed and participants frequently have a lack of awareness and training regarding other medical systems, beliefs, or practices. Sometimes local beliefs and practices are ridiculed and, therefore, discounted and not taken seriously. Since the projects are present for such a short period of time, participants are often ignorant of the possible conflicts between health beliefs and practices that may result in miscommunication or noncompliance.”(15)

Montgomery goes on to point out that because of Americans’ predilection to explain behavior and circumstances in terms of personal qualities of individuals rather than in terms of larger cultural patterns and structural issues, there is an “inattention to or a discounting of the impact of social structural issues of injustice or inequality as being critical factors determining health and poverty... This orientation also tends to obscure for participants the inherently political nature of their activities.”(16)

Worst Practice: Untrained Volunteers and Practicing Beyond One's Abilities

Whereas well-trained volunteers can contribute significantly to global health endeavors, untrained volunteers detract from them. It is the responsibility of global health organizations to train and oversee their volunteers.

"The lack of health resources has been cited in the past as encouragement for students to go and operate in these underserved areas. The operative principle seems to be that some surgery, however expert, is better than none. Raja and Levin disagree and counter that the lack of available resources in a society makes a greater imperative for getting surgery done right the first time. Poor surgical outcomes will burden the health system with increased iatrogenic morbidity."(17)

Practicing beyond one’s abilities: The trend of allowing medical providers to practice beyond their abilities is one of the worst practices in global health. All too often, medical students and residents see medical missions to low- and middle-income countries as opportunities to gain unbarred exposure to techniques and procedures that they could not perform in their home countries. Other times, visiting physicians feel compelled to treat patients outside of their specialty, simply because there is no specialist available. In the Global North, internists do not treat children and general surgeons do not prescribe eyeglasses – why should this be different in the Global South? Lowering the standard of medical care for those in low-resource communities is unprofessional, unsafe, unethical, and often illegal.(18) The following account of a first-year medical student’s mission experience illustrates the dangers of relying on untrained medical volunteers:

“After finishing my first year of medical school, I participated in a mission trip to Mexico.  Before flying to Mexico, I was not given any cultural, medical, or other training, nor could I speak Spanish.  Upon arriving, I was assigned to a clinic where there were hundreds of patients seen by only one physician.  I remember vividly seeing a frail 11-year-old boy with polyuria, polydipsia, and nocturia.  My lack of medical training limited my differential.  With only a scattered history and no other tests, I told him to limit caffeine intake and see if that helps. Thinking back, he could have had a urinary tract infection, any number of renal abnormalities, or worse, I sent him out without ruling out diabetic ketoacidosis.  And while I was seeing patients by myself, other first year medical students were performing surgeries in the other clinics and later bragging about it.”(19)

In newspaper articles, on blogs, and on the websites of NGOs and other organizations, there are countless descriptions of frightening and dangerous instances of non-medical professionals reveling in the unauthorized opportunity to practice medicine.

"A business management major...creates his own adventures to help the less fortunate in the world. During the last two summers, with no medical training, he has gone down to El Salvador to work in medical clinics to help the people there in any way he can and is planning his third trip for this summer. 'I had always wanted to go do something like this...There was only one doctor, and the nurses weren't very qualified, so I helped them out,'" he said. "He had the opportunity to do what he had seen on television to really assist the people. He vaccinated children, sutured wounds and even delivered two babies."(20)

In addition to causing individual harm to patients, these dangerous practices can also cause permanent infrastructural harm to healthcare systems.

"A young medical student, referring to himself as "Dr. Jones" arrived in a village in a Central American country during an unsupervised elective course. He greeted the villagers with bags of candies, quickly winning over the interest and affections of the children. He was able to move easily among them, taking photographs and earning their trust. He was summoned one day to the bedside of an extremely ill baby and was asked by some of the villagers to help her get better. After an exam during which he used his stethoscope and otoscope, both of which were unfamiliar to the family, Dr. Jones recognized that the child was extremely dehydrated with a high fever. Without access to the kinds of diagnostic tools--laboratory tests and radiological examinations--on which he usually relied for information--he was unable to determine the cause of the child's illness. He told the family to give her fluids and acetaminophen to keep the fever down. He was unfamiliar with the family's usual dietary habits and never inquired if the child was being breastfed or if the family had a source of potable water that would provide a suitable alternative. Unfortunately, the child died within a few days of Dr. Jones' bedside visit. The families of the village became convinced that his ministrations were the cause of the baby's death. His instruments and the medications that he gave her aroused suspicions that he may have introduced the 'evil eye' or mal de ojo, a potential source of illness, or even death. Because he had taken many pictures of the children in the village, others became concerned that he had used the images of the children to inflict future suffering. After the death of the child that Dr. Jones saw, subsequent visits by white American medical personnel were prohibited by the villagers, even though a need developed for immunizations when a measles epidemic swept the country."(21)

Medical Context: Even the highly trained western physicians face challenges adapting to a new medical environment. Bioethicist Ross Upshur and Andrew Pinto of the University of Toronto Faculty of Medicine point out that “medical training in a developed world context does not translate to competence in all settings. Rather, one should recognize that being in a different setting puts one at a disadvantage, especially in clinical medicine.”(22)

Furthermore, culturally incompetent medical providers “may want to recommend certain things to patients that are not culturally appropriate... Conversely, [they] may observe traditional or local health practices that they perceive to be harmful.”(23) These challenges are compounded by linguistic and cultural communication barriers.(24) Lastly, all volunteers should be aware of the medical landscape of the communities they are entering, not only to assess need and outline goals but also for the volunteers’ own safety.(25)

Non-Medical Volunteers: Just as medical providers who practice beyond their abilities can cause harm, incompetent non-medical volunteers can be equally counterproductive. Volunteers involved in local education, for example, risk propagating incorrect public health information if trained improperly. In general, volunteers who have not been prepared cannot contribute productively, and they become a logistical burden on the host organization and local community.

Worst Practice: Surgical Safaris

Surgery provided by visiting physicians without collaboration and direct involvement with local surgeons is considered one of the worst practices in global health. Even the most experienced surgeons cannot overcome the significant harm and risks of short-term surgical missions. When visiting surgeons do not work with their local counterparts, there is no surgeon to provide follow-up care or to treat infections that may arise after the operating surgeons depart. The ramifications of botched surgeries affect more than just the surgical patients and their families; poor surgical outcomes can lead an entire community to fear doctors and surgery.

Please visit http://www.uniteforsight.org/pitfalls-in-development/pitfalls-in-volunteering-abroad for further discussion of the effects of surgical safaris.

The photo included here shows a patient who lost all function in his eye due to poor quality surgery provided by a short-term visiting team of surgeons.

Worst Practice: Top-Down Interventions

When global health organizations aim to create change through government or other large in-country organizations, aid rarely reaches those who need it most. This top-down approach has been repeatedly shown to be wasteful and ineffective in comparison to community-based, bottom-up approaches:(26)

“Many countries provide aid to poor and developing countries...[through] national programs and projects and through various international organizations... These national and international programs are top-down and known to be inefficient.”(27) -- Professor Kiyoshi Kurokawa, National Graduate Institute for Policy Studies, Tokyo

“Health contexts are very different from one country to another. If individual needs are ignored, there is a danger of a top-down approach in providing health information, reflecting what a few people perceive to be the needs of the beneficiaries rather than what they actually are.”(28) -- Dr. Payam Fazel, Former UN Health Consultant

The failed response to the bird flu crisis, for instance, provides a representative example illustrating many of the shortcomings of top-down solutions in global health:

“The problems with the global response to bird flu begin with its top-down, centralized approach. Those affected are rarely given useful information about the disease and the corresponding control measures and they are almost never involved in decision-making. Overall, there's hardly been any effort to understand the dynamics of the disease in local contexts or to work with local communities in defining strategies. So what inevitably emerge are big solutions and "global strategies" for wiping out the disease. But these solutions and strategies wipe out the foundations for long term, pro-poor solutions in the process. It's like using a giant club to swat a fly. There's no nuance, no sensitivity to people's needs and, worst of all, no appreciation of the capacity and knowledge that farmers have for managing this virus.”(29)

Worst Practice: Contaminated and Expired Medication

“Expired drugs (at the time of their arrival) and drugs close to expiry still comprise a large proportion of donations from nongovernmental organizations, corporations, pharmaceutical industries, and associations. This practice is defended by a sad assertion that making use of expired, partially degraded drugs is better than having none at all. It obviously raises an ethical issue about the existence of first-hand/first-class drugs and second-hand/lower-class drugs and a disturbing division between the rights and worth of different populations. Some entities seem to find it legitimate to send unusable drugs to nations which are not prepared to dispose of them safely and properly. The recipients receive the drugs as donations and instead are obliged to manage them as waste.”(30)

Global health NGOs and nonprofits rely on donations of health care supplies to facilitate medical care abroad and ease financial burdens. However, not all donations are useful, and contaminated or expired medications can be particularly dangerous. Expired medications often degrade into toxic substances, and lowered drug efficacy may lead to patients receiving incorrect or ineffective dosages.(31) With regards to ophthalmic surgery, the post-operative use of ineffective expired drugs can lead to infection and the consequent loss of vision.(32) Substandard and contaminated drugs yield the same effects. Particularly with antibiotics, expiration and contamination can harm patients and contribute to the ever-worsening global problem of microbial resistance.(33)

Expiration dates are not the only factor to be considered before donating drugs. Pharmaceuticals that are unfamiliar to local medical providers are useless, as are drugs that have not been properly labeled or stored.

“A World Health Organization audit of Albania in 1999 noted that 50% of donated drugs were inappropriate or useless and would have to be destroyed. Two thirds were due to expire, and one third were identified by brand names unfamiliar to Albanian health workers. In 1991 Pharmaciens Sans Frontières, a charity that sends pharmacists to developing countries, found that only 20% of the 4 million kg of drugs collected from 4000 French pharmacies for international aid programmes could be used. The rest of the drugs had to be burnt in a complicated and costly way to comply with international law.”(34)

And when well-intentioned but inexperienced parties, such as church or service groups, collect pharmaceuticals and aren’t cognizant of dating, refrigeration, and humidity-control issues, there is plenty of room for error. Even when qualified medical entities are involved, shortcuts sometimes are taken around normal procedures, out of the desperation that results from dire circumstances in the recipient country. And it’s the patients who suffer, as they’re put at risk by expired, inadequate, or inappropriate drugs. Not only do they sometimes receive substances that aren’t right for their symptoms or are dangerous, but the presence of the unsuitable drugs can eliminate the desire to search for better alternatives.”(35)

Inappropriate pharmaceutical drug dumping has not gone unnoticed by the World Health Organization, which has responded by creating guidelines for proper donations.(36) The core principles of proper donations are:

• Maximum benefit to the recipient

• Respect for wishes and authority of the recipient

• No double standards in quality

• Effective communication between donor and recipient

The WHO goes on to specify donation protocol, emphasizing that drug must not expire for at least a year after donation; packaging and labeling must be clear, complete, and accurate; generic drug names must be included to ensure universality; and all donations must be “based on an expressed need and be relevant to the disease pattern in the recipient country. Drugs should not be sent without prior consent by the recipient.”(37)

Footnotes

(1) Roberts, M. (2006). Duffle bag medicine. Jama, 295(13), 1491-1492.

(2) Wolfberg, A. J. (2006). Volunteering overseas—lessons from surgical brigades. New England Journal of Medicine, 354(5), 443-445.

(3) Pinto, A. D., & Upshur, R. E. (2009). Global health ethics for students. Developing World Bioethics, 9(1), 1-10.

(4) Bezruchka, S. (2000). Medical tourism as medical harm to the Third World: Why? For whom?. Wilderness & Environmental Medicine, 11(2), 77-78.

(5) Suchdev, P., Ahrens, K., Click, E., Macklin, L., Evangelista, D., & Graham, E. (2007). A model for sustainable short-term international medical trips. Ambulatory Pediatrics, 7(4), 317-320.

(6) Montgomery, L. M. (1993). Short-term medical missions: enhancing or eroding health?. Missiology, 21(3), 333-341.

(7) Crump, J. A., & Sugarman, J. (2008). Ethical considerations for short-term experiences by trainees in global health. Jama, 300(12), 1456-1458.

(8) Bishop, R. A., & Litch, J. A. (2000). Medical tourism can do harm. Bmj, 320(7240), 1017.

(9) Decamp, M. (2007). Scrutinizing short-term global medical outreach. Hastings Center Report, 37, 21–23.

(10) Crump, J. A., & Sugarman, J. (2008). Ethical considerations for short-term experiences by trainees in global health. Jama, 300(12), 1456-1458.

(11) Shah, S., & Wu, T. (2008). The medical student global health experience: professionalism and ethical implications. Journal of medical ethics, 34(5), 375-378.

(12) O'Neil Jr, E. (2006). A practical guide to global health service. American Medical Association Press.

(13) Decamp, M. (2007). Scrutinizing short-term global medical outreach. Hastings Center Report, 37, 21–23.

(14) Montgomery, L. M. (1993). Short-term medical missions: enhancing or eroding health?. Missiology, 21(3), 333-341.

(15) Ibid.

(16) Ibid.

(17) Ramsey, K. M., & Weijer, C. (2007). Ethics of surgical training in developing countries. World journal of surgery, 31(11), 2067-2069.

(18) Banatvala, N., & Doyal, L. (1998). Knowing when to say “no” on the student elective: Students going on electives abroad need clinical guidelines.

(19) Shah, S., & Wu, T. (2008). The medical student global health experience: professionalism and ethical implications. Journal of medical ethics, 34(5), 375-378.

(20) Briggs, S. "Student spends summer in service." The Daily Universe. April 29, 2003. Accessed on 1 March 2009.

(21) Levi, A. "The Ethics of Nursing Student International Clinical Experiences." Journal of Obstetric, Gynecologic, & Neonatal Nursing. 38 (January 2009): 94-99.

(22) Pinto, A. D., & Upshur, R. E. (2009). Global health ethics for students. Developing World Bioethics, 9(1), 1-10.

(23) Ibid

(24) Crump, J. A., & Sugarman, J. (2008). Ethical considerations for short-term experiences by trainees in global health. Jama, 300(12), 1456-1458.

(25) Wilkinson, D., & Symon, B. (1999). Medical students, their electives, and HIV: unprepared, ill advised, and at risk.

(26) Ramsey, K. M., & Weijer, C. (2007). Ethics of surgical training in developing countries. World journal of surgery, 31(11), 2067-2069.

(27) Kurokawa, K. “Global Health: A Global Agenda.” 29 May 2008. Science and Technology in Society forum, Fourth Conference on African Development. Accessed on 20 October 2008.

(28) Fazel, P. “Global Health University Research Project.” Response letter to Leon, Walt, and Gilson, 2001. BMJ.

(29) Buster, J. (2006). Fowl play: The poultry industry's central role in the bird flu crisis.

(30) Pinheiro, C. P. (2008). Drug donations: what lies beneath. Bulletin of the World Health Organization, 86, 580A-580A.

(31) O’Gorman, K.R. “Expired Drugs – Are They Safe?” 20 July 2005. Associated Content: Health and Wellness.www.associatedcontent.com.

(32)“Blinded by Negligence: Regulate, Not Ban, Eye Camps.” 26 November 2008. Editorial. The Tribune. www.tribuneindia.com.

(33) Issack, M.I. “Substandard Drugs.” The Lancet. 358.9291 (2001): 1463.

(34) Stehmann, I. “Inappropriate Drug Donations.” Editorial. Student British Medical Journal. 10 (2002): 305-306.

(35)“Drug Donations: Not What the Doctor Ordered?” Nurses Village, b2bcontentsolutions.com/B2B_Donations.pdf.

(36)“Guidelines for Drug Donations.” World Health Organization, https://apps.who.int/iris/bitstream/handle/10665/60844/WHO_EDM_PAR_99.4.pdf;sequence=1, 1999.

(37) Ibid.