More harm than good?

It’s amazing that the academic year has nearly come to an end.  If the old adage “time flies when you’re having fun” holds true, then Juxtaposition has definitely had an exciting year.  I’d like to take this opportunity to once again congratulate this year’s team with their U.T.S.U Student Leadership Award for Outstanding Publication. A very proud moment for Juxtaposition and a testament to the vision, commitment and hard-work displayed by this year’s team. Congratulations to this year’s Editors-in-Chief, Sarindi and India, and to the entire team!

As final exams and essays now wrap up, students interested in global health may be embarking on another journey this upcoming summer. Based upon discussions with students, many will go on to pursue volunteer and research abroad opportunities that will be both personally enriching and impacting in a variety of ways.  This is an important process that will allow one to pragmatically apply the theory learned over the past academic year, to the real-world nexus of complexity in this field.  

World__s_health_by_RizhrdRecently, I received an email through the Global Development Professionals Network (GDPN) list-serve that posed an interesting question for debate: “Volunteers: a godsend or a necessary evil?”  Through this email, the GDPN was trying to enlist participants in a debate to promote dialogue on a topic often considered quite polarized.  It reminded me of Juxtaposition’s first case competition meeting, which incited similar discussions. 

Back in mid-February, Juxtaposition held its first meeting to commence preparation for this upcoming November’s inaugural UofT Global Health Case Competition.  At the start of this meeting, a series of ‘ice breaker’ games organized by Sarindi and India, sought to strengthen collegiality and engage group discussion.  During one game, a variety of statements were posed and each member was to migrate to their chosen position via a likert scale of signs posted across the walls of UofT’s Sussex Clubhouse; distinguishing between ‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’ and ‘strongly disagree’. One statement, in particular, piqued my interest given the reflective discussion that ensued. The statement posed: “Medical volunteerism has the potential to do more harm than good. Similar to the previous GDPN question, both call attention to a myriad of issues pertinent to this field, including — ethical implications, sustainability considerations, codes of conduct, social and cultural responsibility, overall and long-term impact, cultural sensitivity, and potential “harm” (however we choose to define this).

What struck me initially was that out of the roughly fifteen team members in attendance, I was the only one to assume a ‘strongly agree’ position; essentially taking the stance that global health volunteerism has the ‘potential’ to do more harm than good.  I want to emphasize the word ‘potential’ here, as I think this is the crux of where the issue with this statement lies — that there exists a potential, but not necessarily a likelihood, for harm to result.

As the floor opened for dialogue, members in the ‘disagree’ category emphasized the positive outcomes that may result from voluntary efforts, such as filling gaps in service delivery and providing programmatic assistance where local capacity may be lacking.   Other members took a more neutral stance; first highlighting the benefits in offering such support, but also recognizing the potential implications that may result from unethical practice.  I remember one example described by a student that illustrated the importance of a long-term partnership where foreign medical volunteers would come to offer surgical assistance to patients lacking access, but, did not appear to be sustainably strengthening the capacity of local surgeons to lead these medical initiatives.  

And then there was me off in the ‘strongly agree’ end of the spectrum. While I recognize the benefits that can emerge from such efforts, having assumed this role myself throughout the years, I still believe that there is a potential for harm to occur if we fail to respect cultural boundaries, sustain ethical practice and in particular, recognize the implications of our absence once we are gone.

The challenge in this debate for me lies largely in the fact that ‘global health volunteerism’ is so diverse in scope, practice and overall impact, which makes it difficult to criticize or critique this practice as one entity.  Are we referring to volunteers who spend a few weeks in an orphanage offering care and love to abandoned children?;  Or, volunteer medical personnel who offer medical services to patients who lack access?; Or, perhaps we’re referring to volunteer research students and/or interns who provide voluntary programmatic and management capacity to organizations or government bodies?; Or, maybe all of the above?  

This is where the challenge lies given that all of these roles differ so widely in length, scope and output.  And yet, when a question asks if volunteers are a ” godsend or necessary evil,” the distinction between which volunteer one is referring to remains nebulous. Are all volunteers and their associated programs created equal? Do volunteer researchers also fall into this category? Perhaps we require clarity in our definition of a ‘global health volunteer’ before we enter a debate critiquing this role. 

What is clear however, is that if we as a collective of students, volunteers and researchers are not clear in specifying the goals of our mission and practice, the potential for harm (whether ethical, cross-cultural and/or collaborative) can and does result.  I’m reminded of a number of scenarios where initial altruistic intent unfortunately resulted in unforeseeable negative consequences on partnerships, organizations and communities.  One example includes a story of a woman I once spoke with at an orphanage in Jamaica who stressed that while she was happy to see foreign volunteers interested to assist the children, she was also concerned that once the volunteers left, she would not have the capacity to provide the children with the same level of attention.  Another example involves volunteer internship placements that once again, may initially provide much needed programmatic capacity, but may also run the risk of leaving counterparts overburdened if measures aren’t taken to strengthen institutional memory in the long-run.  And another example, where non-medically trained students may enter an under-staffed health system and help with taking patient histories to fill the proverbial gap in service provision, but fail to acknowledge if local communities view these volunteers as more than they are trained for.  

But, once again, all of the above examples are not equal in how these partnerships are constructed and in their overall goals and intentions. Hence, it is difficult to critique them all under one umbrella of ‘global health volunteerism,’ which I find is often the case when this debate emerges. 

In 2010, Crump and Sugarman published an insightful piece on “Global Health Training,” detailing both the ethics associated with and best practices for working in the field of global health.   While differences do exist between voluntary efforts, the authors recommend a number of guidelines that transcend these differences to strengthen all partnerships.  What appears to be a common theme across their recommendations is that all parties involved should have a clear understanding of the expectations and responsibilities of the work to be undertaken.  You’d be surprised how often this key aspect may fall through the cracks. I highly recommend not only students to familiarize themselves with these guidelines, but also organizations, universities, departments and faculty who also play a large role in standardizing practice and ensuring the application of ethical protocols.

While this debate will continue long after this blog post is read, it is important that we remain reflective throughout all the work we do in this cross-cultural field.  Volunteers (in any capacity) are an important piece in this process as we strive to improve health globally and meet Millennium Development Goals. But, as you embark on your journeys this summer, remember to reflect on your role in your placement; question how your presence will be sustained upon your departure; encourage dialogue with your counterparts to elicit their needs and how you can help meet these needs; and last but not least, have fun! Immerse yourself in a very enriching process of cross-cultural learning that will guide you throughout your career in this field.  

I want to leave you with a quote that has stuck with me through the years related to this discussion.  It was told to me by a mentor of mine, John Callaghan (a retired high-school teacher who has volunteered for nearly twenty years in Nicaragua, Jamaica and Haiti) and describes the thoughts of an Australian Aboriginal woman who spoke of her impressions of foreign volunteers.  

 “If you have come here to help us, then go home.  But, if you’ve come because your destiny is tied up with mine, please stay, and let us work together.”

I think she sums it up well. Let us work together because our destinies are all intertwined!  

…. I may see the birth of a new twitter hashtag related to global health — #destinyintertwined

Kadia Petricca is a PhD candidate of Global Health Policy at the University of Toronto’s Institute of Health Policy, Management and Evaluations.  Comments or questions can be directed to: k.petricca[at]  Twitter: @k_petricca