Good Intentions and Murky Ethics

How anthropology matters in short-term global health travel.

According to Volunteer World, an online international volunteer placement platform, “International voluntary work plays a key role in delivering and implementing the Sustainable Development Goals,” such that “Volunteer World provides the chance to become active and help reach the SDG Goal #03 Good Health And Well-Being.” For prospective volunteers wanting to work in health facilities, available placement countries are predominantly located in the global South. Hosting health facilities appear remarkably similar in their need for foreign helpers willing to travel, regardless of whether they are in Tanzania or Guatemala.

The proliferation of online clinical placement companies like Volunteer World echoes a wider trend familiar to many of us working at universities in the global North: Global health travel is “hot.” Short-term medical missions, international health electives, volunteer placements—there’s something seductive about the idea of going to a place seemingly “in need” and “making a difference,” while having new experiences in the process.

People wait outside a short term medical clinic in Guatemala, 2013. Nicole S. Berry. Facial features obscured to protect anonymity.

For prospective global health travelers, the coexistence of poverty and medical need seems sufficient rationale to pack one’s bags and fly to a foreign country to “help.” Global health travelers operate under the compelling assumption that somehow their medicine is universal and that it will be universally appreciated by individuals experiencing presumed pervasive need.

Yet, within the hosting country, context challenges these presumptions. Assuming that populations are primed to receive whatever well-meaning help arrives mistakenly prioritizes volunteers themselves as protagonists. Indeed, such a narrative problematically dichotomizes volunteers as actors and poor populations as passive receivers—a form of decontextualized travel Teju Cole aptly terms “the white savior industrial complex.”

For many anthropologists working in the global South, global health travel has unfolded like the gold rush in the Klondike, with many seemingly “poor” locales, flooding with short-term foreign volunteers. While the vast majority of these volunteers are from the global North, young people of means from the global South are increasingly participating in global health travel abroad. New businesses and initiatives spring up in the volunteers’ wake, catering to their needs and interests, and re-tooling existing resources to accommodate the influx of outsiders.

Volunteerworld.com sustainable development goals page on Goal 3: Good Health and Well-Being, which shows an interactive map of clinical placements possible for volunteers.

Significantly, there is a dearth of empirical inquiry on the effects of global health travel. Most available data come from organizations’ statements of their own accomplishments, often used to attract prospective donors or participants. Absent are in-depth insights about how global health travel operates in practice, let alone the voices of individuals purportedly “helped” within hosting countries. This is a space in which anthropology matters. It matters in its ability to use empirical, longitudinal data to challenge compelling and prevalent discourses about what it means to be a “helper” or to be “helped.”

Our research on global health travel arose from foreign volunteers and missioners pushing into our fieldsites to such an extent that they could not be ignored. Sullivan’s research shifted directions when the number of foreign volunteers in health facilities in northern Tanzania spiked exponentially between 2008 and 2011. Berry’s fieldsite in Guatemala became so popular that short-term medical missions were difficult to avoid. Short-term foreign medical practitioners appeared increasingly frequently in villages, and locals became patients, translators, and drivers.

We felt these forms of global health travel required anthropological analysis to untangle the draw of these particular sites for volunteers, and to determine what the deluge of such outsiders meant for patients, local health professionals, and organizations.

Two volunteers transfer a patient into the operating room fro a c-section, followed by the nurse in charge. Tanzania, July 2014. Noelle Sullivan

We have witnessed many examples of unearthing murky ethics within good intentions. For instance, foreigners in Tanzania often assume their familiarity with Western medical settings affords them more meaningful understandings of proper medical care than Tanzanian hosting health professionals. Yet, in practice, foreigners’ assumptions about best practices don’t necessarily translate neatly into best care.

Sullivan encountered two British volunteers—one a medical student, the other pre-medical—quarreling with Tanzanian hospital staff regarding appropriate care for an elderly male patient. The patient’s issues were largely untreatable at the facility. His overall prognosis was grim. Charging that the Tanzanians were giving up on him, the volunteers clamored for two days for the patient to be transferred to a bigger facility. Without a transfer, they felt, the patient would die. Staff was hesitant, but eventually the volunteers’ insistence worked. However, not five minutes after being loaded into the ambulance, the patient died, surrounded by two well-intentioned strangers.

The volunteers’ agitations had left little room for staff to explain: Transferring a patient in such grave condition was preposterous. He should have the dignity to die surrounded by family at the hospital. The medical student told Sullivan later, “I learned from it that there comes a point when maybe the best thing to do is give them a nice gentle death.” This student understood precious few contextual details critical to making health care meaningful to patients and communities in Tanzania. The presumed universality of her biomedical knowledge remained unchallenged. Presumptions about what is “best” for patients can translate poorly across context.

Foreign health care workers set up a short term medical mission clinic in Guatemala, 2013. Noelle Sullivan

A hosting country’s poverty and medical necessity don’t necessarily translate easily into needy populations welcoming foreigners to assist in health care. An example from Berry’s fieldwork pushes this point further. One of her interviewees related a story concerning four Australian eye doctors who decided, as a personal project, to do a short-term mission focused on eyes in Guatemala, a country they had never visited. They identified El Quiche (a location in the highlands predominantly populated by indigenous Maya peoples) as their destination. They arrived with all necessary supplies and received the mayor’s permission. As the Australians began to set up their clinical space, citizens started to surround them. The townspeople asked the doctors who they were and why they were there. In response to the doctors’ explanations, the people asked, “How do we know that you are doctors? How do we know why you are here or what you are doing?” The townspeople eventually told the doctors to leave immediately or they would be lynched, thus ending the fledgling mission.

Among indigenous peoples in Guatemala, the government and NGOs have often promoted their interventions as purportedly “helpful,” when ultimately those activities more often benefit the NGOs or governments themselves. Due to these experiences of “help,” many indigenous people adopt a prudent skepticism of outsiders’ efforts and claims of selflessness. This echoes a longer trend: Indigenous peoples’ historical experiences of exploitation have provided them a strong understanding of their position in global power relations.

Anthropologists can offer a glimpse into contextual complexities shaping global health travel as a moral practice. Indeed, those of us engaged in the study of global health travel field multiple inquiries from organizations and institutions trying to “do it better.”

For the upcoming AAA Annual Meeting, we couple a panel of ethnographers exploring global health travel (Thursday, November 30th, 8 a.m.–9:45 p.m.) with an Executive Session roundtable consisting of anthropologically minded practitioners engaging with global health travel as intervention (Saturday, December 2nd, 2 p.m.–3:45 p.m.). We aim to blur boundaries between theory, ethnography, and practice, to demonstrate how anthropology matters to global health travel as much as global health travel matters as an issue of concern to anthropologists.

Noelle Sullivan is assistant professor of instruction in global health studies and anthropology at Northwestern University. Her work has been published in Global Public HealthCritical Public Health, and Medical Anthropology, the edited volume Volunteer Economies: The Politics and Ethics of Voluntary Labour in Africa, and various public media outlets.

Nicole S. Berry is associate professor at Simon Fraser University in British Columbia, Canada.

Cite as: Sullivan, Noelle, and Nicole S. Berry. 2017. “Good Intentions and Murky Ethics.” Anthropology News website, November 3, 2017. doi: 10.1111/AN.661

Comments

Great and needed article.

But I have been for a while struggling with — how do we as anthropologists work within this “white savior industrial complex?”

I’ve been asked in interviews how I would “incorporate students in my research abroad,” I have colleagues with field schools who generate research funding by charging students and volunteers, and I do see field schools as something I would like to do in expanding participation in the discipline and higher education…

Medical missionaries love Belize because it is officially an English speaking country – and it is not unusual to have have two or three such groups in the country at a time during the US summer months. As you say in this article, nobody ever checks to see whether they really do make a positive contribution, and I am really happy to see you open the conversation. I have witnessed and read about a number of clear abuses; unnecessary procedures, student practitioners passed off as doctors, outdated and inappropriate medications handed out without prescription, and rushed dental surgery without anesthetics. There are also beach resorts that specialize in hosting these medical missionaries (and religious missionaries too) for some “relaxation” after their stressful work. I have often wondered if there are similar problems with other kinds of study travel – hundreds of thousands of students descend on Costa Rica every summer for example, and many of them end up living with local families. Has anyone studied the effects of placing American teenagers in poor rural Latin American households for months at a time?

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