Jessica Evert, MD, Executive Director, Child Family Health International, Faculty, UCSF Department of Family and Community Medicine

I received an email from a US undergraduate student in April 2013 that read:

“I am trying to establish a long-term and impactful relationship between the [my school’s] student body and the villages and small towns of South Africa. [My school’s] students, who have a reputation for being extremely medically-driven, would be very interested in serving the communities medically, whether it is through patient advocacy, disease/illness awareness, or being able to directly participate in minor surgeries and procedures.”

The email went on to ask me if the student could partner with Child Family Health International (CFHI), the Global Health education organization I steer, to make his interests a reality (my response probing his motivations went unanswered). This email has stuck with me as it captures the underlying curiosity, naiveté, and mis-interpretation that results in ‘service-learning’ within medical and public health setting becoming a dis-service. What is problematic with this student’s interests? Can you pick out the ‘red flag’ that all international educators, faculty and advisors should be able to immediately recognize and probe further? What subtleties indicate this student may have self-centered motivations veiled by a desire to serve?

The tensions between the good intentions of Global Service-Learning (as a field, pedagogy, and movement) and the too often harmful manifestations of it in resource-restricted healthcare settings have several very concrete causes. Before I go into these causes, let’s further define resource-restricted healthcare setting. I am referring to any clinical (hospital, health center, clinic, mobile outreach) or public health setting where patients have less power than is optimal, limited or no choice in who provides their care, scant access to healthcare or choice in where they go to receive care, suboptimal understanding or means to assess the expertise/experience of the person providing their care, and/or other reasons to lack empowerment and opportunity to provide informed consent.

The causes of Global Service-Learning becoming a dis-service in healthcare settings include:

1. The mis-interpretation of the concept of “service.”

The mis-interpretation of the concept of service, lies in students thinking that ‘service’ in medical settings means providing medical ‘services.’ The confusion between ‘service’ and ‘services’ is pervasive. If a healthcare outfit has undergraduate students involved, they should not be providing medical services, but rather supporting its provision through appropriate tasks (if the student is required to provide task-oriented “service” in an immediate sense). These tasks may include (there is no agreed upon list) pulling patient’s charts if they are competent in reading the local language or language of the chart, setting up or maintaining physical spaces (chairs, tables), addressing dilapidated infrastructure (painting a mural, planting a garden), setting up food or drink, distributing health materials that have been locally vetted for accuracy, teaching English to host institution staff, printing a research article that local healthcare workers would otherwise not have access to and tidying/cleaning (not including biowaste or biohazards). However, I would argue that students do not need to provide task-oriented immediate service in order to be of service within such settings.

There is evidence in the evaluation of CFHI’s programs (which place students in existing health systems staffed by local physicians and nurses and does not emphasize task-oriented service within these settings) that the students don’t actually have to do ‘service’ in the immediate sense to be of service to the host institution and staff. Independent researchers found that CFHI program participants have the effect of positively impacting the host healthcare institution merely by being learners and allowing local healthcare workers to be elevated to the level of knowledgeable instructor (rather than subverted to those needing to be ‘helped’ by a student coming from a completely different frame of reference). In addition, it was found that undergraduates observing practice of local physicians increased the respect patients have for their doctors (as the doctor was ‘smart’ enough to teach someone from the US), benefited the host through increasing their contact with the globalized world and engendered a sense of solidarity (Kung, 2013). In addition, CFHI provides opportunity for service in non-clinical settings within host communities in order for students to ‘give-back’ in an immediate sense.

The onus is on program providers, schools, faculty, and hosts to ensure that undergraduate students are not taking part in hands-on patient care or providing medical services that they are not qualified to provide. Students and faculty benefit from resources such as Global Ambassadors for Patient Safety (GAPS) to learn appropriate boundaries, nurture the ability to say no when offered to do something hands-on, and sign an oath to maintain ethical boundaries. If undergraduate students are present for clinical encounters or public health interventions, they should be an observer. If healthcare settings cannot maintain boundaries to ensure students are observers, then the setting is not appropriate for undergraduate students.

2. Actions based on curiosity about what it’s like to provide medical care, dispense medications, and take part in other hands-on healthcare activities usually reserved for licensed, professionally educated individuals, or clinical medical trainees.

The curiosity of what it’s like to be at the next level of a professional path is natural and appropriate. When it comes to the curiosity of pre-health students to be at the next level and mimic the activities of health professions students or licensed health workers, acting on such curiosity is not appropriate. Global Service-Learning programs that aim to provide insights into the world of healthcare delivery for undergraduate students need to do so with curriculum, learning objectives, and competency goals that are appropriate for the student’s level. For example, an appropriate competency for an undergraduate student is to “Articulate the role of social determinants of health in affecting the wellbeing of community members.” Whereas, aiming for competency to “Demonstrate ability to formulate a plan of care for a patient” is not. Aligning curricular content, competency goals, and methods of instruction with undergraduate student’s level is essential so that natural curiosity to learn more about medicine and public health is given appropriate substrate for expression.

3. Exploitation (either conscious or sub-conscious) of resource-restricted settings to get hands-on patient care experience that would not be allowed in high-resource or optimally regulated settings. This is often done, in part, to boost applications to medical school or other post-graduate training.

There is a perfect storm brewing- the lack of regulation of undergraduate students’ scope of activities in resource-restricted healthcare settings + ultra-competitive medical/health professions school admissions environment + undergraduate students’ desire to gain hands-on patient care experience because they think it will boost their medical/health professions school applications. When asked about undergraduate students seeking international experiences a pre-health advisor observed, “Students [seem] to be desperate to get accepted into a med school anywhere, but they are not aware of what happens [to patients] afterwards.” Resource-restricted settings generally have less bandwidth for regulating the activities of visitors and volunteers. In the US there is an entire profession (Volunteer Administrators) and professional community (Association for Healthcare Volunteer Resource Professionals) dedicated to managing volunteers in healthcare settings. In resource restricted settings that are strained to meet the basic demands of patient care, regulations are often inadequate or non-existent to protect vulnerable patients from being the subject of hands-on forays of undergraduate students.   Some countries, such as South Africa, have recognized this problem and created strict rules to prevent students from engaging in these exploits. South Africa utilizes a ‘Health Professions Council” which is a vetting process for any visitor who is seeking access to hands-on patient care.

The “pull” factor of students being under the impression that their application to medical/health professions schools will be enhanced by hands-on patient care experience results from lack of clarity on behalf of medical school admissions requirements about what type of “experience” abroad is desirable. This is despite clear guidelines by the AAMC and the Forum on Education Abroad forbidding hands-on patient care at undergraduate levels. The Working Group on Global Activities of Students at Pre-health levels (GASP) is a collaboration representing 18 disciplines from 25 institutions dedicated to raise awareness of and address this lack of clarity (www.gaspworkinggroup.org – the website will be available beginning in early December).

4. Naiveté that results in thinking medical care, regardless of who provides it, is always beneficial.

The world’s poor, whether in our own backyard, or in a community across the globe, have been victims of the notion that any medical care, regardless of how and who provides it, is a good thing. More contemporary understanding of global health and development, as well as critical examinations of short-term global health activities, point out significant opportunity costs and potential downfalls of such care. This not only includes patients who undergo unnecessary pain, such as the women who gets a pap smear done by a male undergraduate student who has never held a speculum (a true story relayed by an academic advisor), it also includes false reassurance. False reassurance results from patients being given a sense that they are ‘ok’ when in fact they just didn’t receive a competent or thorough enough assessment to detect disease. For instance, this can occur if an undergraduate student who is new to measuring blood pressures, inaccurately measures a patient’s blood pressure as normal when it is actually high. The patient is told they have normal blood pressure and they are sent on their way falsely reassured that all is well. False reassurance can also occur when visiting students are involved in short-term brigades or temporary pop-up clinics. These clinics, often run by outsiders, may only have the ability to check for a few health problems (such as vision problems, dental problems, heart and blood pressure abnormalities). Patients who visit them and go through a limited scope of exams are told everything is normal if no abnormalities are detected. Patients can mis-interpret this ‘clean bill of health’ as being reassuring more broadly and not seek comprehensive evaluation, both preventive and reactive, within local, permanent health systems often better equipped to address a wide array of disease or diseases that fluctuate over time. Thus there are costs resulting from the provision of medical care without mindfulness of quality, professional licensure, and follow-up with patients— the patients may not seek care in a more appropriate setting, may experience unnecessary pain, and may walk away with false reassurance, among a host of other deleterious results.

5. A misunderstanding about what interventions influence the health status of communities and individuals in a sustained fashion.

When undergraduate Global Service-Learning exploration of health is narrowly focused on clinical settings and topics, students do not get an accurate understanding of what determines wellness and disease burden. It is estimated that healthcare (what happens in clinics and hospitals) is about 10% deterministic for whether you have a normal lifespan (Schroeder, 2009). Other factors such as behavioral patterns and social circumstances have a stronger influence on whether an individual lives or dies. Thus, it is important for Global Service-Learning to emphasize determinants of health that reach far beyond clinical walls. This includes social determinants of health, culture, geopolitical realities, and much more. For this reason Child Family Health International’s 25+ Global Health Education Programs focus not only on medical and public health experiential exposure, but also on contextualizing this learning with immersion in the community with host families and integration into existing health systems, as well as home visits, language training, lectures of broad determinants of health, case studies in illness through a biopsychosocial model, and critical reflections on power, culture, and beyond. By focusing beyond the clinic walls, students gain a broader understanding of health and healthcare.

To summarize, when Global Service-Learning is done in such a fashion that it is a dis-service the negative impacts include:

1. Giving students an inaccurate, over-simplified understanding of the causes of and solutions to suboptimal health status in communities at home and abroad.
2. Perpetuating disparities and differential treatment of the poor that the Global Service-Learning, Global Health and Health Equity movements set out to understand and address.
3. Risking the safety of patients and students.

The undergraduate student who emailed me in April 2013 pledged an ‘interest in serving’ in South Africa and went on to qualify service as advocacy, disease awareness, and directly participating in procedures/surgeries. The latter, performing procedures and surgeries, being confused as ‘service’ is the result of many factors and a history of providing sub-optimal care to the world’s poor, both at home and abroad. It is critical that the Global Service-Learning community:

• Understand how to vet and/or design undergraduate-appropriate health-related Global Service-Learning programs.
• Understand how to engage with students who have misunderstandings or veiled intentions that push ethical and safety boundaries.
• Urge students to consider the underpinnings of sustained gains in health, including health systems strengthening, native healthcare workforce development, economic development, security, stable political systems, and much more.

Child Family Health International encourages students to “Let the World Change You.” The transformative process that can result from well-structured, ethically sound, and educationally rigorous Global Service-Learning in resource-restricted healthcare settings is profound. It is only through imparting an appreciation for the complexity of causes of disease that we are able to nurture the leaders of tomorrow who will advocate for equally complex, sustainable solutions.

 References

Kung T. (2013). Voices of International Host Communities: Impacts of Global Health Education Programs. Stanford.

Schroeder S.A. (2007). We can do it better: Improving the Health of the American people. New England Journal of Medicine. 2007;357:1221-1228.

Child Family Health International (CFHI) is a UN-recognized non-profit organization with over 25 Global Health Education Programs in 7 countries.   CFHI has been providing Global Service-Learning for over 22 years for students from undergraduate to post-graduate levels and university partners. To find out more visit www.cfhi.org.

Interested in more global-health related resources from globalsl.org? Take a look at: 

• Our summary of a piece in the Chronicle of Higher Education, Some Global Health Programs Let Students Do Too Much, Too Soon
• Judith N. Lasker, Distinguished Professor of Sociology at Lehigh University, sharing a summary of her upcoming book on international health volunteerism.
• Dr. Lasker has also been kind enough to share guidelines for international service trip participation, How to Have the Best Possible Global Health Volunteer Trip.