Ethics_and_Global_Health_Travel_with_Judith_Lasker_PhD

The podcast features Dr. Rob Murphy discussing sustainable global health programs versus volunteer medical missions. Judith Lasker, an expert in global health volunteering, shares insights on the topic. She emphasizes the importance of evaluating the impact of healthcare missions abroad. Lasker highlights the need for mutual respect and equal partnerships in global health initiatives, stressing the value of learning from local staff and communities. This approach leads to more sustainable and impactful healthcare efforts. Welcome to the Explore Global Health Podcast. I'm Dr. Rob Murphy, Executive Director of the Havy Institute for Global Health here at Northwestern University Feinberg School of Medicine. Today we're talking about the differences between sustainable global health programs and volunteer fly-in medical missions and the kind of questions everyone traveling to another country to provide any type of healthcare should ask themselves before leaving home. Here to discuss this topic is Judith Lasker, Professor Emerita in Sociology and Anthropology in Health, Medicine, and Society at Lehigh University and author of Hoping to Help, The Promises and Pitfalls of Global Health Volunteering. Judith's major area of interest are in the field of medical sociology with particular emphasis on women's health issues and international health. I had the great pleasure of meeting Judith here in Chicago in 2018. She was one of our featured speakers at one of our global health events and subsequently she has started a group called Advocacy for Global Health Partnerships. You can learn more about that at globalhealthpartnerships.org. She's one of the founders of that group. Welcome Judith. Thank you so much for inviting me. I had a wonderful visit back in 2018 and I've been happy to stay in touch with some people from Northwestern and admiring your institute from afar. So I've been working internationally since the late 90s. I've lived abroad before for a couple of years, one year in Germany and over a year in France. I've not lived in a low-income country or middle-income country, but in 2009 Dean Jamieson here at Northwestern decided to corral in like literally, I don't know, three or four dozen global programs of mostly very small and insignificant size and impact and put it into a center. They had found that groups of people were using the Northwestern 501c3 number to raise money. We had no idea what was going on. There were like 85 sites and he said, I've got to get a handle on this. And so I condensed it, we evaluated them, we supported the stronger ones and got rid of a lot of the weaker ones and we tried to corral people into a more sustainable thing. And then along in 2016 comes your book and finally something actually made sense. So look at the science of this, the social science of this, and it just fit with what we were trying to do, but we didn't have the framework which you provided us. And that's why when you came in 2018 it was really important for us because soon after that we advanced to an institute level and grew really exponentially. And it's really been the foundation of our growth and our philosophy here at Northwestern. To take this thing seriously and the points that you bring up in this book just make so much sense. And you gave us the data, the actual scientific argument to make these changes because there was a lot of pushback. A lot of people think, oh, we're doing a great thing flying an entire ICU over to Kathmandu for seven days and leaving all the equipment there and stuff like that. It's been a rub-dub. But we've actually found that because of this approach that the students in particular that are doing this internet, and we have one of the highest rates of students taking a foreign experience. It's one of the highest in the country. And we found that the reviews of that activity are really high, and it's one of the highlights of their medical school career. And so it paid off in kind of a soft way. I mean, it's hard to actually measure that, as you know, but it's really been important to us. And I want to thank you personally for doing this because it was really needed. We knew what we wanted to do, but we didn't know how to do it, and now I think we know how to do it. That is great to hear. I think the spark that got me started on this project, I had a student sitting in my office, I can picture her to this day, saying she had just come back after vacation, spent two weeks in Honduras on a trip where there were a few days of clinic and a few days of going to an orphanage and some tourism, and she said it was life-changing for her, one of the best things she ever did, but she had no idea if it did any good for people in Honduras. That's sort of at the heart of what motivated me, is that so many people are volunteering and want to help, but they often wonder, okay, did it make a difference? And you know, hardly anybody evaluates this, as you said. It's not just students, let me tell you. It's all sorts of people going over there. Oh yeah, oh yeah. Church groups. I've been to Nigeria probably well over a hundred times. Wow. Yeah. I would say, I know the country very well now, but it took really about 10 or 15 times to really settle in and really feel comfortable, and the people there being comfortable with me. They knew I would be coming back because I was coming back so much, and that has made all the difference in the world, and same thing in Mali, another country we work in very closely, and the group here at Northwestern, everybody has the country that they're most familiar with, but it's been a sustainable relationship, and it's really paid off. That makes a difference. Judith, you began your research career studying healthcare systems in Cote d'Ivoire in West Africa. Can you tell us about that experience and how it led you to a career, the career that you have today? Like, how did it start? I think I went into my career of teaching, which included courses on global health, with an understanding that whatever policy decisions are being made, whether it be in the U.S. or in Latin America or Asia, you know, that they were often driven by the needs of people outside the country or people who had positions of power rather than the needs of the people in the country. So that was just kind of a general perspective I learned from working on my dissertation. But when I went into this project, it was really about just trying to answer that student's question, does this do any good, because I was seeing so many students making these short trips and putting it on their resumes and talking about how wonderful it was, and seeing that there was a huge amount being spent on these short-term trips. You know, when I started, I didn't think about the environmental impact. That became clearer to me over time, that all those trips are not necessarily good for the environment. But my real question was, are they good for the people hosting the volunteers? And even the language that folks use, you know, when they talk about donors and recipients, it always seems like this one-way stream of, we help them. And I have seen the problems with that in our own local community, and the change in the culture around how do you do community service, that it should not just be, well, I know something more than you do, I'm well-off and educated, so I can tell you what to do, and I'll just come and do it, without even thinking about, well, what do people really need? So all of that kind of went into the mix, but I really wanted to get a sense of, alright, what works? And what does it look like from the perspective of the people who are hosting? Which is why it was very important to me to interview staff in host countries to say, what do you think? What are the problems? What are the good parts? What do you appreciate? What don't you appreciate? How would you make it different? Fully realizing that as an outsider, a white American outsider, for me to say, so what do you think about us outsiders coming in? People are very polite, so that is why my next step after the book was to have researchers from the countries asking the questions, and yeah, the answers are somewhat different. I did my best to find out what they wanted, and these are people who were working for organizations that organize trips, so they had a stake in it, a positive stake in it, and they saw many positive things, but what I would probe for, okay, if you were organizing it, if you were doing this, how would you do it differently? And then I compared that to what I learned from my survey of American organizations who were organizing trips to see what their practices are, and there was a gap there. And I think that gap is important. I actually have an article with one table in it, like a graphic that says, okay, what do people do? What is it that people in the host countries want? One of the very simple things is the typical trip is less than two weeks, and the host staff were saying, you know, that's not enough. People just barely get oriented, and then they leave, and then we get a new group and have to start orienting them again. They really wanted people to stay longer. One of the issues that's come up in my studies, and I've seen it in other people's studies of host staff, they really want to be respected for what they know. The idea that students or even very skilled specialist doctors would come to their communities and assume that they don't know anything, that they haven't gotten lots of experience and expertise from working there for years, that attitude is probably the thing that bothers people the most. It's like, we're happy that you're here to help. We're happy to learn from you, but acknowledge that you can learn from us and that it's really a two-way street. It's not a top-down donor-beneficiary. This is something that we're now seeing more and more in the literature on this is the emphasis on mutual equal partnerships, where each side learns from the other and appreciates the other for what they are teaching. So the students who go and who are oriented by local staff and who are shown around and have things explained to them and so forth, those local staff are teaching them and need to be acknowledged as teachers and knowledge providers in a way that has not been the case so much in the past. The thing that kind of hit me over the head when I was at the beginning of this, and I had the kind of your philosophy to start with, so I was getting input and I was training people to do all the work and everything. It wasn't me just telling people what to do, but I started reading some of the local literature, local history anyway, and I had studied geography and history and everything and was like, well, the British had this part of West Africa, then the French and then the White Fathers came and then this, and it all started around 1900. When you read the African version, it's like there's all this other history that came, then there was the European colonizers, and then they got kicked out in the early 60s. So it was very interesting seeing it from their perspective, but I certainly get it. And I think our discussion is really going in the direction of our next question was, what did you actually see in the field to make you write, hoping to help? I participated in two trips, which by no means makes me an expert. People like yourself who've traveled over and over and over again get to see a lot more than I did. But I was there as a participant observer. I participated, you know, I packed vitamins into Ziploc bags and that kind of thing, but I was there to really watch. So I saw these incredibly enthusiastic visitors with talents and skills and really wanting to do good, but with no understanding of where they were or of the language. There's one story you may have heard me tell. I was in Ecuador with a group and, you know, we went to several different villages. You get on this bus and you pack up a lot of stuff and you arrive in the village and they've set up the community center as a place for the clinic. And all of these volunteers get off the bus and they take these heavy bins filled with equipment and they march into the community center and they set up a clinic. You know, it's quite impressive. But there was a man standing at the door, very modest in his demeanor, but nicely dressed, wearing a jacket, button-down shirt. And he was saying something to the volunteers, each one who came in. And they just walked right past him and ignored it because they had no idea that he was greeting them in the local language. So the fact that they had never been told, this is what people speak. This is who's in charge of this village. This is how you say hello in this language. Here's how you say thank you in this language. They were unknowingly rude. I mean, can you imagine somebody walking into your house and sort of barging by you and not acknowledging that you're there or that you're greeting them? I mean, guests don't treat hosts that way. And this is a guest-host relationship. I think that image bothered me a lot. The idea that the team was only made up of the Americans and yet all the Ecuadorians who were helping us were somehow not part of the team. Just that division. And, you know, it's really hard when you're only doing this for a week to learn a language, integrate with another group of people, of course. But those are things that I think could be addressed somewhat easily. So when I saw that kind of thing happening, I thought, you know, this could be better. A lot of what they're doing seems good. A lot of people are helped. But then we were spending a lot of money to help a limited number of people. And most importantly for me is we don't actually know whether they were helped. Right? So when you read the reports of all these organizations that do overseas work and they say, we helped three million people. Some of them say that. We helped 300,000 people. Right? Well, maybe they saw some people. They saw a certain number of people and then they extrapolate to their family members or their community members. Even if they just tell you we saw 600 patients. Okay. Did you help them? Are they better off because you saw them? If you can't show that, then what are you doing? You could be wasting people's time. You could be even causing harm. By giving them medication that they can't replace or that maybe not be the right one for them, but you don't know their medical history. Those are the kinds of things that I was impressed by. I think another thing that really impressed me was that everybody I talked to, both in the US and in other countries, and I'd say, well, so how do you know if this is helpful? They couldn't answer. They'd say, well, we just know people are happy. They smile. They thank us. They ask us to come back. Those are good things. And sometimes very specific. We operate on somebody and they got up and they were better, which is wonderful. If I were in a place with limited medical care and somebody solved a problem I had, I would be forever grateful. But the cost-benefit analysis is not done. There's a lot of expenditure. The expenditure can partly help people in areas that don't have much medical care or very advanced medical care, but it really also is about helping the volunteers. Your students who say this was wonderful and they're getting a good experience. So are we using people in poor countries for our own benefit? That's another sort of question that concerned me as I was doing this work. Well, you certainly get into that in your book. Yeah. If we are using people for our benefit, I mean, I did it. I did my dissertation in West Africa. I took up a lot of people's time asking questions and I got my degree and I got a career. I totally did it. But if we are doing that, how do we acknowledge it? How do we respect the contribution that they've made to us? When you're looking at different organizations and their programs, you've evaluated many of them. What are some of the red flags that you look for when considering what's a good program, an ethical program? What are some of the hallmarks? I think one red flag for me is a program that says, send in your fee and you can go. We don't need a reference. We don't need to know that you have any experience. We don't need to know that you're not a jerk. There are a lot of companies that are making money off of this. Oh, sure. Even the ones that are not for profit oftentimes do almost no screening. Many of the ones even that are serious don't do much preparation. If all they do is send you a list of clothes to pack and visas to get and shots that you need, then they are not preparing you to do this work. And I think that is really not acceptable. And actually in our program here, we focus in on about 20 to 24 sites that we've been working with, some for 20 years. And we make all the relationships bilateral. It's not a one-to-one thing because we can't afford that. But at our big sites, we always take somebody from that site back here. That's very helpful. And then we know all the players at those 20 sites pretty well. And some sites come and some sites go. And we're always looking for new ones. And that's fine. But yeah, it's got to be a deep relationship. And that's really the key. And I think it's what Advocacy for Global Health Partnerships, we're increasingly focusing on not the short-term trip, but the long-term partnership within which there may be some short-term trips. But it can't just be as I've seen with too many organizations. You know, I have a friend who's a teacher in a village and, you know, somewhere and who's invited us to come and spend a week and bring a lot of medicine. If it's not part of an ongoing system of follow-up and, you know, continuity of care, the risks are quite large. Another thing that I would be very cautious of, and this is something that's been widely discussed in the medical area, is an organization that says you'll get to do stuff that you're not allowed to do in America. You can go into an operating room and participate. You can attend a childbirth. You know, and those are experiences that students love to get. And it's exciting. But any advertisement that says we can do stuff that you wouldn't get to do back home, I would be very reluctant. Yeah, that's definitely a red flag. We have had issues here, and I'm sure you've heard of them elsewhere, particularly with the, and I sort of alluded to the Kathmandu ITU experience that was going on here. But these surgical missions in particular and surgical subspecialties, they've actually put global health kind of guidelines into their mission. And they've got sort of regulations about it. But, I mean, a lot of those regulations are, you know, related to one and two-week trips. And, you know, they have all the, like, CME type requirements and stuff, all that. But it's still this kind of short, blunt, fly in, fly out. And yes, and we go there every year. But what do you think about those programs? Because we find them very problematic because very few of them are longer than two weeks. One of the problems is you mentioned bringing the ICU. There has been a growing effort among NGOs that are involved in product donations to follow guidelines that would eliminate donating old stuff that doesn't work, or even donating new stuff that works, but only works as long as you have replacement parts, technicians to fix it, electricity going at all times. And, you know, if you do a Google image search for medical equipment graveyard, you find these photos of huge lots in various parts of the poorer countries where they've dumped a ton of really valuable equipment because they can't use it. The equipment issue is one that's being tackled by some big organizations and big corporations. That's a good thing. And they've been developing guidelines as well. Also, the practice of sending volunteers medicines to take in their suitcases. This is actually illegal in a lot of countries. And it's illegal in the United States to be giving out medication. So that's really problematic. The one or two week surgical trips. Again, the biggest problem is complications. Every surgical procedure, as you well know, has complications. And if a person comes to you in an area where they don't live to get a surgery, and then they go home again, and if they have a complication, who can take care of it? Who would know about it? I think a lot of the surgical groups are now shifting more towards training and working with teams that are in place year round. And they might go one or two weeks a year to say, okay, how do we upgrade skills? How do we introduce some new techniques? But with the idea that the work will be done by the people in the country and not by the outsiders. And during the COVID pandemic, with the switch to virtual programs, we're seeing a lot of this telemedicine training online. And there's some real advantages to that. You can reach a lot more people at a much lower expense. Very curious to see if we ever get through this pandemic in my lifetime. You know, how many of the programs will switch to that kind of model? I think some of them have already decided to continue it because of the value involved. Yeah, COVID has really impacted our programs. But I have to say, it hasn't ended them. And we've done kind of exactly what you said. We've done much more training virtually. It's still, I think, important for people interested in a global health career that they actually get into the environment where they're interested in working. But until travel is really opened up, it's going to have to be virtual in many ways. I mean, good, bad, or whatever. I think for people who want to work in global health, I agree. You need the travel experience. But two weeks of travel to a place you've never been and back home again. I mean, it's a taste. It's got to be a longer exposure, more experience. Well, I think in your book, you say like the absolute minimum is three weeks. And we have the way our student schedules are set up is there's four weeks is a nice block. Good. Four is better than three. Let me go to a question here from which is in the same vein here. My name is Mei-Lin Shi, and I'm a second year medical student at Feinberg. When we're working on research projects here at Northwestern, what's the best way to explore how we can apply it abroad? Building off of that, what's the best way to explore how we can apply it locally to an underserved community in, for example, Chicago? Some people have figured out that global health doesn't have to be done beyond the borders of the United States. We have a global population in this country. We have people who don't speak English and who have serious medical problems and not good access to care, and they're down the street in many cases. And I know some medical schools have developed programs with immigrant health centers, refugees and so forth, or just with low income. I think that you will learn a great deal by working in a center that serves the needs of low income and immigrant populations, and probably learn a lot more from that, doing it over a period of time and getting to know people and understanding what the issues are. I want to address the research aspect that the student mentioned, because there are some incredibly creative research projects going on in labs across the United States and across the world where people are coming up with solutions to specific problems, diagnostic problems, water supply problems, and so forth. And so the question about how do we apply them is a tough one, because it requires really some local partners who are willing to do the collaboration. So the collaboration we've talked about, partnerships in terms of clinical care, is also really important with research. And there's been a fair amount of attention recently to the unfairness of publications where the research is being done about problems in the global south or data in the global south, and then, you know, the North American gets the credit and gets the benefits of publishing it, and the people who did the work maybe get mentioned as a thank you note or something. So again, partnerships around research are just as important, and that means really giving equal consideration to what are their concerns? Are there researchers in other countries that you can work with who are thinking about some of the same questions and maybe have some insights, very likely have insights into ways in which what you're working on may be best applied in another country? There's been a lot of sort of innovative ideas that people have come up with in North America, and then they go to some poor country and say, hey, try my water filter or try my light source. It's all potentially very good, but what is the local context? You know, there were students from my university who spent years building a water system in a village in Central America, and it worked, technically, but it didn't work culturally and socially, and it just ended up being a big waste of money. They understood afterwards that they needed to spend a lot more time understanding the local context and the needs and practices of the community before sort of bringing a product. So I'm not sure if that addresses exactly what you're talking about, but again, I urge you to look at some of the literature on global research partnerships and how to make them better. So we have one other question. We have an audio recording of the question. Can we play that? Patrick Driscoll, Masters of Public Health student at Northwestern, concentrating in global health. Can you speak at all towards the intersections of sustainability and ethics in terms of global health program development that you've both witnessed and participated in through your experiences? Well, I think we've been talking a lot about sustainability and ethics. You know, is a program ethical if it's not sustainable? All right. Is a one-time drop-in parachute visit to do something, is that a good thing? If you are the patient who got your cataracts removed on that one trip, it's a great thing. But if there's no training, if there's no continuity, if there's no follow-up, it's not ideal as a program. And I want to distinguish those things because far be it from me to say an individual whose health was improved, whose life was improved in any way, that's great. But the ethics here is, you know, how are we expending our resources? And are we doing it so in a way that is equitable and that makes sense and is a good use of resources so that more people can benefit in a way that is respectful and that really is understanding of the needs of a country? It's a tough dilemma. There is nothing better than helping somebody feel better, right? You fix their hernia, you take out their cataract, you give them a brace for a leg that doesn't work very well, and you see them feeling better. It's wonderful. And that's very satisfying. Again, the balance between those individual efforts and looking at the whole picture of what are the best ways to make those experiences available to as many people as possible. And it really has to do with strengthening the overall health care system. This is the World Health Organization now is very focused on universal health care and strengthening health systems. And we can, I think, as outsiders with resources, contribute to those goals of strengthening systems in a way that will be much more sustainable than one-off visits. I want to thank Professor Lasker for joining us on this podcast. I wish you luck with your global health partnerships group. I hope people listening to this podcast get involved with that too. jspars.org and look at the Brochet Declaration. We're welcoming other organizations to endorse it and use it. And we're very pleased that a lot of organizations have used it as a guideline for modifying their programs, which is great. I'm really happy that Rob and Northwestern are part of that effort. Great. We're happy to be part. Thank you so much. Thank you again for joining us. Follow us on Apple Podcasts or wherever you look at the podcast to hear the latest episodes and join our community that is dedicated to making a lasting positive impact on global health.