As a family physician with a strong interest in international work and travel, I often contemplate how to best balance my personal goals and needs with those of the communities I serve. I have a strong desire to serve internationally but with a full time job here in the U.S., I can only get away for 1-2 weeks at a time and must use my vacation time for any volunteer work. Most medical professionals in the U.S. are in a similar situation to me and thus can only consider short volunteer stints if at all. As a board member of The Minga Foundation, I am always searching for sustainable projects to work on. However many medical projects that accept short-term volunteers are anything but sustainable.
There are numerous medical non-profit organizations that specialize in what many consider “medical tourism.” These organizations send teams of volunteer physicians, nurses and support staff to an “underserved” community for several days or a few weeks, provide donated materials, see hundreds of patients, and then leave. The volunteers have a great time during their travel, enjoy the experience of “roughing it” and leave feeling as though they have really helped people in need. But what impact do these projects really have on the long-term health of a community? It turns out that it depends greatly on the overall design of the project and the behind-the-scenes work between on-site visits.
Short term medical missions not only have the potential of leading to unsustainable health impacts, but can actually undermine the existing health systems of the communities they are meant to serve. Most medical mission projects provide free care which may discourage patients from seeking care from existing health providers in the intervals between mission visits. Frequently there is a duplication of services provided on mission trips without coordination with the local health system. The most irresponsible organizations may also bring donations of donated medications that may be expired, unavailable for patients to continue in their home-country or with instructions printed in a language they cannot read.
Projects that focus on improving the knowledge, skills or capacity of medical providers in the community being served are much more likely to lead to lasting health improvements than projects where care is provided by foreign volunteers only. I recently had the pleasure of volunteering with one of many medical non-profit organizations that truly “got it right.” Prevention International: No Cervical Cancer (PINCC) is a non-profit organization with a mission to “create sustainable programs that prevent cervical cancer by educating women, training medical personnel, and equipping facilities in developing countries, utilizing proven, low cost, accessible technology methods.” Though their volunteer model relies on 1-3 week international trips by American or Canadian providers, their work leads to completely sustainable change and has truly saved the lives of hundreds of women. Knowing this makes the experience of volunteering with them even more gratifying.
PINCC was founded in 2005 by an OB/GYN in the San Francisco Bay Area, Dr Kay Taylor, whose vision was to help eliminate cervical cancer in developing countries where it is a leading cause of death for reproductive aged women. Thanks to cervical cancer screening programs that emerged in the past century (PAP smears), cervical cancer is now incredibly rare in the United States and other developed countries. PAP smears allow providers to diagnose pre-cancerous changes in the cervix that can be easily treated years before they become cancer. Cervical cancer is one of the most easily prevented diseases in modern medicine, yet requires a universally available screening program and access to treatment for women whose screening tests are abnormal. Poorly organized and underfunded health systems, poor health care access for women in rural areas, and cultural stigma are just a few reasons why cervical cancer screening programs have not been as successful in many developing countries. HIV infection increases a women’s risk of getting cervical cancer and so countries with high HIV infection rates have also seen huge increases in deaths from cervical cancer.
I recently volunteered with PINCC for one week in Muhoroni, a remote village in Western Kenya, and then another two weeks along the remote Caribbean Coast of Nicaragua. During my time with PINCC I was constantly impressed with their sustainable approach to providing medical aid. PINCC’s entire model relies on training nurses, clinical officers and physicians in underserved clinics the necessary components for establishing their own cervical cancer screening programs. To date PINCC has trained over 400 providers at 27 different health centers! The exponential impact of this work is so much greater than just the 15,000 women who have been screened during PINCC training trips. Thousands more women have been screened and treated since PINCC ended their involvement with the clinic sites.
Part of the success of PINCC comes from the huge amount of care taken in selecting project sites ahead of time. Before PINCC ever agrees to visit a community, they require a signed contract from the hosting hospital or clinic confirming their commitment to establishing a cervical cancer screening program for their patients. PINCC will then provide between 3-4 site visits over a 1-2 year period as well as remote support between visits as needed. PINCC will also provide donated equipment to help the programs get up and running, but they also make it clear that local health providers will have to determine their own way to fund the screening program in the long run (be it through governmental support, charging small fees for services, acquiring donations, etc). PINCC provides the necessary training and certification for providers and also helps link providers with their in-country medical resources for more challenging cases that may arise. Very importantly, PINCC makes sure not to duplicate services by only visiting communities where there are not cervical cancer screening programs already in place, and gets permission from the national Ministry of Health to make sure they support PINCC’s work in the proposed communities.
As a volunteer, the experience of working with PINCC is incredibly rewarding. One week is spent at each clinic or hospital site with a focus on training providers in the skills needed to perform screening exams for cervical cancer. During our visits to Kenya and Nicaragua, we saw 100-200 women each week and supervised local nurses or physicians as they performed exams. Any of the women who had abnormal exams needing treatment were treated that day and each site had several providers who were learning to perform the simple and low-cost cryotherapy procedure with the goal of certifying them on future visits.
It was rewarding to see a large number of women receiving cervical cancer screening often for the first time in their lives. During our week in Kenya we treated over 25 women with pre-cancerous lesions and during our two weeks in Nicaragua we treated 35 women, essentially preventing each of them from developing cancer in the near future. We also sadly saw 5 women in Kenya who likely already had advanced cervical cancer. There may not be much to do to save their lives though they were referred on to the national hospital system for possible treatment. In my entire 9 year medical career in the U.S. I have only cared for 2 women with cervical cancer. Thus, I also learned from seeing these more advanced cases and the importance of the training we were providing became all the more apparent.
I cringe whenever I hear colleagues talk about volunteer stints in other countries that are clearly not providing sustainable care. I feel that more of our volunteer aid should be focusing on improving the existing systems of care in other countries rather than swooping in and providing care that will not be sustained when we leave. Programs that are designed to teach new skills for local providers, increase access for patients to health services (funding clinics, etc. so long as those clinics can be staffed by local providers) or provide educational and outreach services for patients (e.g. community health worker programs) will ultimately be the most impactful in the long run. As medical volunteers we have an obligation to make sure we are truly providing meaningful help and not actually undermining the health systems of the countries we are intending to help. I urge anyone considering a medical trip of their own to look closely at the model of care that the organization follows and ask questions if it isn’t clear how they integrate with local health systems and ensure the long term sustainability of their work. There are plenty of good organizations out there like PINCC who need our help, but it is important to choose wisely if you want to truly make a difference.
For More Information about PINCC, visit www.pincc.org