General Advice This following advice on how to prepare for international health work begins with some general recommendations, then describes a detailed preparation scenario, provides a checklist and concludes with information on several important topics. Naturally, the kinds of preparation you make may depend a lot on how long and where you are going, as well as what you will be doing. Consideration must be given to travel, personal, and professional aspects of an assignment. Those choosing to commit to a career of volunteer service should ideally start to prepare as early as possible to get all of the proper training. It is, of course, desirable to study the languages of the part of the world where you will work. If you don't yet know just where you will be going, study the language of a region that interests you. You may want to seek specific training in fields such as administration, public health, tropical medicine, education, and even anthropology. Although you may be a doctor or nurse, you may be called upon to perform administrative and planning functions. This is particularly true of long-term assignments. A little training beforehand can come in quite handy. Formal instruction in working well with others (especially with people from other cultures) is often extremely helpful. A working understanding of electricity, plumbing, construction and mechanics can also prove invaluable to those who take on extensive administrative and planning chores. It is a great pity when a well-meaning health worker becomes discouraged because of a bad experience on an incompatible assignment. This kind of mismatching can often be avoided by researching the assignment well before you accept it and by preparing properly before you go. The more thoroughly you prepare, the more effective you will be and hence the more rewarding, you will find the experience. Don't rely on anyone or any organization to provide you with all the information you will need. Learn all you can about the country, its local diseases, cultural norms and language. Poke around the travel and language sections of bookstores and libraries. It is almost always worthwhile to buy a good, up-to-date guidebook to take along. Explore Books in Print to find specific publications of interest that may not be locally available, but which you can order. Consult the library's Reader's Guide to Periodical Literature or indexes of newspapers to find recent articles about your destination. This can help you get a better idea of the local social and political conditions. Brush up on any infectious disease, tropical medicine or public health subjects you think you may need to know about. Remember that you are likely to have only limited access to this kind of information after you arrive. Consult medical libraries for relevant books, and browse International Medical Volunteers Association's on-line annotated bibliography of pertinent medical books. Use the names of your destination and prevalent diseases as keywords to search databases like Medline or even Index Medicus to find important articles. You might also want to find out something about the organization you will be working with. If you are volunteering long-term, it may be important to choose to work with an organization that has a philosophy compatible with your own. Many times, however, the organization's philosophy is not so important as long as you feel the work you are doing is worthwhile. You might also like to learn about other relief groups working in the same country because you may want to share equipment, cooperate on projects or just get their advice. IMVA can help you with the big picture through its descriptions of the major organizations involved in relief and disaster programs. The catalogs produced by the National Council on International Health (NCIH) and Interaction contain descriptions of their affiliate organizations. They also provide tables listing which groups work in which countries. Armed with this information you can call the home offices to learn more about the work they are doing overseas. They can also help you to get in contact with their in country representatives. You may want to talk to people who have recently been to your intended destination. If possible call, write ahead, or even visit to get a clearer idea of exactly what you will be asked to do. Make sure that at least the minimum resources will be available to allow you to function in your medical capacity . Some organizations, especially smaller ones, may have unrealistic expectations as to what the volunteer can do. With this information you can make more informed decisions about any books, instruments or supplies that you may need to take with you. Foreign Language Preparation English, French and Spanish are the three principal languages of international health. Be thankful you already know English; it is the most widely spoken language in the world outside of China and is an official language in approximately 85 nations and territories. French and Spanish are the most frequently studied foreign languages in the United States, and thus you may already have some knowledge of one of these two languages. If you plan to volunteer in a Spanish or French-speaking country, it will be worth your while to study the relevant language or to brush up your language skills, if you have previously studied one of these languages. Classes in these two languages are widely available at colleges, language schools, and night schools. In addition, many hospitals sponsor courses in medical Spanish. If you have the time and money, the best way to learn a foreign language is to enroll in an immersion program in a country where the language is spoken. The International Language and Culture Institute of the American Medical Student Association offers six-week summer courses for medical students in four Spanish-speaking countries. Students live with the families of local medical students. Room, board, fees, and transportation should cost between $1,000 and $1,500. Other international health-oriented language programs in Spanish are run by the University of California Irvine [Contact Dennis Mull, M.D., Dept. of Family Medicine, University of California Irvine College of Medicine, Irvine, CA 92717, (714) 634-5171], and the Hesperian Foundation [Contact Steve Babb or Barbara George, Hesperian Foundation, P.O. Box 1692, Palo Alto, CA 94302, (415) 325-9017]. There are many other immersion programs, without international health orientation; you can probably get information about them and recommendations from a local university language department. With audio, video, and computer-based programs widely available, self-study of foreign languages is easier than ever. Since you will primarily use the foreign language for conversation, you should concentrate on audio tapes and, if possible, sessions with a native speaker. Foreign language tapes are available in most large book stores and public libraries. Those developed by Berlitz, Pimsleur, or the U.S. Department of State are generally well regarded. Commercial television programs in both French and Spanish are shown in many urban areas of the U.S. and may be helpful since the dialogue is usually clear. Movies have less clear soundtracks, as a rule, and less dialogue per minute. Two PBS-funded video courses developed over the past several years are shown occasionally: French in Action and Destinos (a Spanish language program). You can purchase both from Annenberg/ CPB Collection, P.O. Box 2284, South Burlington, VT 05407, 800-532-7637. Part I for each series - including 26 half-hour videos, the workbook, study guide and audiocassettes - costs $299. Part II - 26 videos plus supplementary materials - costs $265 for French in Action and $255 for Destinos. If this seems too expensive, you may be able to find these programs at a local public library, or you may wish to try one of the interactive computer-based language programs now on the market. Two mail-order companies that specialize in CD-ROM-based language teaching programs are Hyperglot Software Co., P.O. Box 10746, Knoxville, TN 37939-0746, 800-800-8270, and International Software/Lingo Fun, Inc., 615 Brook Run Drive, P.O. Box 486, Westerville OH 43081-0486, 800-745-8258. Prices for these programs start at around $100. Discounted CD-ROMs with elementary language lessons can be found for under $15. When listening to audio tapes, it is important to repeat out loud the words, phrases, and sentences you have heard. If you don't have the assistance of a teacher to help you with pronunciation, record and listen to yourself. In addition to audio tapes, another valuable tool in learning a foreign language is the use of vocabulary cards. You can make your own or buy commercially prepared sets. Cards that have pictures rather than English words on the flip side will assist you in thinking in the foreign language. Applause Learning Resources (85 Fernwood Lane, Roslyn, NY 11576-1431, 800-APPLAUSE) sells sets of 1,000 vocabulary cards in Spanish or French for $10.95. If you want to read medically-oriented materials in Spanish, many publications are available from the Pan American Health Organization. The World Health Organization publishes almost all of its literature in both English and French. The Control of Communicable Diseases Manual, published by the American Public Health Association, is available in Spanish and French editions. Finally, David Werner's Where There Is No Doctor, a classic guide for community health workers in developing countries, has been translated into more than 40 languages. It is available from the Hesperian Foundation (see address above). Because of the large number of Spanish-speaking patients seen at many U.S. medical facilities, there exists a large variety of teaching materials for health care professionals who want to learn basic medical Spanish. Two inexpensive and useful paperbacks are ¿Que paso? An English-Spanish Guide for Medical Personnel by Kantrowicz, Mondragon, & Coleman, Univ. of New Mexico Press ($6.95) and Spanish for Health Care Professionals by William C. Harvey, Barron's Educational Services, 1994 ($11.95). DiLoreno-Kearon, M.A. and Kearon, T.P. have designed a course in medical Spanish with 12 audio-cassettes - Medical Spanish ($195). (The book alone for this course is available for $20.50.) Schoenhof's Foreign Books (76A Mt. Auburn St., Cambridge MA 02138, 617-547-8855) carries all the above medical Spanish materials as well as several other texts and medical dictionaries. If you do not have sufficient time to study Spanish comprehensively, one of the above specialized medical Spanish books is a must. Even if you decide to study the full range of the language, these books will provide useful vocabulary and phrases not often covered in traditional Spanish courses. As far as we have been able to determine, only one work in medical French is currently in print - Pocket Medical French by R.R. Bowker, 1995, Russell Dollinger ($9.95). In addition, Schoenhof's Foreign Books (see above) carries several French medical dictionaries at reasonable prices. If you plan on volunteering in a country where English, Spanish, or French is not widely spoken, we strongly urge you to study the relevant language, although Arabic, Chinese, the Indian languages, and the languages of Southeast Asia will be much more difficult to learn than Spanish or French. Even if you only learn the basics, your efforts to communicate in their language will be greatly appreciated by the people with whom you are working. Language courses of interest may be offered in your area. If not, and if you cannot find tapes or other language materials at your local library or bookstore, Schoenhof's Foreign Books (see above) has materials for learning over 270 languages, and Audio Forum (96 Broad St. Guilford, CT 06437, 800-243-1234) sells cassette courses in 92 languages. Case in Point: Preparing for Haiti To illustrate the importance of making ready, consider the following example and imagine how different things would be if these preparations were neglected. You and your spouse have agreed to work for 18 months at a small mission hospital in the rural Haitian town of Bon Chien. One of you is an orthopedic surgeon, the other is a nurse. You will be bringing along your children ages 4 and 7. You have never been to Haiti. The organization you joined up with sends you a packet of information. It provides an overview of the country, a brief description of the hospital and instructions detailing where and when you will be met at the Port-au-Prince airport. You want to prepare yourself and your family as well as possible, so you begin by going to a large bookstore. There you find that only two of the ten guides to the Caribbean even cover Haiti. You buy the better of the two. Browsing it you find that most Haitians speak Kreyol rather than French as you had thought. You find that although the bookstore language section has no books on Kreyol, the clerk at the information desk is able to order a small Kreyol language instruction book. You order that and the next day call a foreign language specialty book shop. They have several English-Kreyol dictionaries, some audio-tapes and even a English-Kreyol medical translator book. You send for this material and begin to review it. You begin to wonder just what kinds of diseases you will be treating so you send a letter to Dr. Mudge, the hospital administrator asking for more details. Not being sure how long it will take to get a reply, you surf the Internet at work and find that the Pan American Health Organization has a fairly recent report on health conditions in Haiti. You learn that there are several diseases you have never seen. Also, as you suspected, tuberculosis is common. You recall that you have treated very few orthopedic complications of TB. You therefore go to a nearby medical library and find some helpful chapters and articles. In addition you decide to buy the latest edition of Manson's Tropical Disease to take along as a general reference. Seeking still more information, you call the American office of your sponsoring organization. Although they can't tell you just what kind of surgical equipment is available, they give you the names of two people who recently were at the hospital for a short stay. Calling them you learn some important news. The doctor you will be replacing, although trained as an orthopod, routinely performed other operations such as hernia repairs and Cesarean sections. You will likely need to take over these tasks when the only other surgeon at the hospital leaves two months after you arrive. You begin to study up and scrub in on some of these cases. Having read a little about the political problems in Haiti, you ask about safety in the countryside. You learn that the Bon Chien is both beautiful and safe. Political intrigue never disturbed this idyllic coastal town even in the days of the infamous Papa Doc and his Tonton Macouts. It becomes clear that your children will be well taught at the mission school. However, the classes are in French. You decide that they will need to start learning it now, in addition to Kreyol. You realize that you must learn some French too, because that is the language used to communicate with the nurses. To get better prepared, you hire Monsieur Jaques, a Haitian man who lives in a nearby town, to tutor you and your family twice a week. From him you also learn many things about Haitian culture and traditions. Your kids ask what kind of sports the Haitian children play. He responds that they like soccer, but that few people can afford a ball. Although he was raised in the city, he is able to tell you something about the rural people in Bon Chien. You learn something about their daily lives and their burdens of malnutrition and illiteracy. He speculates on their likely views of science and western medicine. His voice is a little hushed when he talks of Voodoo. You discuss how these practices and beliefs will affect the way you care for your patients. A letter arrives from old Dr. Mudge in Haiti. He is so very happy to learn that you are coming. He especially looks forward to having your spouse help take charge of dispensary and maternity ward. You both begin to wonder how the seven midwives will react. Somewhat daunted by the prospects of these new responsibilities, your spouse enrolls in a four-week course in healthcare in developing countries at a local public health school. You wish that you could attend as well. Dr. Mudge also writes that x-rays can be taken only a few hours a day when the generator is running and that there are no supplies to perform open reduction internal fixation procedures. You decide to collect material for this purpose and get promises from your colleagues and equipment "rep" friends to send you additional supplies while you are there. You also ask the scrub nurses to collect suture material and other usable supplies. They promise to keep sending whatever they can. As your departure date approaches, you and your family visit a local travel clinic to get all of the needed vaccinations. You learn that all of you will need to take chloroquine weekly. Over the final weeks before your departure, you collect and ship the books and supplies you now know you need. You realize that there will be no television and no electricity past 8 p.m. You decide to stock up on a few more children's books and videos, snorkeling equipment and an AM-FM-short wave radio that is powered by hand crank. As a final thought you purchase a few gifts for your new colleagues and a half dozen inexpensive soccer balls which you carefully deflate for shipping. Checklist of Professional and Personal Considerations Facilities: At how many and at what kind of facilities will you be expected to work? How far are the sites from your living quarters? Who pays for and arranges transportation? What is the physical condition and upkeep of the buildings? Are electricity and uncontaminated water always available? Working Conditions: What kinds of laboratory and diagnostic tests are available? What referral and consultation options are available? Will your skills be well utilized? Is prior overseas experience required? Will local personnel be affected or offended by your presence? What kind of training have the support staff and your colleagues had? What will be your work schedule -- how many patients will you see each day? Will you have sufficient time off? Is "home-leave" available for those performing long term service? Equipment: Will you be using equipment with which you are familiar and which is labeled in English? Can you bring equipment that will work on local power sources? What happens when repairs are needed? Licensing requirements: Is a special license required to practice in a given country? If yes, how is the license obtained and how far in advance must one apply? Will your sponsoring organization assist with the paperwork? Documentation: Are a passport, visa or even a local work permit required? How are these papers obtained and how far in advance must the application be made? Will your sponsoring organization assist with the paperwork? Immunization/Prophylaxis: What immunizations and medications are required or recommended for the region in which you will be serving? Would you like to consult a travel clinic? Insurance: Will your current US health, disability and life insurance policies cover travel and service overseas? Does your sponsoring organization provide any coverage? What medical liability insurance (if any) is required or recommended? In Case of Trouble: What kind of protection and assistance can you expect from US Department of State representatives and/or local authorities in the event of difficulties? Have you left a detailed itinerary and other information (passport number, date and place of issuance, airline ticket numbers, credit card numbers etc.) with a resourceful individual back home? Communication: What means are reliably available for the volunteer to communicate with family, loved ones and sponsoring organizations back in the United States: mail, telephone, modem (e-mail), fax, HAM radio etc.? Language: What languages will you be expected to communicate in? If training is required, who will pay for it? Will instruction take place before or after arrival? If it is not possible for you to learn the language, are there competent medical interpreters available where you will be working and living? Culture: Are you cognizant of and prepared for the customs and taboos of the culture where you will be practicing, which may differ greatly from US customs which you may be assuming are "universal"? (In India, for example, it may be considered insulting to pat a little child on the head, which is seen as the seat of the soul.) Do any religious or cultural practices impinge on the practice of medicine? (Circumcision, dietary restrictions, concepts of modesty that may hamper physical examination). Have you considered how you will react to culture shock, homesickness, anti-American sentiment, suspicion, even ingratitude for your sacrifices? Environment: What range of weather conditions can you expect during your period of service? Is there real danger from earthquakes, monsoons or the like? What kind of insects and animals are you likely to encounter? What kind of clothing and equipment will you need to contend with these creatures (e.g. mosquito netting, high boots)? Living Conditions/Dependents: Where will you live? Who will pay for room and board? How safe and feasible is it to bring your family along? Do your children have to be over a certain age? What kind of schooling is available, and who will pay for it? Can you bring along a partner to whom you are not married? What will the food be like? Will you have sufficient privacy? Are electricity and uncontaminated water always available? How secure are your quarters? Are you personally willing to conform with local customs, such as refraining from alcohol during your entire period of service? Some Final Points to Remember When Overseas Before you depart, study closely the culture where you will be working. Anticipate and plan for cultural biases regarding science, sex, medicine and religion. For example, male physicians are sometimes forbidden to examine female patients in strict Islamic countries. Sharpen your listening and observational skills to pick up on local protocol, greeting patterns, and hierarchy. Don't assume that gestures are an international kind of sign language. What you intend as innocent miming may be perceived as offensive, insulting or otherwise provocative. Global Books, Ltd, publishes The Simple Guide to Customs and Etiquette in ... series, which includes little books on Arabia and the Gulf States, Malaysia, Thailand, and other countries. Global's US distributor is Talman, Co. Inc, 131 Spring Street, New York, New York 10012 Think of yourself as a good-will ambassador. Like it or not, you will be also probably be regarded on some level as a representative of your country. Refrain from behaving in ways that reinforce stereotypes of the "ugly American" as pushy, rude, hurried, wasteful and arrogant. Maintain a cooperative team spirit. If you aren't able to get along, you may adversely affect the morale of the whole team. Be as flexible as possible, in everything: your schedule, the duration of service, personal comforts, etc. Keep sponsors happy so that they will invite you or other volunteers back. Maintain the mind-set that you are volunteering your time not only to give, but also to benefit from the experience yourself. Make a real effort to keep yourself healthy on your trip. Staying fit will allow you to work better, and you won't have regrets later. Have realistic expectations about how much you can accomplish and how local people may or may not show their gratitude. Never promise or imply more than you and your organization can deliver. Be prepared for the fact that some of your in-country health care colleagues may have a very different work ethic than yours, seemingly acting less committed than you feel you are. Make an effort to teach whatever you can while you are there. In this way the benefits of your service outlast your visit. If you have a strong religious leaning, consider an affiliation with a like-minded organization. Schedule extra time at the end of your trip before you return to work to unwind and digest your experience. Extra time can also provide an often-needed cushion in the event of travel delays. Be prepared for "re-entry" culture shock. You may feel life back home is extravagant and wasteful. Friends and relatives may have little interest in accounts of your experiences and the deplorable conditions you encountered there.