Working and living conditions encountered by international health volunteers vary considerably depending upon the location of service. Many volunteers find quite good facilities, with all of the essential supplies and equipment needed to care for patients. This allows them to help lots of people and increases the chances of finding the experience rewarding. They may find good housing, food and camaraderie. The local inhabitants may be welcoming and warm. Caregivers can delight in the new friends they have made and the fascinating cultural experiences they have. Patients may even reward them with emotional expressions of gratitude. These lucky individuals need little help and advice.
The following section is for the those who find themselves in less fortunate circumstances. It describes problems that can be encountered and suggests solutions. Rarely do assignments present many of the difficulties we will describe, but anticipating and preparing for these kinds of challenges are well worth the effort.
Too often in developing countries the health care infrastructure is woefully inadequate. Caregivers must struggle to make any headway at all. Monetary resources available to many organizations and governments are so limited they are able to spend only a few dollars per person per year on health care. The result is shortages of doctors, nurses, medical facilities, transportation and drugs. Exasperatingly, there may also be too many patients or ones with problems that cannot be cared for at the local facility - but with no referral option. There may be a lack of basic supplies: bandages, medications, even simple analgesics. In some cases, just about the only supplies available will be the ones a health worker has brought from home. These shortages combine with malnutrition, infectious diseases, lack of education and in some cases civil unrest. They create terrible, widespread and chronic suffering on a scale unknown in developed nations. Throughout the world many hospitals are really little more than warehouses. Patients are fed irregular, meager rations, receive little or no medications and are only infrequently attended to by medical personnel. Family members are responsible for obtaining and administering medications and meals - tasks they are often unable to fulfill. To the outsider, trained in more affluent circumstances, these conditions can be extremely demoralizing.
Volunteering one's services or traveling abroad does not protect against the same co-worker personality conflicts and turf battles that we find at home. In addition there may be too few staff members or coworkers who are emotionally drained, jealous, untrained or even dishonest. Some positions may be filled by totally unqualified "political" appointees. Sometimes the local staff has not been paid for months and as a result morale is low and staff are ready to go on strike. Resentment against a "foreigner" coming in and "telling us what to do" is not unheard of. Sometimes there is class-based friction between staff and patients of different socioeconomic or ethnic groups. For example, a local clinic worker may resent caring for a member of an opposing tribe or political group. Staff members may seek to get scarce clinic jobs or medicines for fellow tribe or clan members, displacing better-qualified candidates.
Even an experienced traveler can be distressed at a
lack of reliable electricity, bathrooms, privacy and
security. He or she may find the culture and language
alien, and the food, climate and housing difficult to get
used to. Political events may be worrisome. The diseases
may be unfamiliar and support in understanding them may
be scarce. Health workers also can become sick
In lots of poor countries there are more than 25,000
inhabitants per doctor. Any available health care in
these grossly underserved places will often attract
overwhelming numbers of patients. Stress builds on the
caregiver from what seems like an incessant bombardment
with legitimate requests for help. This pressure becomes
especially severe when one cannot help because of time
constraints or lack of resources. Having patients that
need your help is one problem; having too many that don't
really need you is another. Sometimes patients present
with mild illnesses or even without apparent medical
need. Many present in response to the stress in their
lives. Some patients are simply abusive or needy. Others
come for obscure social or mystical reasons. Regardless
of cause, it can be exasperating to overworked caregivers
who feel that they have sicker patients to tend to, let
alone sufficient time for themselves.
Corruption, theft, bribery and dishonesty are unfortunate realities in every country and at every level of society. The hardships of poverty can force otherwise honest and decent people to act recklessly. In some places these behaviors are not uncommon even among the healthcare workers and government officials. These crimes of desperation can take many forms, and though not precisely quantifiable, appear to be more acute in public than in missionary-run facilities. On a small scale medicines or supplies intended for hospitalized patients are pilfered in order to be given to a family member or to sell. Sometimes it takes the form of awarding scarce jobs to poorly qualified family or clan members. On a larger scale it can mean diverting funds intended for health services, accepting salaries for jobs not performed, misappropriating grants and wholesale theft of donated supplies. All aspects of care deteriorate--from record keeping to laboratory testing and equipment maintenance. The net effect can be a virtual crippling of health services.
Many facilities, particularly those run by missionary groups or other outside agencies check corruption. Their success appears to come from having honest personnel at the higher levels and perhaps in having the financial resources to pay their workers regularly and fairly. When funds are not stolen by managers, the staff can get paid - thereby eliminating their need to pilfer to support themselves. The incentive of desperation is removed. Hiring and firing is done on merit; supplies are kept under lock and key.
Because hospitals and clinics are sources of social and financial power within a community, it is not uncommon for administrators to face unusual pressures from government officials or other powerful community members who want to tap or control this power. For example, a local official may wish the clinic or hospital to provide special care or employment to friends and family. At times these pressures are de facto extortion. Imagine the strain on a hospital director when the commander of the local military garrison requests that his untrained daughter be given the job as chief of nursing! Such situations can be quiet intimidating, not to mention time-consuming. They are best approached by having a thorough understanding of the local culture. Unfortunately, in societies where corruption is rampant the best solution sometimes lies in having as much institutional independence as possible. This may mean owning the land and buildings, having independent water, power and sanitation supplies, having the authority to hire and fire all personnel and having adequate funding to pay them a livable wage. Additional leverage against such abuses is held by relief groups who provide and control additional services to the public such as electricity or water. Institutional independence need not conflict with the ideal of full community participation in and responsibility for a health project. They may conflict however, when abuses are perpetrated by or tolerated by the local people who share control of a health project with you. Fear posed by such dilemmas can dissuade one from sharing control of a program in the first place. The risk is then run of being accused of running a paternalistic or "neocolonial?" program. Reconciling this situation fully may be difficult. How fortunate are those who have many honest, powerful local allies, colleagues and supporters.
Although the majority of volunteer assignments are safe, volunteers should investigate potential risks before signing on. Determining your level of acceptable risk is an individual matter. Keep in mind that danger can come from a variety of sources including accidents, crime, disease, terrorism and war. Accidents in vehicles are the biggest overall source of serious danger. However, risks can be substantially increased for those choosing to work in areas of conflict or high crime. Although still very infrequent, humanitarian medical personnel have been specifically targeted for violence. Take, for example, the nurses murdered in Chechnya during the conflict with Russia. Clearly, health personnel in war zones can also fall victim to the same mines, shells and other weapons as their patients. Look to the organization with which you are considering working, or other groups in the area for first hand information. Talk with on site personnel, recent returnees and knowledgeable expatriates. US State Department Travel Advisories and Human Rights Reports are worth evaluating. The UNDHA's ReliefWeb carries additional updates of interest. Press reports can help flesh out the picture. Before anything else, you might consider reading IMVA's primer on keeping safe while volunteering.
Successful coping with difficult conditions found in many developing nations requires preparation, a fundamental readjustment of expectations, an alteration in the roles of health providers, new approaches to care delivery, a thorough understanding of the problems faced by the population being served and a willingness to protect yourself from burn-out.
Personal preparation is essential to functioning effectively on assignment. Issues such as language and medical preparations are discussed above. Through planning and a little research one can avoid assignments which are dangerous, unproductive, unrewarding or overly demanding. To make matters even more confusing, you will sometimes find that the realities on site differ a little from what the central office told you. This is quite understandable given the fact that the central office is usually thousands of miles away and can't really know all of the problems, needs or capacities of each clinic or hospital. Sometimes they are unaware of the full spectrum of personnel that can actually be of service on site, or what equipment and supplies are actually on-hand. For this reason contacting the actual on-site person in charge or people who have just returned is recommended whenever possible.
Given the overwhelming obstacles posed by poverty, malnutrition and lack of resources, health care providers must accept that they cannot deliver sophisticated, first-world medicine to every corner of the globe in the foreseeable future. But decent, basic health care delivery is possible even under adverse circumstances with some innovation and hard work. Some examples of how expectations must be altered include:
Where health care is scarce there are rarely neatly
defined job descriptions. To be effective, members of
medical teams must be highly innovative in the way they
work and respond to challenges. For example, care must
often be organized so that tasks are performed on the
lowest appropriate level on the referral chain. This
means that many of the duties which are performed by
nurses or physicians in developed countries are taken up
by local health workers who are specifically trained to
do so. They may drain abscesses, conduct tuberculosis
follow-up clinics or attend all but the most complicated
births. A more comprehensive discussion on the role of
Community Health Workers is presented elsewhere.
Health care systems in developing countries often operate much differently and more cost - effectively than in highly developed areas. For example, since cost is usually a major concern, donated or low costs supplies are used. Innovative funding ideas such as community shared payment must be devised. Supply and waste disposal costs are reduced by cleaning, sterilizing and re-using normally disposable items such as surgical gloves and syringes. Staffing costs can be lessened by having families feed patients and help with other chores. Frequently, treating without the benefit of extensive laboratory testing and using the least expensive drugs or treatments are required. Clinical efficiency is improved by use of treatment protocols, streamlining and simplifying treatments and minimizing paperwork. For instance, self-retained medical records help minimize record-keeping costs and provide some continuity of care for patients on-the-move like refugees or migrant workers.
Few staff caring for many patients must implement triage and referral systems. Screening out abusers and the "worried well" patients through a triage system ensures that the most needy get the help they need. Referral schemes promote efficiency by ensuring that highly trained staff don't spend valuable time performing tasks that can be handled by caregivers with less training. Triage and referral occurs both within and between healthcare facilities. For example, within a district hospital, a community health worker may treat some cases and refer others to be seen by nurses. They in turn treat some and refer the more complex ones to the appropriate doctors. A referral hierarchy of several tiers may be required depending on the patient-to-staff ratio and the sophistication of services. These same principles apply between facilities. Figure 1 illustrates one such scheme.
DISTRICT or REGIONAL HOSPITAL
VILLAGE DISPENSARY or HEALTH CENTER
COMMUNITY HEALTH WORKERS "BAREFOOT DOCTORS"
In many locations electricity is
unreliable and spare parts, equipment and supplies are
difficult or impossible to obtain. Health personnel
frequently use special equipment to get by. For example,
solar panel arrays and diesel generators can light a
hospital; kerosene fueled refrigerators can keep
perishable vaccines cold; a wood fired water heater can
provide a hot shower at the end of the day. Adaptable or
appropriate technologies such as these also have
far-reaching implications for patients. For instance,
innovative simple equipment can be used to provide
potable water, irrigate crops, improve sanitation and
facilitate small enterprises. Health workers are
encouraged to learn about these technologies and share
this information with their patients. The Appropriate
Technology Sourcebook is an excellent
"You can lead a horse to water, but you can't make it drink"
Understanding the local community is fundamental to the planning and implementation of a health program or project. This implies understanding both their culture and their medical problems. Without knowing about their culture and customs a well-intentioned health care provider might inadvertently insult them or plan treatments that they don't find culturally acceptable. The uninformed caregiver can be tripped up by many subtle and obscure causes and remain unable to gain patients? trust or get them to follow instructions. He or she will remain mystified as to why people return again and again without apparent medical problem, exaggerate symptoms or fail to return for much needed visits. Therefore it is important that health providers make a conscious, serious effort to learn about relevant local customs and beliefs. Usually this information only comes from local people willing to share it.
Volunteers, missionaries and other international health care providers are human beings. As such they must take care to protect themselves from physical and mental exhaustion. They must have adequate privacy, time away from the work and the opportunity to discuss their feelings and frustrations honestly with someone. Without these outlets they are likely to become weary, difficult, unhappy and even develop a kind of natural revulsion to their work. Forcing oneself to take time-out is understandably difficult for the busy caregiver faced with overwhelming numbers of patients. Even the smallest things, like treating oneself to a chocolate bar or dinner out, can trouble the conscience of the worker faced with severe poverty. Nonetheless, refuge of some kind from the work must be taken. Many people find an outlet in family, music, reading, religion or exercise. Find healthy outlets that works for you. Encourage and support your colleagues to do the same.