Electives, voluntourism and the ethics of selling poverty

This article was originally published in Student BMJ, a magazine produced by the British Medical Journal for medical students. An online version can be found here.

Big Business

With an estimated annual worth of $1.7-2.6 billion (£1.1-1.7 billion), overseas volunteering has become big business, with the term ‘voluntourism’ having been coined to describe the trend. Medical students participate in these schemes as much as anyone, often during summer vacations or before starting university. Meanwhile, an estimated 40% of UK medical students spend their elective in a ‘developing’ country. Not only do the projects provide an exciting opportunity to travel to exotic locations, but they promise independence, the chance to develop new skills and become self-reliant.

Yet despite its popularity, the booming voluntourism industry is challenged by some of the core questions of medical ethics.

Compromised principles

Having just finished first year of medical school, I eagerly signed up to a four-week voluntary project in southern Ghana. Before long I realised that the placement was less about realising my own (somewhat naïve) intentions as it was about selling an experience. During one trip to a local orphanage, my supervisor drew a camera from his rucksack. “Photos to remember your trip,” he grinned, as the children were shooed into line for the picture. None had been asked whether they consented to being photographed, nor whether they minded their home being used as a backdrop for a foreign teenager’s profile picture.

Such an approach to voluntary projects isn’t atypical. Although motivated by good intent, many overseas projects resemble the paternalistic attitudes of an archaic global outlook. Lacking any significant understanding of the language, culture or history of the communities they visit, students are often motivated by pre-conceived perceptions rather than any discernible evidence-based need. Among the rush to build schools and libraries for example, are reports that local workers have been hired to reverse the inappropriate building work carried out by inexperienced volunteers.

Projects related to medicine raise further concerns. Volunteers are rarely asked to complete safety or competency checks, and when they are, lacklustre safeguards often disregard the ancient principle to “first do no harm”. One study described a case in which a first year medical student was expected to perform a lumbar puncture during an overseas project, while another was left unsupervised to complete a tubal ligation.

A 2011 documentary made by a physician at Canada’s Dalhousie University explored similar cases, with one medical student describing how she had been “terrified” when left alone to deliver a baby on an elective overseas. She commented that although students would “never be allowed” to perform such a procedure at her home institution, she felt there were “different standards” on her placement. In her words “there had to be; it was the choice between me and no-one”.

It is not uncommon for students to find themselves in a position in which they “don’t feel like they have any choice” to refuse to participate in procedures on the basis of clinical competence. Speaking to Student BMJ, a student currently on elective in East Africa commented that he “earned the doctor’s enmity” after contradicting his suggestions. Admitting that his “expectations didn’t match with a real understanding of the situation in-country,” the experience left him “wracked with anxiety”.

Although the emotional toll and immediacy of such situations may appeal to rationalising a “choice between me and no-one,” medical students should be mindful of the advice presented in the British Medical Association’s medical elective toolkit. Despite asserting that overseas work can be a “significant learning opportunity”, the advice cautions against “the idea that ethical codes are different in different countries”. It also refers to the General Medical Council’s Good Medical Practice guidelines which state that medical students “must work within the limits of their competence” at all times, home and abroad. The message is clear; when students are “asked to act beyond their clinical competence, they should politely but firmly decline”.

Considering this, medical students eager to work in resource-poor clinical environments may be best advised to wait until they are more qualified before travelling overseas. Indeed, the contribution made by UK healthcare professionals during the recent Ebola crisis, as well as in numerous refugee crises, is significantly more tangible than anything a medical student could offer on a voluntary project.

Power dynamics

Nonetheless, despite a number of guidelines having been made available to medical students, it is unclear whether current advice recognises the scale of the problems of voluntourism. A 2011 report by the think tank Demos warned that overseas voluntary projects risked being perceived as a new form of “western colonialism,” suggesting voluntourism allowed wealthy individuals to “assert power” over resource-poor countries. These concerns have been echoed in research conducted with the host organisations that receive volunteers, revealing that medical staff often lack “any choice of which students can come” to work at their clinics.

Indeed, Dr Harriet Mayanja-Kizza, Head of Internal Medicine at Mulago Hospital in Uganda commented that “we sometimes find [volunteers] use up a little more time than they give back,” a point that medical students would be well-advised to consider. Despite extensive reports suggesting students approach overseas work with a “good Samaritan mentality,” the reality is that these projects are first and foremost learning opportunities. Unsurprisingly, their benefit lies primarily with the volunteer – with improvements in “self-confidence, self-reliance and motivation” often reported by participants.

This inequity is perhaps best summarised by one ex-voluntourist, who recounted how a clinic that could “barely function” had been expected to “act as a teaching centre for wealthy and privileged medical students”. The volunteer’s concerns were that by choosing to travel to a resource-poor setting, and in doing so demanding the time, energy and attention of over-stretched clinicians, medical students were participating in an unnerving power dynamic. The scale of the problem is significant too; UK medical students spend an annual combined 350 years on electives in ‘developing countries’. Yet similar opportunities are rarely reciprocated to allow overseas medical students to gain experience in the UK’s own institutions.

It has been argued that these inequities are offset by the economic advantages that the voluntourist industry can bring to local communities. Yet significant questions have been raised about how much of this money reaches these communities. A typical project, such as those arranged by the organisation Projects Abroad, charges volunteers approximately £1,700 for a four-week placement. Only 41% of that fee is spent on the “implementation of projects” and “direct costs on the ground,” with the rest allocated to administrative costs and “awareness, communications and advice”.

Selling poverty

Voluntary projects also have broader economic effects beyond the local spending habits of volunteers. Unlike other forms of tourism, which advertise rest & relaxation, adventure, or scenic beauty, it is poverty which sells in the voluntourism business. The dangers posed by such a market pressure can be devastating.

Attention was drawn to these risks in a 2010 report by the South African Human Resources Research Council, which revealed that “HIV orphan tourism” had become a “niche market.” The researchers described how voluntourism caused an expansion in the numbers of unstable, unregulated orphanages, vulnerable to high staff turnover and compromised care. Perhaps most disturbingly, the report described cases of children being removed from poor families in order to maintain a stock of orphanages for willing tourists to visit.

Similar cases have been exposed in Cambodia, where UNICEF now advises visitors to “avoid working in residential care facilities for children” altogether. The policy resulted from worrying observations that, despite the country’s total number of orphans having fallen in recent years, there had been a “steady increase” in the number of child residents at apparent orphanages. UNICEF believes this perverse trend was fuelled by the array of opportunities to financially benefit from volunteers, and the charity estimates that more than three-quarters of children in Cambodian orphanages have a living parent. In the words of researchers, well-meaning voluntourists have transformed orphanhood into a “globally circulated commodity”.

Although abuses on this scale seem unlikely in medically-orientated projects, these cases clearly demonstrate the devastating consequences that such an artificial influx of capital can have on local communities. After all, if it is common economic wisdom that where wealth and demand exist, supply will follow, then the current global appetite for overseas voluntary projects should be a significant cause for concern.

An ethical alternative?

Considering this, should students be advised to avoid overseas placements altogether, or is there potential for a more ethical voluntourism? Gavin Bate, founder of the organisation Fair Trade Volunteering, notes that he’d “absolutely” recommend overseas volunteering to medical students, stating that overseas work can allow students to “consider their vocation in a different light”. However, he stresses that any benefit is “conditional on the values and ethics of the organisation,” calling for “equitable relationships” with recognised “expectations” and “agreed benefits”.

The national student group Medsin have also drawn attention to the issue, and are currently working with the UK Medical Schools Council to improve the advice available to medical students. Natasha Matthews, a member of Medsin’s National Committee, told Student BMJ that the organisation hope to influence the GMC’s next ‘Tomorrow’s doctors’ document. She highlights a need for a “much greater emphasis from medical schools and the GMC on the importance and value of ethical electives,” drawing attention to Medsin’s own guidance on the topic. The group has made significant progress; last year its policy suggestion was adopted by the International Federation of Medical Students Associations (IFMSA), which now recommends that universities should adopt a framework for overseas medical placements in order to properly consider their effects on hosting communities.

Considering this pressure from student groups, it is possible that medical educators will follow the lead of Professor Jon Dowell, who has set up a “Responsible Electives” program at the University of Dundee. The scheme now organises for around ten medical students to travel to partner hospitals in Malawi every year. Unlike other programs, Dowell describes how the longer placements (three months as opposed to six weeks) allow students to develop skills to an extent in which they can contribute more to their host organisation. The program also champions pre-departure training and encourages its students to fundraise for host organisations, while also inviting students from Malawi to complete their elective in the UK. Despite these moves, Dowell remains hesitant about describing his organisation as “ethical,” explaining that there’s still a “debate about what can be achieved with such electives”.

However, Dowell sounds most enthused when discussing how he’d be “completely delighted” for a national organisation to act on the issue. He urges the GMC to “at least show an interest,” citing the example of Canada, whose licensing body has urged medical schools to reconsider their approach to electives. Similarly, he criticises the inequity of UK medical schools “taking money” from students and the government before “punting you off with little investment” in host organisations.

Aside from these criticisms, Medsin’s Natasha Matthews argues that “the problems of electives are not solely due to a lack of high level governance,” describing students as “important stakeholders in the development of ethical programmes”. Indeed, with only preliminary research having been conducted on the topic, any progress in the foreseeable future is perhaps likely to be limited to individuals making personal changes to their attitudes towards overseas volunteering. This will be difficult, as many of these projects are already motivated by good intent. Nonetheless, the unnatural conjugation of volunteering and tourism is one which will need to be discussed if we’re to confront the difficult ethical questions that overseas volunteering raises.

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