FINDING A HOME IN INTERNATIONAL SERVICE: An Open-ended Framework

By Justin List

In the summer of 2006 over half of my medical school classmates traveled abroad on structured or independent international service learning experiences. Among that cohort, I journeyed to Kenya to a number of resource-poor communities in and around Nairobi with a group of my classmates for what quickly became a profound, life-changing experience. When classes began this summer, many students shared story after story with one another and conveyed similar attitudes. While some of us had more previous experience overseas than others, that distinction quickly became negligible when the impacts of these particular experiences were discussed. With more stories similar to these at schools around the country, there appears a growing student interest in the intersections between health, human rights, and globalization, which become all the more prescient for the future of medical education and a vocational understanding of one's life in medicine.

A rising interest in global health and international medicine may be due to several factors. A recent article posited that some of the reasons precipitating this rise might include students' previous international travel and first-generation Americans' concern for the low-income countries from where their families come¹. There may be other significant reasons to note as well. As the language of the social determinants of health-i.e., the social conditions that impact access to care, behaviors, and health outcomes² -increasingly enters into the vocabulary of today's medical student, students are more empowered with the tools and belief that they can make a difference in the global order, responding to injustice in low-income countries or at the margins in high-income societies. While feeling more empowered, students may be privately wrestling with the question: where is my home in international medicine?

Many readers may be familiar with or influenced by physicians such as Paul Farmer and Joia Mukherjee and their work with Partners in Health; health professionals of Médecins Sans Frontières; or with the countless number of individuals students learn from and work alongside around the world. Many of these inspiring role models have ostensibly found their "home" in international medicine. That is, these individuals are part of a particular community abroad or at home in some way that shows an ongoing commitment predicated on notions of social justice. Their commitments take the shape of their time and collaborative efforts, their financial resources and those of donors. Most importantly, they show a forging of lasting relationships in solidarity with the people in the communities where they practice medicine.

One helpful place to start the discussion comes in defining "international medicine." Is international medicine a primarily geographical or professional notion? Answering this question depends largely on context. Technically, a student from the US practicing in an affluent suburb of London practices international medicine if defined by location. I suspect, however, many students see international medicine inextricably linked to notions of social justice and human rights, working with people having few health rights or access to care, and it is with this conception that I move forward. Broadly defined, social justice refers to relationships that exist between groups and individuals in society and a just distribution of goods within society³. Globalization increasingly raises issues concerning a just distribution of goods in society and the role of high-income countries in addressing an unjust distribution of social goods among all countries. Do physicians have a role in health promotion in this discussion?

Medicine has a rich history of justice embedded in professionalism, which has at its core notions of the pursuit of justice in the lives of patients. Matthew Wynia et al. writes:

Three core elements of professionalism, each different in nature, are necessary for it to work properly. First, professionalism requires a moral commitment to the ethic of medical service, which we will call devotion to medical service and its values. This devotion leads naturally to a public, normative act: public profession of this ethic. Public profession of the ethic serves both to maintain professionals' devotion to medical service and to assert its values in societal discussions. These discussions lead naturally to engagement in a political process of negotiation, in which professionals advocate for health care values in the context of other important, perhaps competing, societal values⁴.

We can quickly see with this framework how physicians might historically play an important role in the moral and political realms of society with the patient-physician relationship as the benchmark for action. Doctors can also serve as a conduit between the privileged individual whose voice is likely to be heard standing in solidarity with the financially impoverished person whose voice goes unheeded by society.

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In this way, a career in international medicine for many medical students today may be more accurately called a career in international social justice and health given the above parameters for what international medicine can mean. A seemingly simple question, defining what international medicine means to a medical student is among the first and important set of important reflections to help guide her or him. It sets the stage for then asking, "why am I interested in a career in international medicine?" The questions only begin there.

Some students may find themselves asking the question "where is my community?"-a place where I will have the most impact. Particularly for students who have traveled overseas on a variety of international service learning or immersion experiences, one might feel frustrated trying to determine if this particular international setting is the one to which he or she will be invited more deeply into, remain dedicated to, cultivating the commitments so many students in international medicine often desire for when romanticizing a career in it. Yet other students may be frustrated in going about how to initiate a process of finding a community where they feel needed and still others will be frustrated in trying to finance their exploration into these experiences.

At one level, it may seem absurd to be frustrated about finding a "place" where we may be invited to become a part of and feel we can make a difference in the international health arena. The question about finding a "home in international medicine" may be misplaced at best and inadequate at the very least. The question itself connotes a certain luxury, privilege, and top-down mentality in our often inequitable world. It is never my community for which we seek; at best, we may become part of their community if the community embraces us as a partner, maybe even a member, in some capacity. At some level, we are always an outsider from a different, often more economically and politically powerful background. We must always remain attentive that international medicine should really never become an end goal unto itself, but rather, a means to achieving goals in solidarity with those in a community left behind or harmed by certain forces of globalization. Rather than asking a question of place, we should ask the question, does our work and the people we care for, partner with, and learn from create health, empowerment, and human flourishing? At one level, it may seem absurd to be frustrated about finding a "place" where we may be invited to become a part of and feel we can make a difference in the international health arena. The question about finding a "home in international medicine" may be misplaced at best and inadequate at the very least. The question itself connotes a certain luxury, privilege, and top-down mentality in our often inequitable world. It is never my community for which we seek; at best, we may become part of their community if the community embraces us as a partner, maybe even a member, in some capacity. At some level, we are always an outsider from a different, often more economically and politically powerful background. We must always remain attentive that international medicine should really never become an end goal unto itself, but rather, a means to achieving goals in solidarity with those in a community left behind or harmed by certain forces of globalization. Rather than asking a question of place, we should ask the question, does our work and the people we care for, partner with, and learn from create health, empowerment, and human flourishing?

We cannot deny the questions and concerns that remain with us as we envision our futures, questions that may seem pedantic, selfish, or even inappropriate sometimes. They are part of our efforts to understand our experiences and define our sense of vocation. Perhaps health professionals and students who find that they encounter these and similar feelings before or after work abroad may find more guidance in reframing the questions informing their discernment about a future in international medicine.

There are many angles from which to approach the question of "where is my home in international medicine?" in the broader sense. There are no formulas or prescriptions for a life in international medicine it seems, and we can see this through the diverse pathways our role models in this field have journeyed. Tempting as it may be to mold our stories to mimic theirs, we must realize that like them, our journeys also continue to weave in unique, often uncalculated ways. Their experiences and actions mentor, inform, and teach us, but mentors can only bring us so far in defining our place and vocation in international medicine. Our experiences in a particular community are unique more often than not. Yet it is important to actively learn from our role models in international medicine who continue to encourage us and offer insight into how to respond to a community that may be drawing us in and to whom we find ourselves drawn.

There are at least four angles worth examining as medical students in remaining open to the often unknown future of our homes in international medicine: (1) articulating our ongoing learning and understanding of international medicine; (2) understanding the calls and demands of justice within the context of international medicine; (3) financial considerations; and (4) recognizing other commitments in our lives.⁵

First, by articulating and reflecting on our experiences in international medicine, we can use praxis-i.e., observing, acting, and then reflecting on our actions before acting further-to help inform the shape of our involvement abroad. This method of learning and interpreting our experiences can happen abroad or at home, privately or in community, cross-culturally or not. During and when students return from overseas experiences, systematically reflecting on their work through presentations, articles, and personal journaling can help elucidate motivations and future possibilities.

Second, if pursuing social justice undergirds one's conception of international medicine, a student benefits from recognizing her values, exploring the values within a community, and educating herself on the social and political contexts in that particular community. Being mindful of whose idea of social justice one is pursuing is essential. Students can ask themselves: (1) can I answer the demands of pursuing justice in this community as community members conceive it in a way that resonates with me? (2) What is the potential impact of my involvement?

Realizing that involvement in a community may be more or less demanding than you think at the outset of an international context exposes some of the complexities of international medical work. A student may feel overwhelmed by the needs in a community and begin to work on structuring his involvement in a creative way. He may feel that he cannot work in a particular community that he feels is calling him. Yet, he may feel a claim placed on him after being a part of community for but a short time and return again.

Third, just as the profession of medicine seeks to increase diversity among its ranks, so too will medical students have varied financial backgrounds and opportunities that make engaging in international work more feasible or difficult for them. On top of the rising debt for many students, many of us will have to consider adding more debt to answer a call to justice and solidarity about which we may feel strongly now. Should I go more into debt to serve others? Some students upon reflection will accept that it may not be in their best interest to go abroad now but to do so will hopefully serve a greater good despite a seemingly unjust "financial penalty" of straining limited resources to do so. Other students will not be able to choose more debt because of other commitments but that in no way negates their dedication to the issues at hand. Still others may not have that much of a choice because of scarce resources overall.

Many medical schools do not have student grants for these types of international solidarity work and additional loan monies may be difficult to come by given their parameters. Raising our voices to influence changes in these constraints is one long-term solution. In the short term, fundraising can be a time-consuming, precarious, and laborious process in order to maximize its financial impact; yet it can be rewarding and surprising. And it may be what is required of us to make our experiences come to fruition. Some of the mentors named above have not come from middle or upper class financial backgrounds and have relied on the financial support of strangers, for example. Students with little savings and from families with limited income can attempt to find a way through networking in medical student organizations or among faculty, among other places. But most importantly, whether or not students are able to go abroad now, they can still educate themselves and others about a commitment to the underserved both here and abroad.

Fourth, we come from a variety of backgrounds and relationships that in part define who we are. This point may be the most obvious consideration but one that cannot go by without mention. Many of our role models in international medicine lead lives that are far from what many people would consider mainstream. In light of our other commitments as students, family members, and friends, a "radical" life in international medicine may not be possible. Each of us comes from different contexts, family experiences, and relationships. International medicine, in all its varieties, somehow impacts our friends and families in different ways.

Some students may feel more encouraged to do international work, perhaps even enlist those closest to them outside school to partner in unique ways. Other students may find themselves in more tense situations as loved ones express concerns of safety or a sense of abandonment. Undoubtedly, an increasing commitment to international medicine that takes the shape of increased time away from one's family and friends can present many interpersonal challenges that deserve attention as students holistically discern where and what they ought to be doing. The decision to reduce or increase your presence in a community abroad is rarely simple, and students can take respite in knowing that pursuing justice anywhere can be done in creative ways that takes into account the many facets of our lives.

Narratives contextualize frameworks, and I close with an unraveling narrative in my life as I propose this modest open-ended framework for finding a home in international medicine. A new commitment grew unexpectedly yet purposefully this past summer. Taking into account my health-related international experiences in various countries over the past few years, it has been in Kenya this past summer in the resource-poor community of Embul-bul just outside Nairobi that my new friends there have in a respect "laid a claim on me" to which I feel increasingly committed.

In this community, there exists structural societal and global neglect of the people here by a variety of players. Additionally, non-governmental organizations (NGO) are virtually absent. Most importantly, community leaders there have requested our partnership, which has charged a group of my peers and me to move forward in helping to mobilize a variety of resources to address a wide variety of the social determinants of health. Still a nascent relationship, in not placing expectations into my future work but remaining in the process of growing into an exciting relationship with the people of this community, my discernment of a possible future in international medicine continues to be woven in an unseen way itself. In shedding my preoccupation of what will come out of this relationship yet remaining ever committed to it as I feel the demands of justice and duties of committing to future work there, I have found a certain empowerment as a student and future physician.

More than that, though, I am thankful to share this sense of commitment with other medical students from this initial trip who felt a call from this community in similar ways. We returned to Embul-bul over our spring break in 2007 to continue and create more community-based public health ventures and now we are amidst planning a third visit at the end of 2008. My parents are supportive but nervous. Some of my colleagues and I are setting aside a portion of our loan money to finance return journeys because of a lack of time for major fundraising this time, though last time the support overwhelmed us. No one knows precisely where this partnership will take us. I certainly did not plan to return to Nairobi before I went there the first time, yet now I cannot image not returning after our experiences of seeing the havoc of HIV, the struggle of children, men, and women there, and the globalizing forces that make these peoples' lives incredibly difficult as they seek to arise out of poverty.

Be prepared to open yourself up to new possibilities as you explore a future in international medicine. Look for the global neighbor in need. Liberation Theologian Gustavo Gutierrez captured what may be an essence of international medicine when he wrote, "If I define my neighbor as the one I must go out and look for on the highways and byways, in the factories and slums, on the farms and in the mines-then my world changes." And so does our world.

References:

¹ Panosian, Claire, Coates, Thomas J. The New Medical "Missionaries" -- Grooming the Next Generation of Global Health Workers. N Engl J Med 2006 354: 1771-1773.

² Link, Bruce G, Phelan, Jo C. McKeown and the Idea That Social Conditions Are Fundamental Causes of Disease. Am J Public Health 92: 730-732.

³ There are many philosophical and theological explorations of social justice. One example is: Medicine and Social Justice. Eds. Rosamond Rhodes, Margaret Battin, and Anita Silvers. New York: Oxford University Press, 2002.

⁴ Wynia, Matthew K., Latham, Stephen R., Kao, Audiey C., Berg, Jessica W., Emanuel, Linda L. Medical Professionalism in Society. N Engl J Med 1999 341: 1612-1616.

⁵ A number of important ethical issues concerning medical students and international medicine lie beyond the scope of this article. More discussion can be found in the December 2006 Virtual Mentor American Medical Association Journal of Ethics on "Global Health: Ethics of International Medical Volunteerism" available in the archives at www.virtualmentor.org