Volunteering in Underserved Regions
Hugh G. Watts, MD
"We make a living by what we get, we make a life by what we give".
One measure of a civilized society is the care it provides for its disabled members, and those less fortunate. Now that we have almost become a world wide globalized society we have to think more broadly than our own country or society, let alone our neighborhood.
In this spirit of wanting to help those less fortunate than yourself, perhaps you've often thought about donating your hard earned knowledge and training to some place in the world that is woefully lacking and you want to know more about how to volunteer. Is it realistically something for you to do? How can you find out more about it? Where and how do you look for a place? If, indeed, such thoughts have crossed your mind, maybe I can help. In that regard, first let me describe the need for your help, then discuss some practical ways to get involved. [Image ]
Right from the beginning, I used the term "Underserved Regions" and not "Developing Countries". Anyone who has travelled, even a little bit, knows that the life and living in the capital of most any country is far, far different from that in even a nearby village. We have "underserved regions" in the USA and Canada.
Also keep in mind as you read, that I am a pediatric orthopedic surgeon; I am male; I have lots of biases, and they will be different from your biases, so you will have to extrapolate what I say so that you can fit it into your own skills and experiences.
JUST WHAT IS THE NEED?
It is always difficult to get such a number. World wide the number of people with physical disabilities is estimated at greater than 250 million. I am not sure just how accurate this number is, but it is an awful lot of people. Now from an orthopedic surgery point of view, two thirds of the world goes without any orthopedic care. Africa is short some 20,000 orthopedic surgeons and that if the USA had the same number of orthopedic surgeons as Tajikistan there would be less than 13 orthopedic surgeons for each state in the USA. What about some other care providers... again these numbers will be approximations, but the number of physical therapists per disabled is grossly disparate between the United States and other countries. Can you imagine as a physical therapist having a caseload of 21,000 children all to yourself, as in Uganda? It is just an unthinkable number. What about occupational therapy? Those data are more scant, partly because in many of these countries the functions of PT and OT are intertwined and they don't necessarily separate those numbers. What is the orthotic need? Those of us in ACPOC who are dealing with children with cerebral palsy know they need orthoses. There are also all those people, children and adults, that have had polio and are paralyzed for life. They need a lifetime of orthoses. Once again, the data are scant. More data are available concerning prosthetists and prosthetics. Three to four million patients are waiting for prostheses... 160,000 worker days worth. There would be less than one O & P facility per state if we had the same, for example as El Salvador or Lithuania. Obviously the needs vary from region to region. Most capitol cities in most underserved countries are reasonably provided. It is only when you go outside of the city limits that the problems soar. Is there a war going on or not? Are we talking about adults or children? Children are always under served, and women are very under served. In Saudi Arabia, if a woman gives birth to a daughter, you say, "Mabrook", which is "congratulations". If she gives birth to a son, you say "Alf Mabrook", "a thousand congratulations". Right from the minute of birth, the female is valued at one one-thousandth of a male, and this reflects in their education, and in their healthcare.
Anti-personnel mines, increased mechanization, bone and joint infections, difficulties of immunization, poor prenatal care, poverty, all of these thing make their impact. Consider the effects of anti-personnel mines–there are estimated to be 50 to 100 million unexploded land mines, (a US state department figure). Now many of you were appalled when, some years ago now, you heard about the Oklahoma bombing. These land mine numbers are the equivalent of an Oklahoma bombing each day for 1700 years. That is a lot of damage. The anesthetic affect of high numbers, numbs the mind... every decade the deaths from landmines is equal to Hiroshima plus Nagasaki. Land mines are a weapon of mass destruction in slow motion. To dig a hole in the ground and put a high explosive in it and walk away is immoral in anybody's culture. And yet it continues to happen.
This little butterfly land mine [Image ] can be dropped from the air by helicopter. It is about the size of the palm of your hand. What child seeing this, wouldn't pick it up?
This boy from Columbia couldn't leave it alone. He lost both his hands and was blinded, when it blew up in his face. [Image ]
Increased mechanization is a real problem. The transition from walking, bicycle, motorcycle, cars, and trucks takes its toll. Hanoi noted a 400% increase in open lower extremity fractures with the increase in automobiles. Poor orthopedic care such as surgeons closing wounds that should be left open for later closure, poor sanitation, and limited availability of antibiotics, are additional problems everywhere.
Every time I mention "Polio", people in this country are amazed that it hasn't died out entirely. It is much better than 30 years ago, but did you know there were 500 new cases in Tajikistan in 2010? In most underserved regions, it has been estimated that probably only one in ten are reported. The difficulties of immunization are enormous. The biggest obstacle is war. You have to have peace if you are going to immunize. Polio vaccine also has to remain at 4 degree centigrade if you are going to use the oral variety (it is much too expensive to use the injected variety). Can you imagine trying to keep a vial of the vaccine refrigerated when that vaccine is made in Milan, Italy then has to go the airport, and then has to go to the airport in Zimbabwe, then sits in the hot tarmac, then it has to go into the customs shed, (and the person in customs couldn't give much of a care, he just wants the papers filled out). And eventually the vaccine will get to the ministry of health and from there to the village. The amazing thing is that any of the attenuated virus is alive when it gets there. In addition, keep in mind that even if we obliterated polio today, there are decades of rehabilitation care needed while those currently affected live through their paralyzed lives.
A few things are getting better. However, for most people in the world, they are getting worse. Populations are getting larger, resources are diminishing. Unfortunately, the relative difference is increasing and the relative difference is becoming more and more visible as television and the Internet show the world our profligate ways.
Huge numbers are always difficult to deal with. A few years ago, a note came across the Internet from the library of the University of California, San Diego. They suggested that we should try to imagine how things would look if we could shrink the earth's population to a village of precisely 100 people, with all existing human ratios remaining the same. What would the world look like? There would be 57 Asians, 21 Europeans, 14 from the Western hemisphere (North and South) and 8 Africans. 70 would be non-white, 30 white, 70 would be non-Christian, 30 Christian, 80 would live in substandard housing, 50 would suffer from malnutrition, 1 would be near death, 1 would be near birth, (and I will add that 5 will have a physical disability), 70 will be unable to read, one would have a college education, no one would own a computer. Fifty percent of the entire village wealth would be in the hands of only six villagers... and all six would be citizens of the United States.
Clearly there is a need. Now what can you do about it? You may just get so overwhelmed that you just say NIMBY (not in my backyard). "Sorry, thank you very much, no thank you." Or you can be a help in a number of different ways, perhaps in ways that only you have the talents for.
Now the urge to help is there, almost everywhere. Certainly it is in a group like ACPOC. What can be done? What should be done? Those are two very different questions. Do we simply export our American version? Do we focus on "prevention", rather than "cure"?
We cannot be the World Health Organization, Mother Theresa, and Albert Schweitzer to all countries. We must make choices. Lets talk about ways we could, should or shouldn't be helping. Most of us are in the curing part of the medical world... we probably are not going to go out there with our shovels and dig latrines or drill for fresh water. We are going to use the expertise we already have. Clearly, in most situations prevention is the best, but it requires peace... you can't immunize with a war going on. When we talk about curing we can talk about doing, and/or providing supplies versus teaching. And the question is, "Are there enough hours in the day, to make any kind of an impact with just doing?"
In 1992 at an AAOS Instructional Course on International Medicine, the late Dr. Mercer Rang, a pediatric orthopedic surgeon in Toronto who had worked in a number of foreign regions, established a principle that I would like to reiterate... the needs are too great to provide purely service assistance. We must have a multiplier effect. We simply cannot treat everybody. Whatever services we provide must lead to self-sufficiency. The main thrust must be to teach. You have all heard the proverb, (probably too often): "give a man a fish and he eats a meal; teach the man to fish and he eats for a lifetime". While you may think the proverb trite, it is still all too true. We must include multiplier effects in anything we do (By the way, the most recent version of the fish parable is... "Teach a man to fish and he'll call in sick every Friday").
And in many diseases, it is important not only to rehabilitate patients, we must work to make them useful members of their community. Dr. Ronald Huckstep, of Australia, from his days in Uganda had disabled people making braces in the local brace shop, so that the patients not only were able to walk after polio, but they were able to earn a living.
We always must ask ourselves, "What happens when we leave?" Are we doing this because it makes us feel good? Are we doing something worthwhile that will be left behind? If teaching is the primary goal, whom should we teach? We must be willing to train people who are not our educational equals. It does not mean that they are not our equals as human beings, just because they may have a high school education where you have a zillion years beyond that. Do we focus on generalists or specialists, e.g. orthotists or orthotic techs, keeping in mind that these are not inferior people; they have just had less opportunity and lesser education. Obviously, whom to teach will depend on the local situation. In Tajikistan, where I was three months ago, there are no PTs or OTs... zero! They started by retraining some of the nurses, which is what happened in the USA 80 years ago when there was no such professions as Physical or Occupational Therapy at the time.
If teaching is the primary goal, there is the issue of training people in their own country or here in the USA. After a trainee has come to the land of milk and honey, it is awfully hard to go home. And even if he or she wants to go home, the chances are high that the spouse or children will want to stay in the USA. For most of us, the adage "Train at Home, Stay at Home" has become our mantra.
The help we provide must be appropriate... appropriate to the culture, the religions, the climate and the geography. Culture and the religions, may well shape a people's expectations of cures. People differ in what they expect.
Treatments need to be simple and the benefits obvious. And very importantly, you must learn when not to treat. It is very easy as a surgeon, say from the USA, thinking "I'm from the West, I know more than anyone else around here" and you take on the most difficult of all patients and the patient dies or the patient is no better as a result of your care. That doesn't do anybody any good, besides being a waste of resources. Trying to fit a child from a big city slum who has a four-limb deficiency (congenital or acquired) is seldom a recipe for success. And so one of the best bits of advice I have had given to me is treat patients that you can win on. Know when not to treat.
I don't want you to be turned off by the reality of the many problems, because there is an enormous amount to do. There is a children's riddle: "How do you eat an elephant?" The answer–"One bite at a time". And while there is, indeed, a mighty big elephant out there, that is what you are going to have to do... take it on one bite at a time, and not be overwhelmed. [Image ]
IS THERE A PLACE FOR YOU?
The answer is very definitely "Yes". Some questions come to mind: With whom to volunteer? Short term (a few weeks or months) or longer (a year or more)? When to go (e.g. now or when I retire)?
With whom can I volunteer? How long should I go for? When should I think of going?
These questions are intertwined. Different organizations are focused on specific goals and may only be willing to consider taking you for shorter or longer periods. Most government organizations such as Peace Corps. don't have places for a person who wants to go for one or two weeks or even months. NGOs (i.e. Non-Governmental Organizations) and religious organizations vary. Trying to sort them out can be difficult even with the help of the Internet since the organizations are frequently just known by their initials, so it rather a mush of alphabet soup.
Let's start with "When should I think of going?" There are a number of choices:
- during your training;
- between basic training & specialty training;
- right after specialty training;
- during active practice for short stints;
- after retirement for short stints or longer periods.
Obviously these are not mutually exclusive (and once hooked by a trip you may find that you will indulge yourself in a variety of these).
Going during your training years can be enormously rewarding. You will be amazed at how much you have to contribute even if you have had only a year or two of training. The problem is that there are not many organizations that are willing to take trainees. Usually the way to find out is to ask a member of your faculty for suggestions. Even if the faculty person has no personal experience, they will usually know of other faculty members to direct you to.
Going after you've finished your basic degree and before going on to, say, a residency program again is similar to the problems of finding organizations willing to take you. At least with your basic degree, and presumably having passed your licensing exam, you are more useful, and religious organizations are more likely to be interested in you. An advantage of going at this time is that you can see if you like the activity and then go and get the training you see you need, which is what I did in Afghanistan right after my internship in general medicine.
Going over after you have completed specialty training makes you a sought after person. Since you won't have commitments to a practice, you can consider going for one or two years. This is a great way to get some excellent experience under your belt, (usually with a vast array of complex cases) making you a much sought after person when it comes to looking for a career position on your return.
Usually after you have started into a practice, long-term trips of more than a week or two or maybe a month become very much more difficult. At this period in life you will generally do better turning to independent groups (that you usually hear about through friends or your professional organization). An extremely important resource is Health Volunteers Overseas (their new web address is www.hvousa.org ). This is a consortium that began 30 years ago with Orthopedics Overseas, and now includes Anesthesia, Dermatology, Hand Surgery, Hand Therapy, Hematology, Internal Medicine, Nurse Anesthesia, Nursing Education, Oncology, Oral Health, Pediatrics, Physical Therapy, Wound & Lymphedema. Their usual expectation is a commitment of at least one month. For the Orthotists and Prosthetists, their professional organizations AOPA, AAOP, as well as ISPO (the International Society for Prosthetics and Orthotics) have been very active in these endeavors and should be a rich source of information.
Who pays your expenses? With longer-term commitments, the organization usually pays for your transportation and up-keep. For short trips it varies. Many organizations will pay for the transportation and upkeep, or some combination. On the other hand, Health Volunteers expects the volunteers to pay for their transportation and their in-country upkeep. Check it out so you don't have any surprises.
What about going with a Religious Group? This can be very easy to very tricky. Some religious organizations don't care a great deal about your personal religious beliefs. Others very strongly do care. To find yourself going with a group that expects your primary function to be that of a proselytizer rather than a health-care worker has proven to be very awkward for some.
On the other hand, a number of religious organizations have been involved in many decades of overseas work and have very well established programs that some find very comforting to work with, especially newcomers to the field of volunteering.
Issues of children small, and bigger: Usually, taking the children along for the one or two week trips is not a good idea, unless you've been there before and know what the children will get into. Poorly supervised teen-agers, while you are busy seeing patients, can present special problems.
On the other hand for longer trips, the experience for the children can be life changing. Usually there is plenty of help with childcare. The obvious worry is health care, and it is difficult to give advice in the abstract and will obviously differ with the anxiety level of the parents. My oldest child was born in Afghanistan and lived there for a year and a half, so I have my bias.
What about personal safety? Again, this is difficult to answer in the abstract. Countries may be at war. HIV may be rampant, so obviously common sense is needed to assess the situation. Most organizations aren't the least bit interested in being responsible for you if there is any real danger, and so won't send you there. Ask around, search the Internet, but bear in mind that if you give mind to all the State Department's travel advisories you'd have to live under your bed.
Ask around: I can assure you, that will find that if you ask people who have worked "overseas" they will give you all the time you want... perhaps a lot more than you want since people do become enthralled with their volunteer work.
OTHER WAYS TO TAKE A BITE OUT OF THE ELEPHANT
Maybe you have small kids at home, so you don't want to go overseas now, are there other things you can do to help? Indeed there are.
1) Translating to Break the Logjam of Literature: Sending your old journals and text books overseas, is not helpful if they can't read English. And English is certainly the lingua Franca in the medical world. If you have another language, or a friend that does, you could do a great service by translating... simple patient instructions that many therapists hand out on a fairly regular basis. What a joy this would be for somebody to have it in Swahili, or Russian, or Farsi.
2) Help another person who is going over to collect things that may be useful. There are things that you can do even if you can't personally get over there. It takes lots of strands to give a rope its strength. Everyone can contribute and be important.
Let me end by repeating the quotation from that master of words, Winston Churchill, who said, "We make a living by what we get, we make a life by what we give".
I know that many of you in ACPOC have been trying to get a life by giving. However, it is a constant battle not to focus on making a living, particularly in these more difficult times when American health economics is in such flux. But, please, focus on making a life.
Hugh G. Watts, MD lives in Los Angeles, CA, USA