This document was prepared by Academy member James D. Smith, MD, as a handout for his instruction course by the same title. He presented this course for several years at the AAO- HSNF Annual Meeting & OTO Experience. In 2008 , Dr. Smith received the Distinguished Award for Humanitarian Efforts.
Medicine in developing countries certainly is a lot different than in the U.S. First of all, there is usually a shortage of physicians. Second, the resources spent on medical care may be only a few dollars per capita per year compared to the U.S. spending of thousands.
Are you frustrated and stressed from medical practice in the U.S.? Do you enjoy travel or have a yearning to help others? If so, why not try a volunteer vacation?
Opportunities
Multiple opportunities are available for someone who would like to experience a foreign culture in the setting of medical practice. Before deciding whether this type of vacation is for you, there are several questions one needs to honestly ask and answer.
1. Why do I want to do a volunteer vacation?
- To enjoy a new experience
- A yen for travel
- A desire to help others
- Curiosity
- Adventure
- Surgical experience (This is a sensitive area in some places as the nationals’ perception may be that you are coming to practice on them.)
- Personal satisfaction – You may just want to visit another otolaryngologist overseas for your own knowledge.
Any or all of the above may be suitable reasons to decide to go.
2. What are my interests?
- Do I enjoy teaching? – Nurses, medical students, residents, other physicians
- Surgery – Would like to help the most people possible.
- Clinics – May combine this with teaching and/or surgery
- Help established programs – local hospitals or physicians
- Providing resources – May supply finances or equipment for a trip, or for others to go.
3. Where do I feel comfortable going?
- Primitive facilities – Hard bed, bugs, strange smells, minimal hospital facilities
- Urban setting – Better and more modern facilities for living and working
- Safe environment – Stable government, good police, and medical facilities
- Willing to take risks – A little excitement and danger are stimulating
- Climate – Can you tolerate a hot, humid climate without air conditioning?
- Just like home – I want a McDonald’s available and all the comforts of home.
4. What are my shortcomings? A very important question to ask and analyze honestly. Ask your colleagues, office personnel, or scrub nurse if you’re not sure.
- Impatient
- Short fuse
- Prima donna in surgery
- Hate inefficiency
- Rigid
If any of these describe your actions, can you control them? If not, think twice before you take a trip.
5. Practical questions
- How long can I be gone? Who will cover my practice?
- Short term (1-8 weeks) If you can only go for 1-2 weeks, it would be best to be part of an organized group for surgery or teaching fairly close to the U.S. If available for 3-8 weeks, one could go to a hospital and relieve someone going away, have more time for teaching and demonstrating surgery. Long trips will also develop deeper friendships and allow better understanding of the culture.
- Long-term – Overseas contract may be available.
- How much will it cost? Most short-term trips will require you to pay for transportation. Some organizations ask for a contribution and/or payment for food and lodging. Some will furnish lodging on site.
- Should I take my wife and/or children? Depends on the trip, facilities, and attitudes. It can be an incredible learning experience for children if they will be interested. If they hate long trips at home and complain about facilities here, it would be better to not take them until you have gone once and see what it is like.
- Do I need to know a foreign language? This is usually not necessary, although obviously helpful. In most countries, one can find someone who knows English.
6. What potential opportunities are there?
- AAO-HNSF Humanitarian Committee opportunities map/listings
- American College of Surgeons Operations Giving Back lists of volunteer opportunities.
- Religious organizations. If you have a church affiliation, it will most likely have some medical mission outreach that would be an opportunity for service.
- Many medical missions will accept visitors, but you need to know if you agree with their goals. It would not be fair to undermine their mission with the people they are working with; if you don’t agree, look for other opportunities. Also research any restrictions placed on visitors, such as , attending chapel services or no alcohol or smoking.
- Government hospitals. Some governments may hire otolaryngologists on a contract basis. These would usually be long-term commitments and will be in third world countries. As an example, Malawi in Africa has 235+/- physicians for eight million people. Over 200 of these are overseas physicians on some type of a contract.
- Personal contacts. This is an ideal way to make a trip, especially if short term. Every year we have overseas visitors at the AAO-HNSF meeting. Walk up to one, introduce yourself, take them out to dinner, invite them to visit you, and I will guarantee that you will get a reciprocal invitation.
7. Recommendations
- First trip – It is best to go with an organized group or with a person who has made similar trips in the past.
- Tax deduction – If you want the trip to be tax deductible, you will need to have an organization that will give you a receipt for the expenses. In some organizations, if you give them a tax-deductible donation to cover your expenses, they will then pay the expenses. Be sure and check with your tax advisor regarding what steps are necessary to make your trip deductible. This is particularly important if you set up your own trip.
Preparation
Once you have answered all the previous questions and found an opportunity, what is the next step? Start planning now! It will take 6-12 months to get everything in place. If you go on an organized trip, this may take less time, but if you try to set something up on your own, it can be agonizingly slow. Round trip communications may take two months or more to some countries in Africa. E-mail may help, but many countries will not have it.
1. Travel documents: First, you will need a passport if you don’t have one. Applications are available at your local post office. When you get your passport photos, get extra prints; you will need them for visas, work permits, and other documents. A good travel agent can help with airline tickets and visas, if necessary. Be sure and check the Sunday travel section in your local newspaper for fares. Sometimes one can get real bargains on consolidation fares. I have had round trip tickets to Singapore for less than I can travel to Washington, DC.
2. Practice needs: Depending on where you are going, what you are doing, and under whose auspices you will be working, you may need a medical license. Most organizations will help arrange this, but you will need copies of your medical degree, current licenses, etc. Check with your malpractice carrier and your host country to see if extra coverage is needed.
3. Medical needs (personal): Contact a local travel clinic or the Centers for Disease Control for information on what immunizations and medicines you will need in the area that you plan to visit.
- Immunizations: You will want to take the available hepatitis vaccines. Depending on the area, you may also need the yellow fever vaccine. Typhoid and cholera vaccinations depend on whether you will be in really primitive settings; neither are very good vaccines and you may choose to be careful and take antibiotics with you.
- Medications – I like to take an antibiotic that will cover GI problems and usually choose Cipro® or Septra®. I also take Peptobismol® and Lomotil®. Depending on your setting, you may want a 6 to 12-day course of Prednisone® for drug reactions. Of course, take any personal medications you need.
- Malaria prophylaxis – Check with the Centers for Disease Control and/or people you are visiting to see if this is needed and if so, what is recommended. In most areas, malaria is chloroquine resistant, so other drugs – or a combination of drugs – will be necessary.
- Health insurance – Check to see if your medical insurance will cover you overseas, as some HMOs may not. You may need supplemental travel insurance to cover this gap. Your travel agent should be able to help with this.
- As a general rule, drink only boiled water, and eat only what you can cook or peel. Don’t eat salads. Be careful about uncooked milk products.
4. Equipment
- Is equipment in place?
- Make sure what equipment is available or take any special instruments you may need for the surgery you plan to do.
- What medications are available? Some third world countries will have very little. You may be limited to penicillin and aspirin. If you would like to take medications with you, a Travel Pak may be obtained from MAP, which has several hundreds of dollars of medication in it and can be left at the host site. Call 800-225-8550.
- If you are taking any electrical equipment, such as headlights, drills, microscopes, etc., you will need a good, heavy-duty electrical converter for 220V to 110V.
- Any specialized dressings you want should be taken. In some places, bandages may be washed and reused, which might make you uncomfortable.
- Try to take your own sutures. If you are doing a pro bono trip, some suture companies may donate suture material. Also leftover suture in your local hospital may be available.
- Shipping – If you are taking supplies for a pro bono trip, some airlines may allow excess baggage at no extra cost.
Cultural Differences
1. Local living conditions – Standards of cleanliness, housing, etc. may be much different than what we are used to. If you have never been to a developing country, be prepared for a big difference.
2. Medical/hospital conditions will be much different. No ICU. Two patients to a bed. Beds that look like they are from the ’20s. Large crowded wards. The smell of disinfectant.
3. Operating facilities – These facilities may be primitive or even makeshift on some trips. Anesthesia machines may be from the 1930s.
4. Schedules – Clinics and OR clinics may have overwhelming numbers, and you may have to decide who will and will not get surgery. It can be heartrending to turn down a pleading patient. The OR schedules may be unrealistic, or you may even consider them unfair.
5. Who is eligible for treatment? You may want to help the poor but may be pressured to take care of the local VIPs if your expertise is perceived to be otherwise unavailable. How will you handle a delicate situation?
6. Overwhelming numbers of patients: the needs may seem endless, but help where you can and it will be appreciated.
7. Different view of patient care: this is something I can’t really explain. It may be that in most countries the physician is an authority figure and we are used to considering patient care as a partnership.
8. Finances available for medical care. In most developing countries, finances are meager at best. A return visit to the clinic may cost 1 or 2 weeks of the family income. A CT scan may cost the patient 6 months’ income. Be sensitive.
9. Be sensitive!
- Things won’t be like home.
- Local physicians may be well trained but not have the equipment and finances. You may be considered competition, especially in urban settings.
- Many are doing the best they can with the facilities they have. Be complimentary.
- Standards of cleanliness, sterility, etc. will be different. Accept it. Their infection rate is probably no greater than that of the U.S.
Remember:
- Try to fit in!
- Listen!
- Don’t demand!
- Compromise!
- Don’t insist on it being your way!
- Ask and suggest!
- Surgery in an Unfamiliar Setting
Surgery in an unfamiliar setting may be out of your comfort zone. It can be risky. The first time I visited China I was hesitant about doing surgery. Anesthesia was primitive. They did more clefts in a year than I had in my career, and I was supposed to demonstrate to them. In discussing this with a more junior staff person via an interpreter, he told me that the previous team had not done much surgery and how disappointed they were. He said, “We never get to leave here and see anyone else operate.” I realized that if I did cases, and it was different, he might pick up some ideas. If I struggled with a difficult case, he could think to himself, “I could do that better,” and feel good about his own skills. I think some of both happened. I had a wonderful time and developed a close bond with him. Try it; you will like it!
1. Bring any favorite or special instruments.
2. Bring your own sutures, gloves, shoe covers, etc.
3. Anesthesia – What is available? Local vs. general. This is probably the scariest aspect unless you can take an anesthesiologist with you.
4. Fit in with the host’s method of scrubbing, prepping, and draping.
5. Scrub nurses may not gown or glove you and may not pass instruments. That may be the assistant’s responsibility. Don’t insist that they accommodate you.
6. Watch how your host does things.
7. Be prepared to demonstrate and share experiences.
8. Have your host do a case and assist him.
9. Remember your host may not do things “the American Way,” but that is okay.
10. Language barriers – It is best if there is some type of interpreter in the OR. Scrub and circulating nurses may not speak English. Try to learn key words for knife, suture, hemostat, etc. in the local language.
11. Speak slowly and distinctly – This is the most important thing when communicating with people to whom English is a second language. It may even be important in some primarily English-speaking countries.
12. Be conscious of resources.
13. Be prepared to give talks and demonstrations on surgical technologies.
Summary
1. What is your purpose for going?
2. What would you like to achieve?
3. Show a genuine interest in the country, people, and patients you are visiting.
4. Keep a sense of humor.
5. Be flexible.
6. Adapt to the unexpected.
