Serving as an international medical volunteer can be immensely rewarding. The authors, volunteers themselves, offer a practical guide to embarking on the journey.
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Serving as an international medical volunteer can be immensely rewarding for pediatricians and pediatricians-in-training. The authors, volunteers themselves, offer a practical guide to embarking on the journey.
Emily is beginning her third year of pediatric residency. She has an elective month in late winter, about six months from now. In order to improve her Spanish and gain exposure to tropical medicine, she wants to do an international elective, but doesn't know where to look for such opportunities.
Kanishka is a pediatrician in a community practice. Over the past few years, he has been suppressing a nagging itch. Today, he again watched media coverage of the plight of children in impoverished South Asian countries, including his homeland. He has decided that now is the time to act.
Malaria. Schistosomiasis. The sequelae of polio. Geography and socioeconomic differences make these diseases that affect millions of children worldwide seem remote and exotic to pediatricians in North America. We usually learn about them from textbooks. We look at stock smears of red blood cells harboring Plasmodium falciparum, memorize the side effects of albendazole, and administer vaccines to prevent illnesses we've never seen.
We're peppered with vignettes and hypothetical situations, but without real cases our intellectual arsenal becomes speckled with cobwebs. It is only when vignettes assume a human face and have a first name that they become truly unforgettable.
International medical volunteering can give faces and names to illnesses we seldom or never encounter. It allows pediatricians and pediatricians-in-training to see diseases that are rare in developed countries and to make a difference in the lives of children and their communities. Medical volunteers not only aid children at risk of being overlooked by beleaguered health systemsby performing physical exams, giving vaccinations, and diagnosing and treating illness. They also have opportunities to teachand learn fromlocal medical professionals and to help initiate community health programs, which can be immeasurably rewarding. Moreover, international medical volunteering increases understanding of epidemics in other parts of the worldSARS, measles, possibly even smallpoxknowledge that is becoming essential as media coverage, the ubiquity of the Internet, and the ever-present threat of biologic warfare close the distances between nations.
Pediatric leaders and educators have emphasized the importance of international volunteering. Recent articles in the literature report on the many benefits international electives offer medical students and residents, including fostering more empathetic attitudes, increasing knowledge, and enhancing physical examination skills.1,2 The American Academy of Pediatrics' Section on International Child Health focuses on health issues particular to children in developing nations and has recommended guidelines for international electives. As a result, more residency programs are including overseas opportunities in their curricula.2
So, what do you do once you've decided you want to volunteer overseas? Physicians seeking such opportunities must sort through an array of choices related to cost, time commitment, professional responsibilities, and location. They must consider risks such as personal safety and adverse health exposures and investigate such potential obstacles as primitive accommodations, religious requirements, and language barriers. Although finding an organization that sponsors overseas pediatrician volunteers is not necessarily difficult, finding one that meets all your criteria can be immensely challenging.
First and foremost, take a moment to answer this question: Why do you want to volunteer overseas? Are you a romantic humanitarian? Are you a thrill-seeking tourist using medicine as an enabler? Are you seeking personal answers to cultural questions?
For most of us, the truth lies somewhere in the midst of these alternatives, so it is imperative to define your expectationshonestly. Because volunteer organizations vary greatly in their demands on your time, understanding your motives for traveling is an important first step in securing a valuable international experience. A frank self-assessment will significantly improve your ability to ask intelligent, pertinent questions. If near-total immersion in a culture is important to you, for example, or if you insist on keeping weekends free for exploration, you'll need to ask sponsoring organizations about these issues.
There is nothing wrong with permitting yourself a mountain trek to track gorillas or a weekend journey to visit the Taj Majal while volunteering abroad. Once-in-a-lifetime refers not only to the medical marvels you see while overseas but also to the historic and natural wonders that surround you. Keep in mind, however, that whereas an overly intensive volunteer experience can foster exhaustion and dissatisfaction, frolicking around a foreign country without much medical responsibility can engender a feeling of emptiness and missed opportunity.
What is your budget for the trip? You might assume that sponsoring organizations have funds to support volunteers' travel, lodging, and food needs, but this is rarely true. More often than not, you will have to pay for a significant portion of the trip, including an airplane ticket and perhaps accommodations.
A plane ticket to Asia or Africa can easily cost more than $1,000. Some volunteer organizations require a participation fee ranging from hundreds to thousands of dollars. Daily expenses can range from $5 to $30, depending on exchange rates and room and board arrangements. And preparations for the tripincluding immunizations, equipment, and required paperworkadd a few hundred dollars if these expenses are not subsidized by the sponsoring organization.
For doctors carrying outstanding loan balances, supporting families, or taking a sabbatical from private practice, the cost of international volunteering can be an imposing obstacle. Budgeting realistically and recognizing your financial limitations will help you sort through volunteer opportunities. Discussions with your insurance company about health coverage also may influence your decision.
It is important to define precisely when and for how long you are available to travel. Sponsoring organizations have different requirements for volunteers; some ask only for weekend service while others expect a six-month commitment. The AAP guidelines suggest a minimum of four weeks of hands-on responsibility, but your own circumstances may dictate a shorter or longer period.
Who will be your colleagues? What resourceshospital facilities, living arrangements, medical equipmentwill be available to support your volunteer work? Do you need to speak the language? Will sleeping under a mosquito net aggravate you? Can you subsist on only potatoes and fish? What is the sociopolitical environment of the region you are considering? It can be difficult to decide which intangibles such as these are most important to you before you even know your travel options, but recognizing that each volunteer opportunity will have details to be considered and potential deal-breakers in the fine print may prevent subsequent frustration. Considering intangibles is an ongoing process that begins the day you decide to go overseas and ends only when the plane lands back home.
First, look around. Talk with colleagues and peers who have volunteered overseas about people they know and places they've been. Ask open-ended questions about their experiences: What did you learn? What were your responsibilities? How did you make the arrangements? These volunteers may be your best resources, and you might find enthusiastic storytellers among them, who, if nothing else, get you excited.
Next, go to a computer. If you haven't been given a lead by a colleague, a good idea may be to start your search at the American Academy of Pediatrics Web site ( www.aap.org ). The AAP has compiled a pediatrician-specific listing of international volunteer opportunities that you can browse by country or agency ( www.aap.org/cgi-bin/overseas/aapartcl.cfm ). The site also includes discussion of issues related to overseas volunteering.3
Several other Web sites offer more detailed information and a more inclusive listing of international medical volunteering options. The International Medical Volunteers Association, at www.imva.org , maintains an exhaustive listing of opportunities (which the AAP has condensed on its site) in pediatrics and other areas of medicine. Many of the organizations listedincluding Operation Smile, Doctors Without Borders, and Health Volunteers Overseasmaintain their own Web sites (see "Where to find international medical volunteer opportunities").
Once you've settled on your destination and cemented arrangements with the sponsoring volunteer organization, you need to prepare to travel abroad. A good resource is the Centers for Disease Control and Prevention Web site ( www.cdc.gov ), which maintains an extensive listing of travel restrictions and vaccination requirements for different areas of the world. Timely receipt of immunizations is important and is probably best done at a travel medicine clinic because such clinics offer region-specific advice and updated information on vaccination regimens. Travel medicine clinics are often affiliated with hospitals or universities and can be located on the Internet or in the yellow pages of the phone book.
Also, it's never too early to obtain or update your passport and research visa requirements for the country to which you will be traveling. Many foreign embassies maintain informative Web sites that can help in this effort. And be sure to keep abreast of US Department of State announcements and travel warnings, which are updated regularly at www.travel.state.gov .
There will always be children in dire need of the most basic health care both at home and abroad. As pediatricians, we have a great deal to contribute to humanitarian efforts. If you choose to give your time to a volunteer endeavor abroad, be prepared for the formidable task before you: lots of phone calls, mounds of paperwork, big decisionsall necessary legwork that will help you land feet first on foreign soil. Once there, be prepared for an experience that may shape the way you practice medicine and change the way you see our world. (For personal accounts of two overseas volunteer experiences, see "One month in Nairobi," and "A willing heart, a bit of daring.")
1. Thompson MJ, Huntington MK, Hunt D, et al: Educational effect of international health electives on US and Canadian medical students and residents: A literature review. Acad Med 2003;78(3):342
2. Torjesen K, Mandalakas A, Kahn R, et al: International child health electives for pediatric residents. Arch Pediatr Adolesc Med 1999;153(12):1297
3. Staton DM, Harding MH, Harding CR: Directory of International Service Opportunities for Pediatricians. www.aap.org 2000
In 2002, while I was a senior pediatric resident, I spent the month of November as a medical volunteer in Nairobi, Kenya. My search for a volunteer opportunity started five months before my intended departure date. I simultaneously browsed the Internet and spoke with colleagues who had international contacts. I found my best leads on the Internet, specifically at the International Medical Volunteers Association Web site ( www.imva.org ).
My residency educational stipend allowed me to spend $1,000 to $1,500 for this elective, so I eliminated options that required significant additional expenditures. Besides financial considerations, the overall philosophy of the sponsoring organization and the expected medical responsibility were the determining factors in my selection process.
The Catholic Medical Mission Board (CMMB) had several suitable programs available, and I eventually selected a wonderful Kenyan orphanage called Nyumbani, which cares for children with HIV/AIDS and has an onsite clinic and laboratory. Room and board, as well as traveler's insurance, were provided. The plane ticket, with a small discount, cost about $1,100. Recreational expenditures amounted to approximately $200, which included a three-day safari to the Serengeti.
CMMB accepts Catholic and non-Catholic medical volunteers. More information about this organization can be found at www.cmmb.org . Nyumbani also accepts volunteers directly. Volunteers should be prepared to participate in basic child care and day-to-day operations. Further information is available at www.nyumbani.org .
The children at the orphanage were relatively healthy during my visit, so my diagnostic and treatment responsibilities were fairly light. Additional duties included performing physical exams, dispensing medications, and making hospital referrals on my many visits to nearby communities. I was amazed at how the children lived their lives with such hope and courage, brimming with smiles and love for everyone. I came to Kenya to help others, but I left infected with the contagious happiness and optimism that even great social and medical adversity could not eradicate.
My first experience in international health occurred during my tour of duty in Tripoli, Libya, with the United States Air Force. Besides caring for military personnel, the base physicians cared for many local residents, presumably those of political interest to the US. It was an unforgettable cultural experience, and I vowed to serve overseas again someday.
When my son was in college, we decided to do something different together, so we signed on to work in a mission hospital in Kenya. It was challenging, fascinating, scary, and mind-boggling, all at the same time. It was also unbelievably worthwhile. Patients often arrived comatose, and the differential diagnosis would include bacterial meningitis, encephalitis, cerebral malaria, and toxins, to name just a few possibilities. The hospital had limited laboratory capabilitysometimes we would receive a report of "no growth" on a sample of purulent spinal fluid. The radiology department would run out of film, leaving us without radiographs for days on end, and our pharmaceutical resources were not at all what we were used to stateside.
Trauma included bow and arrow injuries (only the military had guns), some intentional, some unintentional. We even saw a pneumothorax in a young Masai herder who had fought a lion successfully. Many patients arrived with wounds in chronic stages of infection, accompanied by osteomyelitis. And every condition we treated was complicated by malnutrition, including kwashiorkor, and the type of hygiene associated with living in mud huts and bathing in the river where the animals crossed. I have returned to that hospital several times over the years and been overjoyed at the progress I've seenthe new buildings, the native health teams that go into the local villages to teach about health and hygiene, the immunization programs, and best of all, the increasing numbers of Kenyan physicians assuming care of their own people. I grieve, though, at all the AIDS patients the hospital now takes care of.
In recent years, I have volunteered in other countries, including Cambodia and countries once separated from us by the Iron Curtain. Tashkent, Uzbekistan, is a sister city to my hometown, Seattle, Wash. My first encounter there was with children in orphanages. I served with teams comprising physicians (including pediatric residents), nurses, psychologists, teachers, occupational and physical therapists, and audiologists. After we identified hundreds of children with neurosensory deafness, we came home and raised $50,000, which has been used to provide hearing aids to about 350 children.
My volunteer experiences have focused increasingly on teaching. For the past eight years I have been visiting professor of pediatrics at the Tashkent Pediatric Medical Institute. My wife and I have hosted many physicians from that institution in our home when they came to this country to attend conferences at our local children's hospital. One graduate of the medical institute, who served as my translator for years and whom we encouraged and helped to come and study in the US, is now a pediatric resident at the University of Iowa.
All of that to say this: The opportunities to serve overseas in international health are endless. All it takes is a willing heart, a bit of daring, and some effort to find the right fit (as well as money to pay expenses, of course). You can help with disaster relief, provide hands-on care in a remote mission hospital, or teach in a medical facility. Just get connected to the right agency. The best resource to start with, in my opinion, is the publication entitled Working in International Health, which is available from the AAP's Section on International Child Health: telephone 800-433-9016, extension 7658.
The following list of resources for physicians interested in volunteer opportunities overseas is not meant to be all-inclusive. Rather, it is a selective directory designed to provide high-yield information. Many of the hundreds of organizations that might sponsor a pediatric volunteer are listed on the Web sites below.
The American Academy of Pediatrics Web site includes a Directory of International Service Opportunities for Pediatricians that allows searches by country or agency. The site lists many organizations that sponsor pediatric volunteers along with information about costs, duties, and required time commitments. Web site: www.aap.org/cgi-bin/overseas/aapartcl.cfm
Also, the AAP's Section on International Child Health publishes a booklet entitled Working in International Health. To obtain a copy, telephone 800-433-9016, extension 7658.
The International Medical Volunteers Association maintains a comprehensive Web site with extensive listings of medical volunteer organizations. The listings are not specific to pediatrics. The site is an excellent place to start your search, but its 60-plus pages may be overwhelming. Web site: www.imva.org; e-mail: firstname.lastname@example.org
Health Volunteers Overseas, a nonprofit organization with projects in more than 25 countries, has 10 medical specialty divisions, including pediatrics. Commitment requirements vary. Volunteers pay travel expenses, but housing may be subsidized. Web site: www.hvousa.org ; e-mail: email@example.com; telephone: 202-296-0928 (programs)
Doctors Without Borders (Medecins Sans Frontieres) provides emergency health care to victims of armed conflict, natural disasters, and social and geographic isolation. Volunteers must have at least two years of medical experience after graduation from medical school. An interview is required. The minimum commitment is six months. Expenses are covered by the organization. Web site: www.doctorswithoutborders.org ; e-mail: firstname.lastname@example.org; telephone: 212-679-6800
Operation Smile provides reconstructive surgery and related health care for indigent children in the US and abroad. The average mission lasts eight to 12 days. Pediatricians and subspecialists are recruited. Costs to board-certified volunteers are minimal. Operation Smile pays travel expenses. Residents may participate if they are affiliated with one of the organization's educational partners and are under the supervision of an attending physician. Fees for residents range from approximately $1,100 to $1,800, depending on the location of the mission. Web site: www.operationsmile.org; volunteer forms: 6435 Tidewater Drive, Norfolk, VA 23509; e-mail: email@example.com; telephone: 757-321-7645
Bryan Fine, Tien Vu. Thinking of volunteering abroad? Contemporary Pediatrics October 2003;20:87.