The Evolution of Global Health Experience: What Physicians Should — and Shouldn’t — Expect from Projects Abroad

This is an extended version of a story that appeared in the print edition of Vital Signs.

As more physicians seek out medical experiences in the developing world, efforts are underway to build global health into physicians’ career paths and raise standards in the systems and organizations that support health projects abroad. These trends reflect a shifting understanding of global health. Increasingly, global health is recognized as an essential component of public health, benefiting everyone, rather than a philanthropic add-on. This comes with an urgency around learning from past mistakes, including efforts that inadvertently burdened the countries and communities they were intended to help.

Physicians in the US seek out global health experiences for various reasons. Frequently, they are looking to support under-resourced communities abroad, maybe by helping manage a disease outbreak or natural disaster. Physicians may hope to experience medicine in a new way, gain relevant insights and skills, or take a break from what can feel like the burdensome elements of US practice. Vital Signs talked with physicians connected with the Massachusetts General Hospital (MGH) Center for Global Health about what clinicians can expect to bring to, and get from, their global health experiences.

Professionalization of Global Health

Medical training in global health settings has increased in recent decades, according to the American Association of Medical Colleges’ annual Medical School Graduate Questionnaire. In 1984, six percent of graduates reported a global health experience during medical school; recently the figure surpassed 30 percent. Similarly, growing globalization has led to an increase in physicians engaging in international medical volunteerism — short-term placements in low-resource settings that allow doctors to maintain their practices in the US.

That trend is part of a gradual professionalization of global health. “Maybe 10 years ago people used to think of global health as a sideline issue, and there are people who will continue to do it in that fashion. But there are people who are trying to professionalize it and make it much more part of their career,” says Adeline A. Boatin, MD, MPH, an OB/GYN at MGH who has a longstanding collaboration with a hospital in Uganda.

Past mistakes in global health are focusing attention on how to maximize the benefits across the board. Poorly executed projects may come with a cost to the country or community that they are supposed to benefit. “Projects abroad can be very reinvigorating for the person leaving North America, but for the people in the countries that they’re visiting, it takes a lot of resources to receive a visitor,” says Dr. Boatin.

The pitfalls have been striking in some disaster response scenarios, says Paul D. Biddinger, MD, chief of the division of emergency preparedness at MGH, who helped direct recent domestic post-hurricane relief efforts in Texas and Puerto Rico, and also has global disaster experience. “Historically there have been challenges with ‘disaster tourism,’ people who have a desire to help but also to see other parts of the world and to get a life experience in a difficult setting.”

In global health, good intent is not enough. Volunteers may end up consuming scarce resources, undermining local care systems, or performing misjudged interventions, says Hilarie H. Cranmer, MD, MPH, director of global disaster response at MGH. After the Haiti earthquake, Dr. Cranmer ran the largest field hospital there, confronting the challenges of ad hoc medical volunteerism. “More than 80 percent of responders were under 30 with little to no disaster experience. More than 40 percent of amputations were unnecessary,” she says. Some volunteers had health needs that required medical evacuation; others developed post-traumatic stress.

The news that Oxfam aid workers had sexually exploited Haitian girls similarly highlights the need for personal and institutional accountability. “There are beliefs that the rules don’t apply in a disaster situation,” says Dr. Biddinger. “To treat it as the Wild West or a ‘practice area’ [to expand scope] is unfair to those affected by the disaster and I don’t think that is ethically sound.” Following the Haiti earthquake response, the World Health Organization (WHO), working with the Pan American Health Organization (PAHO) and other nongovernment organizations and stakeholders, subsequently developed standards for emergency medical teams (EMTs). “This is a worldwide movement,” says Dr. Biddinger.

Without those standards across the board, volunteers may continue to sense an imbalance in the impact of global health projects. “We hear it all the time: ‘I served three months in a mission hospital in Malawi and I still felt like I gave nothing, in terms of what I learned from this amazing community,’” says Dr. Cranmer. “Any time you go, you’re going to come back. You hope that the footprint you leave is deeper and stronger for the community than for yourself. It’s about how to serve, but not how to serve yourself — how to serve that community.”

Forming Long-Term Relationships

Developing ongoing relationships between practitioners, institutions, and countries helps ensure the value of global health efforts for both sides. Dr. Boatin’s connection with the academic medical center in Mbarara, Uganda, is part of a long-term capacity-building partnership between that hospital and MGH; she is currently working with faculty and staff there to reduce maternal mortality and infection rates.

For the first two years of her involvement, Dr. Boatin spent about four months a year (not consecutively) in Mbarara, an arrangement she negotiated with MGH first as a global health fellow then as an attending. In 2017, she made five two-week visits. “It’s much harder to get anything done in two weeks if you don’t already have an established relationship,” she says.

Supporting Not Displacing

A key to successful partnerships is collaboration, says Dr. Biddinger, who also serves on a federal disaster response team. “Emergency medical teams should be working in support of and under the direction of local health authorities, so they are supporting and adding to, but not replacing, the local health infrastructure.” Otherwise, local practitioners, clinics, and pharmacies can be implicitly discredited or displaced by visiting medics.

This is the same learning trajectory that saw public health practitioners move away from “top-down” interventions toward community-based, participatory models. Laura E. Riley, MD, vice chair of obstetrics at MGH, who works with Dr. Boatin in the Uganda program, says, “We needed to not be two women from Harvard coming in and telling them how to run their business. That was not going to work.”

Setting Realistic Expectations

Dr. Cranmer, who chaired the nongovernmental organization advisory board on EMTs for the PAHO, has pioneered screening and training systems designed to ensure MGH volunteers’ physical and psychological fitness and preparedness. “The willingness to help is very powerful and it is the mission of our center to help those who want to help others, and to get you back home to your family and your work so you can continue to help others in your job at MGH,” says Dr. Cranmer.

MGH volunteers are trained to understand the security situation and the medical command system that are part of disaster response efforts. The hospital provides logistical and infrastructural support, including a home-based backup team, satellite phones, and full supplies; the teams must be 100 percent self-sufficient. The hospital also brings established relationships with the federal government, the WHO, other organizations, and teams from other Boston hospitals.

Disaster experience leads some volunteers toward other projects in low-resource settings. “I like to call disaster response the gateway drug to global health,” says Dr. Cranmer. “Your heartstrings are immediately pulled. But then how do you get your heartstrings to stay pulled, and to keep your feet in that community for long-term, sustainable progress? Disaster response is band aids; we know it. But sometimes we can bring that media spotlight or funding when these heartstrings are pulled.”

Physicians’ Added Value

Volunteer physicians unquestionably — and appropriately — benefit from their experiences abroad. “Most medical providers have a desire to help their fellow human beings, especially at times of disaster. We recognize that we have special skills that are often in short supply,” says Dr. Biddinger. “It’s the wrong thing to do this to go get experience — it should be about victims, not yourself — but that being said, you can’t help but get something out of it, you can’t help but grow and be changed.”

The contrast between practicing in resource-rich and resource-poor countries can serve as a powerful reminder of physicians’ reasons for going into medicine. “For some physicians in the US who feel there’s a lot of patient pushback and entitlement, and bureaucracy pushing down on you, there can be rejuvenation in going to a place that’s about raw clinical practice, where every patient you interact with really needs your care,” says Dr. Boatin. “As a physician that can be really invigorating, to feel your clinical skills are truly needed and appreciated.”

Physicians are also especially valuable as educators, she says. Her colleagues abroad benefit from exposure to unfamiliar subspecialty skills. The potential impact of such teaching is magnified in a region where clinical skills are in short supply. “Those residents are going to go out and be the only doctor with that training in an entire region. To spend an hour with a resident, you’ve made a huge impact. It feels whatever you’re doing goes that much further,” says Dr. Boatin.

Perspective Shift

Physicians also report that global experiences can help restore their faith in US practice. “They’re able to do amazing things [abroad] with very few resources,” says Dr. Riley, “but you also gain an appreciation for all the things that we do have that makes our job easier. For example, at the Mbarara hospital they don’t have nurses that work alongside them like we do. A tremendous amount of work that I take for granted, like someone coming and telling me the patient’s vital signs are unstable, they don’t have.”

Experiences in low-resource settings may help enhance US physicians’ communication skills (for example, feeling better equipped to provide culturally competent care in the US). The experience may also help preserve basic clinical skills. “I have a greater appreciation for physical diagnosis, as opposed to going directly to a CT scan or MRI,” says Dr. Riley. “We have a tendency to not use or even develop our physical diagnosis skills. That may be a lost art at some point, because our resources are not unlimited.”

Finding a Global Career Path

Career paths in global health are emerging and vary by specialty, says Dr. Boatin, who co-authored a 2017 article exploring the opportunities for creating sustainable work models for academic OB/GYNs in global health work (Obstetrics & Gynecology). The avenues include grant-funded research projects, flexible hospitalist shift models, and global health fellowships.