#84 Passports and Procedures: Receiving and Providing Care Abroad

Dr. Noelle Sullivan and her colleague, Chris Mmbwambo in Tanzania, who runs the NGO TEKUA. The two work collaboratively for the charity, Worldview - Education and Care.

November 4, 2020

As Canadians, we're usually quite proud of our excellent healthcare system. However, as we learned in Episodes 83 on organ donation, 82 on amputation, and others, gaps in public coverage and long wait times sometimes prevent Canadians from accessing the best care. Enter "medical tourism", or "medical travel". In this episode, we explored what it might be like for Canadians to access care abroad. We spoke with Adele Kulyk, the CEO of Global Healthcare Connections. Adele has worked for the last ten years as a coordinator to help facilitate Canadians traveling elsewhere for care. Adele explains what may drive people to leave and what sort of procedures are accessed abroad. As we explored this topic, we discovered another reason Canadians travel abroad related to healthcare: as medical students and other trainees to actually provide care, a practice colloquially known as "medical voluntourism". To understand this theme, we sat down with Dr. Noelle Sullivan, a professor in anthropology at Northwestern University, and Dr. Jessica Evert, Family Medicine Physician at UCSF. Both guests spoke to their extensive research and experience working with medical trainees travelling abroad to provide care, shared their concerns about the impacts of these experiences on host communities, and offered insights on how to approach these opportunities with humility and grace.

Written by: Larkin Davenport Huyer

Global Healthcare Connections
2017 Fraser Institute Report on Medical Travel by Canadians
Birth Tourism in Canada - Article
Dr. Noelle Sullivan - Website
Dr. Jessica Evert - Profile
Child Family Health International

Colleen Farrell [00:12] Welcome to Rawtalk podcast episode #84 on the topic of medical tourism or medical travel. You might already be familiar with the term medical tourism, but as we'll learn later, the term medical travel is often more appropriate. In developing the episode, we also found that there are two different types of medical travel. First, as patients access in care abroad and second, as medical learners looking to experience providing care abroad. In today's episode, we'll explore both these themes, starting with access and care abroad.

Aditi Desai [00:43] Before we begin, we would like to acknowledge that Toronto was founded on the traditional territory of many indigenous nations, such as the Mississauga of the Credit River, the Anishinaabe the Chippewa, the Haudenosaunee and the here on one date. This place is still home to many First Nations. In you it in May, people, and we're grateful to live and work on this land as we explore stories of medical travel, which is defined by issues of privilege within and between countries. We ask you, our listeners, to learn about and reflect on the disconnect between Canada's proud health care system and the lack of access experienced by indigenous and other marginalized communities.

Colleen Farrell [01:23] I'm Colleen Farrell.

Aditi Desai [01:25] And I am Aditi Desi.

Colleen Farrell [01:26] And welcome to Episode #84 of Rawtalk.

Colleen Farrell [01:38] Accessing healthcare outside candidates may not be something that many people consider. Given our universal healthcare system, while this is true for many of us, there are factors within our system. In situations, you need to every person that would motivate individuals to leave their province or country to access care.

Colleen Farrell [01:56] Our first guest, Adele Kulyk, discusses the work she does with her team to connect patients with accessing health care needs abroad.

Adele Kulyk [02:05] I am a Canadian entrepreneur and I have been involved in the medical, travel and tourism industry for over 10 years. I first came to know about medical travel and medical tourism back in 2008/2009, when a few friends of mine ventured out for, inn those days it was bariatric surgery. And then I came to have a keen interest in the medical travel industry when a friend of mine was diagnosed with stage 4 lung cancer and had very limited options for treatment here in Canada. That set us off on a journey to, you know, do our own research and figure out how one could even connect to medical doctors outside of Canada. Everyone's heard of the Mayo Clinic, and so that's sort of the first go to for a lot of Canadians. Unfortunately, in his case, there wasn't much by way of treatments that were viable to offer him. So now for over the past 10 years, what I have done is submerged myself in learning about international health care, medical travel, medical tourism. And it just blends nicely with my background in sales, marketing, research and my own innate curiosity.

Aditi Desai [03:26] So the experiences that Adele described led her to establishing global health care connections. A team of experienced health care navigators who facilitate connections and provide information allowing individuals to make informed decisions about how they can access health care abroad. We asked Adele to define medical tourism for us.

Adele Kulyk [03:46] I think the industry itself prefers the term medical travel over medical tourism. And the reason for that is that in most cases, aside from the airfare and maybe a small interaction with, you know, the local fare in the country, it's really about the medical experience. And so it's medical travel because it's basically defined as bringing specialist surgeons/surgical centers and most importantly, the patient to provide affordable, safe, licensed and accredited health care at locations around the world. And so medical travel would be defined as anyone leaving their local jurisdiction for the purpose of receiving a medical treatment. And you can have multiple forms of medical travel. You can have domestic medical travel, which we have right here in Canada all the time. So you might have someone traveling from Saskatchewan to Ontario or to British Columbia for services, depending on what is available in each region. Or you may have national travel where you have the patient travelling within North America. So that would be Canada, the United States or Mexico. And then we have international patients. So then we have those individuals who are looking for very specific or maybe very specialized services that are offered at only a few centers in the world.

Colleen Farrell [05:23] We asked Adele, where would patients seeking health care abroad typically travel to, to receive care?

Adele Kulyk [05:28] USA and Mexico for Canadians tend to be, you know, destinations that are highly sought after. When it comes to different procedures, there are different countries that are known. So we see a lot of people going to Turkey for a hair transplant and that type of procedure. We see individuals going to Germany, Switzerland, the USA for cancer treatments and also Mexico for cancer treatments. We have individuals that are diagnosed with conditions that there are few known treatments for, such as ALS or Lou Gehrig's disease, multiple sclerosis. And so we see those patients looking at places in Asia or Mexico for things like stem cell treatment or other procedures that are not available. You know, again, here in Canada and as well, in conjunction with those procedures, when it's a neurological condition, we see them going to a facility that not only administers a treatment by way of stem cell and other supporting IV's, but also a very good integrative program where they get them active. So a neuro rehabilitation program in conjunction with treatments. So really we see people traveling all over again. The destination is dictated by the type of procedure that one is looking for.

Colleen Farrell [06:56] But with universal health care at home, why might Canadians pursue health care abroad? According to a report published by the Fraser Institute, over 60,000 thousand Canadians receive non-emergency medical treatment outside Canada in 2016. The top reasons for seeking care abroad were long wait times, lack of local treatment availability, state of the art technologies and patients hoping to receive better outcomes. So what kinds of patients does global health connections typically serve?

Adele Kulyk [07:25] I think the most common patient we see is someone who is middle age and needs a hip or a knee replacement or spine surgery. That would be our number one inquiry. That individual tends to have the means to pay for private health care and they're highly motivated in many cases to be able to get back to work and to be able to get back to a fully functional lifestyle.

Aditi Desai [07:57] According to the Fraser Institute report, patients could expect on average to wait 10.6 weeks for medically necessary treatment after seeing a specialist, which is almost 4 weeks longer than the time physicians consider to be clinically reasonable. For example, according to Health Quality Ontario, high priority knee replacement candidates should have operations within a target time of 6 weeks, but they typically have to wait an average of 19 weeks. Aside from long wait times, Adele describes increased care options and cost savings as other reasons why patients seek care outside of Canada.

Adele Kulyk [08:31] One of the other subsets of patients that we see a lot of are those looking for bariatric surgery. When we look at the privatization, while you can book a private bariatric surgery or vertical gastric sleeve here in Canada, the cost, I believe is $19 500 Canadian dollars. And for a savings of ten to twelve thousand dollars, you can have an elevated experience as an inpatient in a private hospital with fully concierge service, meaning private room, a place for your companion to stay with you. Two days inpatient where in Canada, it is generally 24 hour outpatient and seven days of follow on care by your nurses, doctors and staff. So it's really a totally different level of care that's offered. And at the same time, you still see a savings of between eight and ten thousand U.S. dollar or Canadian dollars. I had a client, a cancer patient survivor who had gone through treatments and unfortunately, the chemotherapy had an effect on their dental hygiene. So it really eroded all of their teeth. And so now this individual is free from cancer, but unable to eat properly because her teeth are such a mess that she needs a full mouth restoration. The cost for that full mouth restoration here in Canada and this was a Saskatchewan patient, their quote was over $60,000 Canadian dollars. Crazy. And it's a dental procedure. So she had no coverage for it. It's an out-of-pocket cost. So in her case, what we did was we aligned her with a dentist that we've come to know and love. He's absolutely an amazing dentist located in Mexico again. But really, he practices on an international scale. He's trained in Switzerland, the USA, highly credentialed. He did a full mouth restoration and the total cost to her was just under $30,000 Canadian dollars. She had to travel three times. Destination was could. So cost savings were great to her. Her teeth fit beautifully. She could eat steak, something that she hadn't been able to do.

Colleen Farrell [11:12] That in itself was a huge success story with any medical procedure. There are inherent risks. What happens if you step outside of Canada for a medical procedure and you have a complication while you're at your destination? Who pays for additional costs?

Adele Kulyk [11:26] You do. It's not included in your medical procedure. And so many individuals travel outside of Canada without mitigating their own risk and exposure to risk of a complication. And now we know that anytime that you undergo a procedure, whether the procedure is here at home or abroad, there is an inherent risk of complication that comes with any medical procedure. But how do you mitigate that risk? And again, that's one of the things that we worked very, very hard on, because when we first started in this industry, there was zero coverage for anybody for a complication. And so we've now worked with Global Protective Services and we have coverage that we offer an individual when they're going to travel outside of Canada. It's called medical travel and medical complications coverage. It is designed specifically for that individual or patient traveling outside of Canada or outside of their home country for care. It's open to anybody globally, but largely our patients are Canadian. So we worked with the underwriters and the administrator to ensure that that program would be accessible by Canadians and our clients…and it does happen. We have had individuals who have had a complication. And the nice thing about this coverage that was designed is that it also stays in place for six months after you arrive home at your destination. So perhaps, you know, most complications are going to manifest within the first 72 hours. But on the very rare occasion that something manifest after you've returned home, then you have a benefit that you can actually return back to the destination. Any complication you need to have dealt with an emergency, of course. But if it's a non-emergent case, then part of the benefits would afford for you to have your airfare, some accommodation and go back to your treating physician to have that complication or unfavorable result addressed.

Aditi Desai [13:35] So what happens if you're back in Canada and you have an emergency complication?

Adele Kulyk [13:39] You know, that's one of the privileges that we have. And I'm going to call it a privilege because it is a privilege, our Canadian health care system. And while we're very fortunate to have universal health care, you know, there is the need for those individuals who have barriers to their access of care here in Canada. But if you return home, you cannot be refused care. What I'd like to add to that is that it's very difficult for a surgeon and I want to put the lens on of a surgeon. So you have a patient who's traveled outside of the country for a surgery. It's been an unfavorable result. And you come back and there is a view by surgeons and this is not indicative Canadian surgeons, it's surgeons or specialists anywhere in the world, that they are now dealing with a situation that is someone else's - and let me just say it as it is - they call it “someone else's mess”. And so it becomes complicated and not only complicated in the way that they have to go back in and correct the situation, but also on liabilities, you know, where liabilities lie. And so in most cases, what we suggest to individuals is, of course, if you have an emergency, you go to the emergency department, you will not be denied treatment if there is a complication that requires a second surgery or a revision of any kind. It's always in your best interest to go back to your originating surgeon regardless of where you had that surgery done.

Colleen Farrell [15:22] We also asked Adele whether Global Health Care Connections helps arrange travel into Canada to access care from other countries.

Adele Kulyk [15:30] The difficulty with inbound medical travel into Canada is that we are a publicly funded health care system. There is a lot of pushback and I'm a Canadian and so rightly so. Why would we open the doors in our public hospitals to international patients when we have a number of Canadians who cannot access services? It really just does not make sense. And so there's been a lot of pushback from various professionals within the health care services on medical travel. Does it happen? Absolutely. Are there private surgical centers that offer medical travel to individuals from outside of the country? Yes, absolutely. That they exist in Ontario, they exist in Quebec, and they exist in British Columbia. And the government of Alberta has just made an announcement two weeks ago looking at inbound medical travel for private clinical services. So, there's an interest, but there's no one in Canada that's really gotten this off the ground in all of the years that I've been involved. There's been interest, one of the most controversial pieces that we read about in the new. Whose is birth tourism? And those are individuals that are looking to come to Canada to have a child born of Canadian citizenship. This happens every week here in Canada. Again, I'm a Canadian and so I look at it that I also have an ethical responsibility in the work that we do. So we don't touch any different types of cases. And inbound birth tourism would be one of those types of areas…that's not within our service.

Aditi Desai [17:27] Adele has alluded to a rising concern specifically in British Columbia, known as birth tourism. This practice occurs when individuals come to Canada partway through their pregnancy with the intention of giving birth here. In the last year, it has been estimated that birth tourism increased by approximately 20%. Canada, similar to America, grants citizenship to an infant born in this country. There are many underlying perspectives and ethical issues to consider around birth tourism. Although some foreign citizens are able to pay for the birthing procedure, many health care professionals have argued about difficulties with resource allocation within the publicly funded health care system. However, restoring birthright citizenship to those whose parents are Canadian citizens would be considered unjust to some populations, including asylum seekers and those who have been illegally trafficked who later on give birth in Canada.

Colleen Farrell [18:23] So far, we've discussed medical travel and how and why Canadians may access medical care abroad in other countries. We now want to shift gears and focus on the concept of students, volunteers and health care professionals providing medical care abroad, typically in low and middle income countries. This concept is commonly known as medical volunteering or short term global health experiences.

Colleen Farrell [18:52] To understand the ethics surrounding medical volunteering, we spoke with Dr. Noelle Sullivan, a cultural anthropologist and associate professor of instruction in global health studies at Northwestern University in Illinois. Among other projects, Dr. Sullivan researches the impact of international medical volunteering and interventions on under-resourced health care settings. We asked Dr. Sullivan for the definition of medical voluntourism.

Noelle Sullivan [19:18] It's basically when aspiring health profession students, these tend to be medical students, nursing students, midwifery students, other kinds of health profession students. They'll often want to get an international placement as part of their education. And some universities have those kinds of partnerships where they can actually directly arrange placements in other teaching hospitals in other parts of the world. But depending on the students, some of them want to go elsewhere. They would like to go someplace that their university doesn't have that kind of connection or they don't have a university that has those connections or for some other reason. So there's these private companies that actually will arrange that placement for them in health facilities, primarily in low and middle income countries and primarily in places that are also attractive for robust tourism industry. And so they go for between one and generally it's one to three weeks, but some stay as long as six weeks and they're supposed to be working and assisting in health facilities. The reason they call it voluntourism is it kind of joins the word volunteer and the word tourists, because for certain, if any of us go to another country, we're going to want to check out sites and those kinds of things. So that's pretty characteristic that people that are working in these health facilities also want to do some sort of tourism while they're there. And so it brings those things together.

Aditi Desai [20:38] So what are some of the reasons why individuals choose to participate in a medical volunteering experience?

Noelle Sullivan [20:44] I interviewed 50 foreign volunteers from all over the world, so they're not primarily from one region of the world, but they all have very similar motivators. And that didn't really differ based on where they were from. And they were primarily because they wanted to get out and try something new. Some of them were trying to test whether or not medicine was for them. Primarily that was actually the undergrads or high schoolers. They were like, I want to be in medicine. So I'm going to go do medicine and see if it's for me, and then I'll join medical school. For the health profession students, it was often sort of testing their limits to see what they could do. There's a lot more limits on what students are allowed to do in their home countries and less supervision or restrictions when they go to a low income country. There's a variety of reasons for that, but for most of them, it was about gaining access to an experience for them that would take them out of their comfort zone or test their limits a little bit. Very rarely did you ever hear any of these students talking about a desire to be helpful or that they wanted to make a difference. That's not a major motivator. And if it is, it's almost entirely a side thing. The main thing was I have to do an international elective or I have to do an elective. I really always wanted to come to this region and test my limits. Now I do my work in Tanzania…so they always had the whole globe to choose from. And I would always ask them why Tanzania? And they would say things like, “I've always wanted to go to Africa” as though Africa is one country. And some would say things like, “well, I went on vacation in Morocco or I was in Tanzania or rather Egypt once, but that's not really Africa…so I wanted the real Africa” So that's why I came to Tanzania”. So a lot of it's built on their impressions of what's going to have the kind of health care system that would allow enable them to get a little bit more hands on. Some of these experiences are facilitated by major academic institutions and even medical schools. So if you've got universities that have partnerships with other medical schools in other countries, the ethics there are still potentially problematic. It can still be pretty neocolonial in that if it's a preceptor that's bringing their students over to teach them about that health care system and talk about issues there without really allowing the expertise from the ground to teach those students, then it gets to be problematic pretty quickly. But the advantage of it being done between universities as partnerships is if it's done in a in a dual direction fashion. So that if you've got a partnership with the Nigerian medical school, you know, what is your institution doing to bring Nigerian medical students over to do a similar kind of placement in your home institution? The other thing about a medical school as a placement versus going with a for profit company is that medical schools are filled with people who know how to teach medicine, who know how to teach nursing, who know how to teach those health professions. So they've done that before. Teaching foreigners about it is a little bit different. There's often sort of a barrier in terms of the culture of medicine and how it works, but they actually know how to teach that particular profession. And they can tell those students a lot of things about what this particular ailment looks like in this context. You don't get that at the kinds of health facilities where for profit companies are placing students. These are not health care workers that are working in medical schools. They are tremendously overworked, very under compensated, often have had to work with really challenging resource constraints. And that creates a lot of ethical dilemmas for everyone and a lot of resource challenges for everyone. What I see often is a medical or nursing student will come in and for them, their training is in providing the best possible care for that one patient in front of them. They have a sense of what that might look like depending on what year they are in medicine, but they don't know the local drugs that are available and they're not always the same ones. They don't know about how supplies get used. And so that causes a lot of judgment and no one to provide context for that in the hospital. One of the hospitals where I do my work, they're actually very careful with the anesthetics because they only get a certain amount of supply each month and they want to make sure it lasts for as many patients as they have coming in. In practice, what that means is that individual patients may not get the full amount of anesthetic that would ensure that they're not going to be feeling any pain in a C-section. They may start to feel a little bit at the end, which if you're looking at an individual patient, is unethical. But the wider concern there is that they have to make sure that supply lasts for every other person that needs to come in for a C-section. And so in order to ensure resources are used appropriately, they have to make decisions about how they're going to use those supplies. So often the volunteers coming in from elsewhere will use an abundant amount of really expensive drugs or really insist on that one patient in front of them without ever realizing that there's way more patients than this one and that those resources are not infinite. The way that they can often feel when you're at a well resourced institution.

Aditi Desai [26:02] Given some of these challenges, we asked Dr. Sullivan, our short term international medical volunteering experience is ethical.

Noelle Sullivan [26:10] Not at all. No. And I think this ultimately comes down to the question of “what is a health profession student?”. And first and foremost, that person is a learner. And there's a sense of like you can learn and serve at the same time. And while every student ultimately needs to learn on patients. You do that with really close supervision and you have someone that's there that can sort of guide you through all of that and you don't necessarily have that kind of support in another place, especially if it's not a medical school with people that are trained in how to teach what they know in their profession.

Aditi Desai [26:52] Dr. Jessica Evert. A family physician leader in global health and executive director of the Child Family Health International, embarked on a medical volunteering trip during medical school.

Jessica Evert [27:03] When I got to medical school, I had a background in anthropology and biology, and I was kind of concerned when I got to medical school about how global health was being interpreted both by students and by universities, medical schools and others. It seemed like there was a disconnect between what global health was in terms of definitions and goals of health equity and how activities and even education was happening. It wasn't until I was between my first and second year of medical school that I got to kind of feel how this happened. I went on a program in sub-Saharan Africa, in Kenya, and it seemed from the outside and from the recruitment and from the way that it was framed, that it was going to have ethical integrity. Yet when I got in country, I found that there was a lot of unethical things happening. As a student, I was actually encouraged to do a spinal tap on a young child and something I'd never been trained to do. And a perfectly capable local doctor who'd done hundreds of them sat next to me and allowed me to futz around and not get the spinal tap and then delay the diagnosis and put the child through extreme pain and suffering. And so as I learned more about global health, I had a lot of moral distress around what I'd done. You know, I was a really well intended student and I was the top of my class. Like we all are, you know, always like, you know, from many in many respects consider to be intelligent, well intended, you know, humanistic. Yet I found myself in this situation.

Colleen Farrell [28:40] In addition to Dr. Sullivan, Dr. Evert also brings up important ethical dilemmas surrounding international medical volunteering experiences.

Jessica Evert [28:50] I think there is a lot of issues with short term medical missions. And I think medical missions is a term that sometimes conjures up faith based institutions. So I just want to be cautious that this is not related to faith based only activities. So when we're talking about this, I just want to level set that. When I'm saying short term medical missions, what I'm talking about is short term international activities that are done in clinical and non-clinical realms that can be harmful. And it's really sometimes hard to understand because on the outside, a lot of these activities look really helpful, that they look inspiring. They speak to our desires to help the most needy, poorest people globally. However, what we're realizing and has been kind of uncovered over the last 20 years or so is that in reality, these activities have huge downsides. And so, you know, when I say that these activities have downsides, they're not just, you know, quote unquote, medical missions or faith based activities, but activities that can be undertaken by volunteer organizations, by universities, by student groups, by professional organizations, by all kinds of different types of stakeholders can undertake these activities. And we look at what some of the problems are. You know, what comes up is that on the outset, they look super inspirational. They look really good. Like what could possibly be wrong with jumping into a poor setting and helping right away and what could possibly be wrong with jumping in to a place where there's not great health metrics and providing clinical care? Well, what can be wrong with that is that we have learned through evidence and practice that what actually changes health status is not kind of short term outsiders coming in, packing medications in a suitcase or doing other things that are kind of quick, you know, high intensity. The reality is they don't have the continuity or the longitudinal approach that's necessary to actually impact health metrics either for individuals or for populations or communities. Aside from that, they also come with a lot of assumptions around who is in the position of fixing and who is in the position of needing fix. There’s a lot of complex academic thinking around this. You know, in anthropology and psychology and sociology and political science, all the different realms, right. But some of the things that this brings to light are concepts such as colonialism. You know, colonialism was built in many ways on the idea that outsiders knew better than local indigenous populations conquering certain areas and trying to change cultural practices or other practices that seemed weird or incorrect to outsiders. Another concept that comes to bear on this is racism. So, you know, a lot of us have unconscious biases and we have ideas on, you know, who has the know-how and who needs to receive that, know-how. And you can see that many times these missions are predominantly white or privileged and powerful individuals, regardless of the color of their skin. Going to places that are predominantly brown, people of color, or black populations. And there can be real power privilege dynamics by virtue of both the unconscious bias of those going to these places, but also the reverse racism, internalized racism that can be present because of generations and many years of white supremacy. In addition, you have things like ethnocentrism of visitors and thinking that, you know, if these places were just more like us, they would be better. In addition, you have the power and privilege dynamics or the intellectual supremacy of that. You know, our health system in the U.S. or in Canada looks very different than a health system and say, Nicaragua or Tanzania. However, when you look at health metrics and return on investment and how well some of these health systems are doing with extremely limited resources, they're actually doing quite well, even though they look very different from when you and I are used to. And so we bring this mindset of like this is how it's supposed to be. We'll recreate this real quick in a school or in a clinic or in it some sort of building, and then will we'll fix this. And the reality is, we know that's not true. The last piece I want to emphasize is that there is huge opportunity cost of this. So if I go for a week to Nicaragua and pay for airfare and pay for a place to stay and bring a bunch of drugs in a suitcase, and I use my professional skills as a doctor to do this parachuting or duffel bag medicine. The question is, what am I not doing with that week? You know, what I'm not doing is like actually contributing to sustainable capacity building, actually contributing to evidence based intervention, actually contributing to reinforcing the existing longitudinal health system. I'm not using that time to advocate for structural changes. So those opportunity costs are not to be overlooked because our time and our financial resources are valuable. And if we choose to use them in a way that is not proven to be effective and also can perpetuate problematic power and privilege dynamics, then we have huge opportunity costs for doing those short term kind of short sighted activities.

Aditi Desai [34:39] While we weren't able to connect with patients who have directly received health care or treatment from people on medical volunteering trips, we asked Dr. Sullivan about what she'd found in her research in Tanzania.

Noelle Sullivan [34:51] The vast majority of medical students coming in from abroad are wearing scrubs or white coats, regardless of their training level. So you're talking about a high schooler will come in with her stethoscope and their white coat, and sometimes they even have the logo of the company that they came in with. That's really difficult because patients have no idea what kind of training these folks have. And the Tanzanian health professionals don't always tell the patients that the people that are there from elsewhere don't have any medical skills or they have very limited medical skills. So the patients don't necessarily know. There's also just a long history of mission work of foreigners coming. I mean, there's sort of some decolonization that has to happen there. But then just this being really used to foreigners coming in and intervening because they've seen that a lot. So there's often a presumption that they're coming in with better resources, better knowledge, better training, even though the opposite is usually the case. So it's complicated because the patients often are dealing with sort of their impressions of people rather than actual information. And a lot of times, if they were to say something, if they had concerns about the ways that these foreigners were doing things, they might be jeopardizing the quality of their care. If they're questioning the health practitioners that are there, at least that's an impression that they often will have.

Colleen Farrell [36:20] Dr. Sullivan describes how medical volunteering can have negative effects not only on patients, but on local staff and host institutions as well.

Noelle Sullivan [36:30] The volunteers will pay thousands of dollars for these trips. Out of all of that, the hospitals where I work get between 100 and 150 U.S. dollars per volunteer, regardless of how long they stay. The staff have to do an insane amount of explaining, translating, trying to figure out how to get them involved, and that's really burdensome. So a few years ago, the hospitals that were doing the hosting decided to start compensating some of the staff with more of a thank you. It was around 11 U.S. dollars per person that they were teaching and translating for some of the staff. We'll hope that the connection with that foreigner might help them out personally or professionally in the future. Maybe they'll be interested in sponsoring the Tanzanian healthcare worker or through additional schooling, which is always a very popular dream, or help sponsor their kids through their own schooling or, you know, invite them to come and do a placement at their hospital at home. And this almost never happens, but they always sort of hope for that. And then, you know, their work is tough. So some of them enjoy the interruption from the doldrums of their daily work. The big issue is in high season, these hospitals are flooded with foreigners. There was one point at one of the hospitals, which is a large hospital I was at. The foreigners outnumbered the local staff. You couldn't go anywhere without it. And a lot of the volunteers were complaining that there were too many volunteers at this hospital. They should better distribute them. They should better coordinate volunteers or they'd get better outcomes from the labor. But for the staff, every day is Groundhog Day, because every day you have these fresh new people coming in that don't understand anything about how medicine works. They don't understand Swahili. They don't understand the ailments that are there. They don't understand the workflow or procedure. And they stay for two or three weeks right around the three week mark. Those volunteers actually understand enough to maybe be helpful. And then a leaf every day, like there's a sense of more hands is better. But the reality is not that because they are constantly investing in and training these volunteers that are coming through and just waves and then just as they start getting useful, they're gone. And you've got another wave of students coming in.

Aditi Desai [38:57] Dr. Evert and her colleagues have published a number of studies analyzing community perspectives of medical trainees participating in volunteer medical experiences. One study in particular explored the competencies trainees should possess to better serve the host community.

Jessica Evert [39:13] That paper was perspective and kind of setting out competency aims that were agreed upon by a group of leaders in global education. And so the competencies across the multitude of domains from professional practice to ethics to program management to socio political awareness, capacity building, other concepts. However, when you look at who was informing that list of competencies, you saw that a lot of these folks were based in North America, U.S., Canada and high income settings. But there was a real gap in kind of like, OK, what is the on the ground grassroots perspective of what students and professionals should learn when they go to a different environment. And so that study that you're mentioning was trying to start to untangle that. And it asked folks across 35 different countries what they want and people who were coming to visit for short term global health experiences to learn. And what was resulted from that was that they really felt like understanding their culture was much more important than understanding the technical aspects of medical or public health approaches. In addition, there was an emphasis on humility that they were asking for outsiders to come in with a sense of humility, not feeling like they were superior to the populations in the community, but also just humility around their pre-existing knowledge, pre-existing biases and kind of all the baggage we bring with us when we go from a richer setting to a poor setting. So humility around all of that and really an openness to critically reflecting on those assumptions. In addition, there was a desire for trainees to defer to local expertise. So to not come in feeling like we are the experts, but actually feeling like we are more in solidarity with local experts, local leaders. And then in addition, it showed that communities where we go abroad are not expecting students to act independently. They're not expecting us to set up clinics by ourselves and do things really quickly. And I think that's really helpful because many students and many predatory organizations kind of have this notion or perpetuate the notion that these communities are like asking us to come and set these things up and create these little mini short term health settings. And the reality is the evidence did not bear that out.

Colleen Farrell [41:49] We asked Dr. Evert whether any organizations for medical volunteering and training abroad actually support their students to meet these competencies and work to actively prioritize the integrity of host communities in existing health systems. In fact, Dr. Everett is the executive director of such an organization called Child Family Health International, or CHFI for short. CHFI provides global health educational programs for health, science students and institutions with the goal of fostering reciprocal partnerships with local communities and participants. We asked Dr. Everet the impact of CHFI.

Jessica Evert [42:29] Another paper we did looked at what are the real impacts that we have on settings when we go for a short period of time. And some of the impacts that are evidence based based on this research is that, number one, we help people learn English. So that can be a very useful skill. As you know, to participate in the global economy, it helps to to speak English. And so that's a real advantage that we give to community members who interact with us and in settings abroad. Number two is that we bring prestige to any institutions that we physically go to or we affiliate with. So when we're at a clinic, when we're at a public health organization or a social service agency, we, by virtue of being an outsider who is spending our time in that setting, are bringing prestige in the eyes of the greater community to that institution, which of course, then calls us to say like, OK, are we doing our homework about what institutions we're going to? Because we definitely don't want to bring prestige to organizations that aren't doing the best work locally. We want to make sure we're not partnering with organizations that are further marginalizing people like women or indigenous populations or others. Thirdly, another impact we have is that we bring resources along with us. So we either bring money in terms of our purchasing power for housing, food or other activities. If organizations are practicing fair trade learning, they're going to be compensating folks locally for their time and energy put into visitors. And that's totally appropriate. But communities do recognize that outsiders come along with resources. We can also come along with potential resources after we leave in terms of a longer term relationship and support. The last thing that we can. The impacts that we can have are through discrete projects or initiatives that we support in country. So not pop up clinics, not doing things we're not fully trained to do, but actually looking out what do we know how to do and how does that align with what's needed locally? So I'll give you some examples. In many CFHI programs, students are contributing to evaluation of locally led health initiatives. Why? Because we have extra bandwidth. We know how to create and work with Excel with survey instruments and what data sets. So we can actually, in collaboration with local partners, help them evaluate the effectiveness of certain programs. Other things we can do. We can extend the bandwidth in terms of doing chart reviews or other activities, quality improvement projects that are nice to have. But when you're in a lower middle income country, there often isn't the human resources for health or the bandwidth to do to some of these. Nice to have projects. So when you're working with a quality organization, they're going to be aligning your real skill set with local needs. And that's where the win/win and the reciprocity happens. Other things we can do, we can help build out Facebook pages, we can help build Web sites, we can work on social media campaigns like there's some activities that are really low hanging fruit for us. It is not doing, you know, brain surgery. It is not delivering babies. It is not even giving shots or starting IV's. It is not handing out medications or prescribing pills. So look at the skills that you can actually bring. And it's often not going to be the sexy technical health skills and clinical skills that you may be tempted to do. And there are a lot of reasons for that. And so you need to find an organization that is going to support those ethical engagement opportunities.

Aditi Desai [46:02] Given the fact that many students seeking to participate in global health experiences are often misguided. We asked Dr. Evert for any general advice she would give to students looking to participate in such programs or otherwise wanting to help lower resource communities.

Jessica Evert [46:17] My advice to any pre medical or medical students who want to help under-resourced communities is to approach this as a stepping stone process. Approach it as a long term lifelong commitment to helping communities in need. Don't feel like this is a box you can just check off in two weeks or four weeks. And as such, you need to come up with your own personal and professional development plan that takes into account the stepping stone process. And so partner with organizations like CHFII or other reputable organizations that are giving you an authentic narrative. Make sure you're mapping out like what skills you need to achieve in order to actually be effective in low resource settings. Find mentors who are impacting house in a measurable and real way in low resource settings so that you can pick their brains on what they needed to learn before they could be effective. But this is a marathon, not a sprint. And if we treat addressing health equity as a sprint, we actually are going to not achieve it. Are we going to waste a lot of our time and resources and we're going to have performative actions because basically we may look like we're achieving something. We may have really good photos, but in reality, we're not moving the needle. So let's all be authentic. Let's all really be critically thinking about what we're doing and about laying out those stepping stones for ourselves and for our organizations to truly hold ourselves accountable to addressing health inequities.

Colleen Farrell [47:51] Like Dr. Evert, Dr. Sullivan echoed similar advice. Students wanting to participate in these experiences should go in as humble learners for people that are thinking about going.

Noelle Sullivan [48:00] I would say if you're going to do that, go to partnering medical institution, find out whether or not that institution has precepts that are adequately compensated and ensure that that person that is going to be your preceptor and host has the time to teach you and ensure that you would not do anything there that you would not do in your home country. So, you know, going to help when you're still a health professional student is a great intention. But the reality is there's not much that foreigners can do in a short period of time to actually be helpful and the ways that people have gone. I mean, they're very satisfied usually with their experience. Right. And they'll often be like, well, if I could ensure that one patient had a better experience than they otherwise would have, then I've done my job here. And my retort to that is at what cost? How do you know? How do you know that what you did was actually perceived as helpful? Well, you don't. I mean, they don't get to follow up with their patients. They can't even talk to their patients. So, you know, I would say to someone, if you want to get a really good learning experience and actually learn about what medicine looks like somewhere else, go to a place where they're used to hosting students and go there and be a student. And moreover, there's another model which is go and be in communities and understand like what does public health look like, learn from communities about what their healthcare needs are. That's really eye opening. And, you know, talking to people and understanding the way they live can tell you a lot about social and political determinants of health. About the ways that people navigate uncertainty in ways that can help you in your job at home. Right. Because we encounter people in medicine from all over the world no matter where we live. So that can be a far more eye opening experience than getting your hands on in a hospital. If it's a premed university student that wants to help people in other countries, they should either do a study abroad with a preceptor that's again able to contextualize things like that whole bit. That which we should be able to help and learn at the same time, when you're right at the beginning of things, I think needs to be troubled. So, you know, get into programs that will train you in something that you need training. And I do qualitative methods training with my students when I've done study abroad and they're going in there practicing their Swahili skills and they're practicing their interviewing skills. And their projects are all based on information the local community would like us to do that research on. And worst case scenario, they had some interesting conversations with people in the community and got to know a little more about it. And it's a really strong learning experience. And I think just reversing this idea that a study abroad shouldn't count for your med school application, for instance, it has to be voluntary service or, you know, in hospitals or this. Thing to expand the kinds of things that are necessary, because also we have to remember that medical school is extraordinarily classist. Right. Lots of racist problems there, too. But it's really classist. The people that are going to be the shiniest pennies in the applicant pool are the ones that had access to the resources in order to access those experiences. So there's a lot of things that we could be doing in our own communities over the long term that make us actually impactful. And those kinds of things can be totally eye opening for for aspiring health professions students. So those kinds of things. If you want to help abroad, instead of going through the big resorts in this kind of thing, support locally owned businesses. And that's easier than ever. You can go on TripAdvisor and you'll find all kinds of businesses in the country that you're trying to go to that are owned. And they're not easy to find other places on the Internet, but they're fantastic. Right. Go to the locally owned restaurants, buy directly from the artists that you see doing the art on the road instead of in the fancy stores. Try to get your feet on the ground and spend your dollars that way. Spend less time worrying about safety because ninety nine percent of people everywhere you go are awesome. And if you're awesome too, and you're trying to get out there and try to authentically be curious and humble around others, people will take care of you. If you want to have an impact, that's a great way of doing it. If you want to learn about another place humbly, they go into a program that actually specializes in helping you do that and go as humble learner. If you're thinking about a medical active abroad, great prefer going to one where you know it's affiliated with a medical school. That you're preceptor is someone who is well versed in how not only to teach their profession, but also to teach their professors to foreigners who don't necessarily understand the culture of how medicine and ailments work where you are. I promise it will be a far better experience because most of the time with the language barriers where what I see is a lot of frustration, they don't understand how the system works and then they try to sort of make the system do what it would do at home. And neither of these things are good outcomes.

Aditi Desai [53:19] Despite all the challenges with these experiences, Dr. Sullivan emphasized that students taking part in these programs often go in with the best intentions and their work is typically praised by peers. Stepping back from individual experiences, we asked her to explain where the allure of medical volunteering comes from.

Noelle Sullivan [53:38] I don't know anything about psychology, but what I will say is. The allure of being able to feel like you made a difference is really high. And we get socialized about that, starting very, very young. And if you're someone with privilege, then for sure the idea is you're responsible for giving back. But we don't really hold the givers responsible for anything. And that needs to be part of the conversation, not just. What do you think the impacts of your work are? But actually, what are the impacts of what you do? What are the wider landscapes? And we don't talk about that. We don't talk about how you donating cans of food to the food pantries, actually, really not good. It's not because if you take the money that you would have spent on those cans of goods and just give it to the food pantry, the food pantry can buy four times more stuff wholesale. That's actually the stuff that their clients need rather than the random cranberry sauce that's in your cupboard. Right. And when you tell people that they get upset because they want to have some control, I want the material so that I know where my money is going. And I think we just need to start with a lot more humility of understanding that when we want to help, we're responsible for how and that the best way of helping is to help where there's a stated need. Do they ask for the kind of thing that you have to provide? If not, leave them alone. If someone's asking for a particular skill and you don't have it, help them locate someone who does. Don't go shopping around for where you're going to be useful unless it's the community themselves that are saying we need this particular thing. So things have to be far more community run and it tends to be much more. This donor has this great idea for this great thing. And wouldn't it be great if we did X, Y, Z without ever being accountable? And that whole lack of accountability in the way we want to help people with that idea that I want to do it with my own two hands. And it's like you have to think critically, what can these two hands provide? Sometimes you can do things. I'm great with Swahili, English translations when people are at the hospital, but I'm not going to give some kid value. Even though I've seen a nurse do this on a regular basis, it's not happening. I don't have that skill. You know, knowing your limits and if your limits aren't helpful and you can't figure out a way to stay out of the way, you probably ought to not do that. Well, when we get to be gratified when we're in service. Right. I mean, that's fine. We're allowed to have an emotional experience, but we also need to pair that with being responsible for the consequences of what we do. And when you have a situation like international medical electives that are poorly supervised or, you know, clinical voluntourism, you don't have that responsibility and everyone knows it. They absolutely are aware of this when they're on the ground, a bunch of them. Well, even asking them, you know, have you seen any things that other volunteers are doing that give you pause? And they can name all kinds of things that their peers have been doing. They're super unethical. But then they don't see how their own actions might be unethical. It's much easier to sort of see it and others than to have that kind of reflexivity yourself. But, you know, again, the whole thing of like lambasting people because they have an experience that matters to them. Sentimentality is what gets anybody into medicine to begin with. Right. Unless they're really pragmatically, I want to be a doctor because I want to make billions, which you can't do in Canada anyway. The United States, on the contrary, at least millions. But most people get involved with medicine because they care, right. They feel a sense of empathy. They want to do something to help people. But our systems are there to ensure that we first do no harm. Those same systems are not in place to ensure that kind of thing elsewhere. And so then what is our responsibility?

Colleen Farrell [57:54] That's it for now. We hope you enjoyed joining us to learn about health care elsewhere, both as patients access in care abroad and as trainees hoping to gain international experience. Both types of experiences, although potentially life changing, are rooted in social and financial privilege and are often associated with lasting impacts on host countries. But as Dr. Evert and Dr. Sullivan discussed, engaging in global health requires lifelong learning, humility, respect and mutual empowerment through formation of reciprocal partnerships.

Aditi Desai [58:29] If you would like to continue learning both about medical travel or medical voluntourism, please find a list of references online with our episode show notes. Of course, this episode would not be possible without the insights of our amazing guests Adele Kulyk, Dr. Noelle Sullivan and Dr. Jessica Evert. We'd also like to thank our production team, including Larkin and Swapna, who helped develop the content. Helen, our audio engineer, and Jesse are executive producer. Tune in again in two weeks for episode eighty five on disability and ableism. Until next time, keep it raw.

Jesse Knight [59:13] Raw Talk Podcast is a student presentation of the Institute of Medical Science and the Faculty of Medicine at the University of Toronto. Your opinions expressed on the show are not necessarily those of the biomass faculty of medicine or the university. To learn more about the show. Visit our website, rawtalkpodcast.com and follow us on Twitter, Instagram, YouTube and Facebook, @rawtalkpodcast. Show us support by using our affiliate link on our website, when you shop on Amazon. Also, don't forget to subscribe on iTunes, Spotify or wherever else you get your podcasts and rate us five stars. Until next time, keep it raw.