Introduction

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.

Inadequate Infrastructure

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.

Problems with Personnel

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.

Personal Hardships

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 themselves.
Some caregivers have worked hard for years to set up a health program, but feel unable to take even a short vacation for fear that the program will grind to a halt. In many cases their fears are justified. That is why planners are encouraged to try to get genuine local participation in projects so that others can take over when a caregiver dies, retires or goes on leave. Likewise, caregivers who are the sole providers of a particular service feel trapped because they worry that no one can take over for them. Others feel unable to take time off because they feel badly about burdening their colleagues with extra work.
Some volunteers undergo these hardships only to encounter patients desperate enough to steal or lie or otherwise behave ungratefully. For those who are unprepared for or unaccustomed to this kind of conduct, these factors can be overwhelming and cause a kind of "medical culture shock."

Problems with Patients

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.
Staff may need to devise strategies to protect against abuse of the healthcare system by patients. To do so they must rely upon a careful analysis of the local culture and social dynamics. Sophisticated local inhabitants, experienced foreign nationals and community leaders can often provide valuable insights into the causes and resolution of this problem. Charging patients at least a token amount helps to discourage unnecessary visits, but care must be exercised to ensure that the poorest people still get help.

Corruption

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.

Danger

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.

How to Cope

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.

Preparation

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.

Readjustment of Expectations

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:

• In a busy outpatient ward or clinic not all patients may be able to be seen by the doctor. 
• Work-ups of medical problems may need to be simplified; thus, not all illnesses may be definitively diagnosed. 
• Not all illnesses may be treated as well as might be desired. 
• Equipment, supplies and referral options will likely be limited and therefore at times inadequate. 
• Patients? families may be expected to provide meals, medications, bedding and supplies for hospitalized patients. 
• Don't expect to be tremendously effective your first time out. Like any new job there is a steep learning curve in the beginning. 

Medical Staff Must Adapt Their Roles to the Situation

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.
Even short-term volunteers should be prepared to take on new kinds of duties. The doctor or nurse often becomes teacher, supervisor, organizer, and consultant. The long-term volunteer is often called upon to shoulder administrative and organizational tasks. These may include responsibilities with which the volunteer has no prior experience, perhaps acquisition of food, water, fuel, electricity, shelter and medical supplies. Project planning, construction, transportation, logistics, budgeting and funding can also become new, but crucially important burdens. The person taking on these responsibilities often becomes a liaison and conduit for aid and the taskmaster-friend who listens to, guides and advises the community on ways to make the best use of any available resources.

New Approaches to Care

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.

(FIGURE 1)

TEACHING HOSPITAL

DISTRICT or REGIONAL HOSPITAL

COMMUNITY HOSPITAL

VILLAGE DISPENSARY or HEALTH CENTER

COMMUNITY HEALTH WORKERS "BAREFOOT DOCTORS"

Innovations and Appropriate Technologies

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 starting point.
In the hospital or clinic, health workers must be ready to use makeshift equipment, modify existing equipment, or use equipment in new ways. This may mean fashioning medical equipment and devices out of existing materials or creating simplified versions of equipment. For example, low cost wheelchairs and prosthetic limbs can be produced allowing disabled persons to regain productivity. Surgical instruments can be made on site to substitute for unavailable or expensive manufactured ones. One way practitioners throughout the world have shared innovative ideas for equipment is through the journal Tropical Doctor, which is also an excellent source for clinical strategies for use in developing countries.

"You can lead a horse to water, but you can't make it drink"

Understanding the Patients

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.

Avoiding "Burn-out"

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.