As I discovered on my trip from Panajachel to Antigua, it isn’t hard to find Americans in Guatemala during the summer months. As I was getting to know a fellow American passenger in the van I was in, I was intrigued to hear that he had spent the past three weeks working for a clinic in Quetzaltenango. He had spent most of his time cleaning the clinic and performing tasks such as sweeping out the operating rooms, painting exam rooms, and washing the exterior of the building. However, he was most excited about the time he was able to spend in the OR assisting with surgeries. He spent a good thirty minutes describing how he assisted with appendectomies, inguinal hernia repairs, and how he was even allowed to help “sew up” a woman after a C-section. His time at the clinic sounded interesting and I asked which medical school he attends. To my surprise he was not a medical student, much less an undergrad student; rather, he was a rising senior at a high school in California.

The last fact I learned about this high school student sent my mind racing and led me to reflect on the ethics of short-term medical missions. Why is a high school student with no medical training able to assist in surgery? Why is an undergraduate pre-med student or even a medical student between their first and second years able to assist in the practice of medicine in another country if they aren’t allowed to do so in their own country? Sadly, the ethics surrounding these short-term trips has been a problem since at least the early 1980s and the topic still needs addressed today (1).

Medical students have a limited amount of time to travel abroad. A majority of medical schools provide a substantial break between the first and second years, but there is not usually another lengthy period of time until the fourth year. Most medical students are only able to travel abroad for one or two months at a time. When done correctly, short-term medical trips can provide great benefit to both the medical students travelling and the host countries to where they travel. However, the majority of these short-term trips are not done properly and have the potential to do more harm than good.

I will speak from a personal experience later in this article, but in the general sense, ‘medical tourism’ occurs when students and physicians visit poor countries unprepared and without clear educational objectives (2). Travelling to resource poor areas can lead to situations where medicine is practiced with more liberties than would normally be taken in the United States. Students find themselves in situations where they are working with limited supervision and as a result they may be working beyond their level of competence often at the expense of the patient. As an estimated 250 million dollars is spent on short-term medical trips and thousands of physicians, students, and support staff travel abroad the problem of medical tourism is likely a larger problem than most people would like to admit (3).

I believe that global health has never been as glamorous as it is now. Celebrities like Bono and Angelina Jolie make global heath their platform for social change, and young adults are increasingly interested in working in developing nations. I witnessed this fascination after a speech I attended last year by Dr. Paul Farmer, the founder of Partners in Health. After his speech, Dr. Farmer was available for pictures and autographs. I expected people to come to Dr. Farmer with their Pathologies of Power books or their copies of Mountains beyond Mountains, but I was surprised to witness Dr. Farmer signing students’ t-shirts, hats, arms, and lower backs. Until this moment I had only seen this level of celebrity obsession with athletes, movie stars or musicians; never with healthcare professionals.

I believe we need an ethically sound outlet for the enthusiasm global health is generating. This enthusiasm needs to be harnessed in a way that provides mutual benefit to both students travelling abroad and host countries. Students should not be sent out on their own without supervision and host organizations should not foster medical tourism. Situations like that described in my opening paragraph should not take place. However, each summer more and more students travel abroad to participate in the emerging field of global health.

In Guatemala brief medical trips are referred to as jornadas. They usually consist of a group of American physicians, nurses, medical students, and non-medical staff coming into a community for a few weeks to provide medical care to the people of select communities. The jornada I took part in this past summer consisted of two ER physicians from New York City, three nurses, and fifteen medical students and non-medical staff. As a medical student studying medical Spanish I participated in the jornada because the group coming wanted more assistance as they were expecting a lot of patients.

Over the course of the week long jornada I was able to use my limited Spanish to take vitals, chief complaints, pass out prescription drugs and explain to the patient what the drugs were for and when to take them. I sincerely hope I did more good than harm, but in all honesty I had no idea what I was doing most of the time. I spent one day shadowing one of the physicians in a rural village and it appeared to me he knew very little about what he was doing as well. Although he is a very experienced ER physician in New York City, the fact he has never practiced in Guatemala left him looking a little shell shocked. At one point during the day he resorted to prescribing Ibuprofen to almost every patient because he was tired of not knowing what to diagnose and he figured if he sent them home with something it was better than nothing.

I was disappointed by the group’s lack of preparation for the trip. They didn’t take the time to research the common illness in the part of Guatemala they were going to be working nor did they seek out ways to learn about local practices and cultures. If they had done a little research they would have understood that many people who visit the physicians of the jornadas are not actually sick, they simply want an American physician to examine them. These are just some of the points every participant in a shortterm medical trip should consider. There is exceptional need for medical assistance abroad, but how can we provide the needed assistance as future doctors in training?

There are a few things to consider before participating in an international medical trip. First and foremost are our own motivations for going on a short-term medical trip. Are we going to visit an exotic country, practice medicine, see a large number of patients in a very short period of time, help the underserved, or somehow gain an advantage over our peers because of the glamour associated with such trips? There may be multiple reasons for travelling, and we need to make sure the main reason we are going is to serve.

It is important to learn as much as possible about the people you will be working with, their cultures and beliefs, and the illnesses you will see. This will allow you to bring the correct medications and equipment, and may minimize the amount of cultural faux pas committed. During my stay in Guatemala I was taught about the hotcold paradigm of the Mayan people who believe that disease results from a disruption of hot and cold in the body. Some people refuse to drink cold beverages on very hot days because putting cold into their bodies will cause a shift in balance and cause them to become ill. This paradigm could have ramifications for medical treatment if the physicians coming to Guatemala do not understand this cultural belief.

Also, the values and preparedness of the organization you will be travelling and working with is important. One of the most common themes in literature about shortterm medical trips is the importance of returning to the same place in hopes that mutually beneficial relationships with a community can be established (4, 5). These relationships will hopefully become lasting partnerships which will provide the framework for shared resources. Academic institutions and others organizing shortterm medical trips in the United States can share equipment and train the local staff on new medical procedures while the local staff can share their knowledge of local disease processes and physical diagnosis which must be relied upon in resource poor settings. These partnerships provide a deeper meaning to the shortterm trip because there is an opportunity for community building which will be allowed to continue once the individual has left.

Medical students are leading the call for more opportunities for global health experiences and education in our medical training (6). With the recent earthquakes in Haiti and Chile there will be an increased need for short-term medical trips. As the summer months approach quickly, it is important to make responsible decisions regarding such trips. A 2006 article in JAMA titled Duffle Bag Medicine asks us to consider the following:

A foreigner sets up a clinic in your city. He does not speak much English, he will leave after a week or so, and he is not very likely to ever return. This foreigner tells you that he is a physician in his home country, but that he has never been to your community before and is not going to be working with your family physician or with other health professionals in your local health care structure. Would you take your children to see him if you had any other choice (7)?

The energy for global health is almost palpable and it would be disappointing if we did not attempt to harness this energy in a responsible manner to provide quality care to resource poor populations.

Works Cited

1. David R. Welling et al. “Seven Sins of Humanitarian Medicine”, World Journal of Surgery 2010 Jun; 34: 467.
2. Jon Dowell and Neil Merrylees. ”Electives: isn’t it time for a change?”, Medical Education 2009;43: 124.
3. Jesse Maki et al. “Health impact assessment and short-term medical missions: A methods study to evaluate quality of care.” BMC Healh Services Research 2008 Jun; 8: 121.
4. Jon Dowell and Neil Merrylees. “Electives: isn’t it time for a change?”, Medical Education 2009;43: 125.
5. John A. Crump and Jeremy Sugarman. “Ethical Considerations for Shortterm Experiences by Trainees in Global Health”, JAMA 2008 Sep; 300(12): 1457.
6. Paul K. Drain et al. “Global Health in Medical Education: A Call for More Training and Opportunities” Academic Medicine 2007 Mar; 82(3): 227.
7. Maya Roberts. “Duffle Bag Medicine” JAMA 2006 Apr; 295(13): 1491.