Judith N. Lasker, Distinguished Professor of Sociology at Lehigh University, has been deeply immersed in research on international health volunteerism. Below she has offered a summary of her book, Hoping to Help: The Promises and Pitfalls of Global Health Volunteering. She has also been kind enough to share guidelines for international service trip participation, which I’ll be sharing here next week. Dr. Lasker is eager for your feedback and comments, so please share your reflections, additional resources, or constructive criticism. – EH

By Judith N. Lasker, Ph.D.

Short-term volunteer service trips across national borders are increasingly popular in Europe and in the United States.  Whether for a few days or a few months, hundreds of thousands of people travel annually from wealthier to poorer countries to participate in programs intended to improve the health and well-being of citizens in underserved communities.  Despite their growing popularity, there has been little attention to the question of whether these volunteer efforts actually contribute to improvements for the recipient communities, and whether there might be costs to those communities that diminish or even outweigh the supposed/theoretical benefits from the service efforts. I am very glad to see that Eric Hartman and his colleagues, through this blog, publications and conferences, are addressing these important questions.  My recently published book, “Hoping to Help; the Promises and Pitfalls of Global Health Volunteering” addresses this subject based on surveys and interviews with a wide range of people involved in this growing enterprise.

Most people assume that poor people are benefiting from the goodwill and skills of the volunteers. Yet, with such an enormous human and economic investment in health service trips, it is essential to gain a better understanding of this ‘industry’ and to examine if, and how, the recipients of service projects are benefitting. Are service trips, in their existing frameworks, the best allocation of precious resources to improve the lives of people in poor communities of the world?  Are there ways to improve short-term volunteer programs in order to increase their value?

To date, most attention to this phenomenon has focused on the advantages to the volunteers and their sponsoring organizations (Caprara et al., 2007; DeGilder et al., 2005; Sherraden et al., 2008; Turker, 2009).  The goal of my book is to focus on the benefits, and possible costs, of short-term health-related service trips for host communities.  Do these programs really make a positive difference in the health of people in poor countries by contributing to better services, a healthier environment, or healthier behaviors? Is it possible in a few weeks or months (the timespan of most trips) to have a measurable effect, or is it perhaps the cumulative effect of many such visits that makes a difference? What are the characteristics of programs that appear to be most beneficial for the health of host communities? What is being done to evaluate the impact of short-term volunteer trips, to see if they actually ‘help’?  So far, very little.

This book provides a much-needed description of the wide variety of types of short-term health service trips, while at the same time offering insights into how they might be organized and evaluated most effectively. The number of people who sponsor and participate in short-term service programs is constantly growing. Organizers and prospective participants alike want a better accounting of whether what they are doing really makes a difference for the people they hope to help (Griffith, 2011).  The research I carried out for this book is intended to provide insight into the scope and nature of the volunteer industry, their benefits and costs to the ‘recipients’ of service, the ways in which they have been and could be evaluated specifically with regard to their value for host communities, and the characteristics of the best programs in terms of such benefits.

“Hoping to Help” focuses on programs that involve people from wealthier countries traveling to poorer countries to engage in health-related projects.  These projects include provision of primary care, surgical missions, medical training programs, public health interventions, and prevention education. They are sponsored by faith-based organizations, educational institutions, non-faith-based NGO’s, profit-making tour organizations, and corporations.  The choice of health makes it possible to focus our gaze on one part of what is an immense and diverse phenomenon.  Health is also an area in which the benefits often seem the most obvious and dramatic: medicine provided to alleviate symptoms, surgical interventions to correct disabling problems, activities to promote behaviors and conditions that will prolong life—and therefore the least likely to be questioned.  It often involves very expensive human and material resources, and it has the potential for impact measurement that is more difficult in some other areas of volunteer activity.  All of these reasons make this topic an ideal and urgent topic for further exploration and study.

In 2007, it was estimated that about one million Americans volunteered outside the country, for a total of 162 million hours and at a value of close to three billion dollars (Lough, McBride, & Sherraden, 2007).   Since then, the numbers and expenditures have continued to expand.  Today, community churches and national religious organizations, non-profits large and small, colleges and schools of medicine and public health, agencies (for profit and not) promoting volunteer vacations and alternative spring breaks and corporations through their social responsibility departments are all recruiting volunteers to participate in efforts that claim to alleviate the wide disparities in health and medical services throughout the world.

Despite this enormous interest in volunteer health service trips, there is still very little evidence demonstrating their impacts, both positive and negative, on host communities.  It is unclear what their real benefits are. This raises questions for consideration: What are these impacts? Are there costs and disadvantages for those communities?  For example, is it more burdensome than not to host, train, and integrate visitors and their activities? Do service projects have lasting impacts on needy communities?

The history of foreign aid is littered with cautionary examples of waste and of good intentions gone bad–innovations that were rejected by the people who were intended to use them: gifts of food and goods undercutting local producers and increasing hunger and poverty; staff training that resulted in health professionals from poor countries finding jobs elsewhere; water purification systems that did not function properly or were not accepted by communities for political and cultural reasons.  As international volunteer programs become ever more popular, are they experiencing similar failures?  Do short-term volunteer programs also introduce ill-suited technologies, reinforce dependency, devalue local knowledge and culture, and promote stereotypes among both hosts and visitors about the superiority of Western technologies and techniques?

Indeed the criticism of short-term volunteer efforts has grown, with references to ‘drive-by humanitarianism’ (Nagengast, Briggs, & Misawa, 2012), ‘cowboy’ surgeons (Wall et al., 2006) and ‘slum tourism’ (Frenzel, Koens, & Steinbrink, 2012).  Some claim it is a new form of colonialism, in which the wealthier continue to extract benefits (e.g. satisfying experiences, career building credentials) from the poor, all the while believing that it is in the best interests of the latter and a demonstration of the humanitarianism of the former (Cohen et al., 2008; Devereux, 2008; Boffey, 2011).

Some people involved in organizing short-term volunteer projects and student internships have raised concerns, usually framing the problem in terms of the ethics of medical students’ involvement in clinical care (Ackerman, 2010; Crump & Sugarman, 2008; Csoman et al., 2012; Montgomery, 2000; Provenzano et al., 2010; Welling et al., 2010).  There is a larger ethical challenge in that the benefits, and lack of disadvantages, have not been clearly demonstrated.  When evaluations have been carried out on international service trips, they focus either on the value for the volunteers/students or an accounting of number of patients seen, and they are based on a few interviews with agency leaders on both sending and receiving ends  (e.g. BD, 2011; BTW, 2010; Hills & Mahmud, 2007; Vian et al. 2007).

In recent studies of global health volunteers and interns, researchers have begun to ask host country health program staff about their own perceptions of the benefits and disadvantages of having volunteers (Green et al., 2009; Lough et al. 2011; Wendland, 2012, Kraeker et al., 2012).  This is an important start, and it is one of the approaches that was used in the current project to determine actual impacts/benefits.   Since short-term international volunteering involves many actors and perspectives, it was my goal to use multiple methods of research and to include a comprehensive range of individuals and organizations.  Thus the study has included the following elements (to date):

• Review of existing studies
• Online survey of 176 U.S.-based organizations sending volunteers to other countries for health-related programs, representing faith-based (49.7%), non-faith-based NGO (33.7%), educational organizations (14.3%), and volunteer matching services (2.3%).
• Field observations during a three-week volunteer trip to Haiti and a ten-day volunteer trip to Ecuador
• Survey of Haitian laboratory technicians following training by volunteers (N=92)
• Pre- and post-surveys of company employees who participated in a volunteer service trip to Haiti
• Interviews (112) of people involved in faith-based, NGO and educational volunteering:
  • People associated with programs in the US that send volunteers (N=24)
  • Americans/French working full-time overseas, receiving volunteers (N=14)
  • Host country nationals in Haiti, Ghana, Niger, Ecuador (N=54)
  • Volunteers (N=13)
  • Global health experts (N=7)

This mix of qualitative and quantitative methods enriches our understanding of the short-term volunteering phenomenon and provides multiple viewpoints while cross-checking the validity of results from each type of method.   I will be happy to hear readers’ responses to the results and recommendations that emerged from this research and also welcome the work of others who are working very hard to make this enterprise more ethical and effective.

REFERENCES

Ackerman (2010).  The Ethics of Short-term International Health Electives in Developing Countries.  Annals of Behavioral Science and Medical Education. 16, 40-43.

BD–Becton Dickinson (2011). Our Envisioned Future; Assessing the BD Volunteer Service Trip Program. Ghana 2007-2009, Final Report. Prepared for BD by Corporate Citizenship

Boffey(2011). Students given tips to stop gap year travel being ‘a new colonialism’; Think tank Demos warns poorly planned volunteering stints in developing nations can do more harm than good. The Guardian, 30 July 2011.

BTW Consultants (2010). The Worth of What They Do; The Impact of Short-term Immersive Jewish Service-Learning on Host Communities: An Exploratory Study, Repair the World.  Downloaded from http://werepair.org/blog/short-term-volunteering-can-have-long-term-positive-effects-on-communities/4387

Caprara, Bridgeland & Wofford (2007).  Global Service Fellowships: Building Bridges through American Volunteers.  Brookings Institution Policy Brief #160

Cohen, Küpçü, & Khanna (2008). The New Colonialists, Foreign Policy, June 16.

Crump, J. A., & Sugarman, J. (2008). Ethical considerations for short-term experiences by trainees in global health. JAMA: The Journal of the American Medical Association, 300 (12), 1456-1458.

Csoman, Nagengast, Misawa, & Briggs (2012). Ethical Predicaments of Promoting Student Internships in Africa”.  Presented at Eighth Annual Conference, Forum on Education Abroad.

DeGilder, Dick, Theo N. M. Schuyt, Melissa Breedijk (2005). Effects of an Employee Volunteering Program on the Work Force: The ABN-AMRO Case. Journal of Business Ethics: 61, 143-152. Springer.

Devereux (2008).  International Volunteering for Development and Sustainability: Outdated Paternalism or a Radical Response to Globalization? Development in Practice, Vol. 18, No. 3, pp. 357-370.

Frenzel, Fabian , Koens, Ko, & Malte Steinbrinklum, eds. (2012).  Slum Tourism; Poverty, Power and Ethics. Routledge

Green T, Green H, Scandlyn J, Kestler A. (2009). Perceptions of short-term medical volunteer work: A qualitative study in Guatemala. Globalization and Health, 5:4.

Griffith, James (2011). A Decade of Helping: Community Service Among Recent High School Graduates Attending College.  Nonprofit and Voluntary Sector Quarterly 2012 41: 786 originally published online 22 August 2011,  DOI: 10.1177/0899764011417720

Hills, Greg, and Adeeb Mahmud (2007). Volunteering for Impact: Best Practices in International Corporate Volunteering.  Boston, FSG Social Impact Advisors.  Downloaded from http://www.fsg.org/tabid/191/ArticleId/81/Default.aspx?srpush=true, March 19, 2012.

Kraeker, C., Chandler, C., & Gothard, P. (2012) Global Health Education: Perceptions of Visiting Healthcare Professionals. Unite for Sight Global Health and Innovation Conference, New Haven, April.

Lough, B. J., McBride, A. M., & Sherraden, M. S. (2007). The estimated economic value of a US volunteer abroad (CSD Working Paper 07-29). St. Louis, MO: Washington University, Center for Social Development.

Lough, B. J., McBride, A. M., Sherraden, M. S., & O’Hara, K. (2011). Capacity building contributions of short-term international volunteers. Journal of Community Practice, 19(2), 120-137.

Nagengast, Briggs, Misawa, Ethical Predicaments of Promoting Student Internships in Africa, presentation at Forum on Education Abroad, March 2012

Provenzano, A. M., Graber, L. K., Elansary, M., Khoshnood, K., Rastegar, A., & Barry, M. (2010). Short-term global health research projects by US medical students: Ethical challenges for partnerships. The American Journal of Tropical Medicine and Hygiene, 83(2), 211-214.

Turker, Duygu. (2009). How Corporate Social Responsibility Influences Organizational Commitment. Journal of Business Ethics. 89:189–204

Vian, Feeley, MacLeod, et al. (2007).  Measuring the impact of international corporate volunteering: Lessons learned from the Global Health Fellows Program of Pfizer Corporation. Boston U. Center for International Health.

Wall, L. Lewis, Arrowsmith, Steven D., Lassey, Anyetei T., & Danso, Kwabena (2006). Humanitarian ventures or ‘fistula tourism?’: the ethical perils of pelvic surgery in the developing world. Int Urogynecol J 17: 559-562

Welling, Ryan, Burris, & Rich (2010). Seven Sins of Humanitarian Medicine. World J Surg (2010) 34:466–470 DOI 10.1007/s00268-009-0373-z

Wendland, C. (2012). Moral Maps and Medical Imaginaries: Clinical Tourism at Malawi’s College of Medicine American Anthropologist, Vol. 114, No. 1, pp. 108–122.