William & Sharon Bieber
The Short Term Medical Mission Dilemma
“There has to be a better way,” he said. “There I was in a foreign country, pretending that I was knowledgeable in general medicine ,when I have been so specialized for years!”
We were having a conversation with a frustrated specialist physician who had just returned from a recent medical mission trip. He continued: “The first patient I saw had high blood pressure, not in my specialty area, but I looked in our pharmaceutical box and found some drugs labeled hypertension. So I gave him a week supply, not knowing who would follow up or whether any more of it would be available locally. That’s when I realized there had to be a better way for my skills to be utilized.”
We had to agree. This was not the first time we had talked to someone who had participated in such a mission trip and had similar questions. There is a better way.
We too have seen these projects from the inside—the excited medical personnel looking forward to serving the poor, the boxes of North American pharmaceutical donations ready to take along, young medical or nursing students eager to try out the skills they are learning, pastors at the other end waiting to have their churches chosen to facilitate the medical mission. Along with our two teenage children, we were part of one such organized trip some years back with about twenty others—medical practitioners and their families. After the thrill of the experience wore off, discomfort with the whole process told us that we could not do this again.
We could see that by treating patients and dispensing medicine without cost, we were unwittingly undermining the local health care facilities and workers. Our own experience of working with the Department of Health in Papua New Guinea for eight years when our children were younger was enough to tell us that. Not only were the medications free, but they were often not available or too expensive in the country for ongoing treatment. And did our translators understand enough to adequately explain to the patients when and how to take the medicines? Did the treatments prescribed meet local protocol? Did the Canadian and US doctors who had spent years in other specialties really understand the tropical diseases they were treating? Was our well-intentioned help really helping at all, or were we hurting their long-term health? Their need for better health care and living conditions was obvious. But did our one-week foray into curative medicine in this rural area do anything to better their future community or family health status? Perhaps it was simply a great experience for our kids, as an enthusiastic team incorporated them into the program by letting them weigh babies, take blood pressures and assist the dentist. But at what expense, if there was damage control needed after we went home or if we had somehow tarnished the confidence of the people in their own healthcare system?
Best Practices for Medical Missions
In his excellent book When Healthcare Hurts, Greg Seager has thoroughly researched the complications of such short-term medical missions. The four intertwining categories of best practices Seager outlines are:
Integration and collaboration with the national healthcare system.
Facilitating health development.
He starts with similar questions that our specialist colleagues and ourselves had asked after reflecting on our trips. He concludes that short-term healthcare workers could bring improvements to healthcare quality and empower communities to help themselves by working alongside the government system and providers who would like to upgrade to international standards. Knowing how to do that, taking time to research the local government systems as well as international initiatives, and then making connections with the appropriate authorities is essential.
Fitting in with the country’s health objectives rather than our own agendas is the first step in dropping the paternalism that usually characterizes our efforts. Most of us tend to be skeptical of systems that are different from what we are used to, every country assuming its own is best! Researching the current Health Plan of the country where we are going is a good place to start. We must first of all be learners if we are to leave our paternalism at home.
Medical Ambassadors Canada
Our own learning experience has evolved over the course of a long career. A few years of full time medical practice in Canada was followed by eight years in Papua New Guinea both in clinical teaching and as a Provincial Health Officer within the Government system. What we learned there was applicable as we returned home to help found a Calgary street clinic called CUPS and a full service community family health clinic.
Encountering Medical Ambassadors International (MAI) at a conference led us into early semi-retirement. For the better part of twenty years, we have been volunteering part-time (upwards to eight months a year and now much less) for MAI and the Canadian counterpart, Medical Ambassadors Canada (MACA). Here the focus is on empowering communities to lift themselves out of poverty by addressing health from the broad WHO definition—“health is a state of complete physical, mental, social (and some areas add spiritual), not just the absence of disease or infirmity.”
The strategy, called CHE—Community Health Education/Evangelism/ Empowerment depending on the region of the world, has taught us that we must address the whole person and whole community in order to see health status change long-term. CHE equips national trainers to work in their own communities by giving training in using prepared lesson plans, booklets, and ongoing workshops on topics relevant to human flourishing, as well as facilitation skills for engaging adult learners. In many countries, early interventions and The First 1000 Days initiative is a current focus, while in others social or economic issues are at the top of community agendas.
Bottom Up, Top Down, Outside In
This idea of working with communities to take ownership of their own health issues using peer-to-peer teaching, is arguably the way to see long-lasting change. In their book Just and Lasting Change, Drs. Carl Taylor and Daniel Taylor-Ide, (Carl founded the International School of Public Health at Johns Hopkins University in 1961), propose a model that makes sense to us. They talk about a “bottom-up, top-down, outside in” three-way partnership. The “bottom-up” initiatives at the community level are the base of the pyramid in all regards and must take the lead. But if the “top-down” support from the appropriate government agencies and the “outside-in” objectivity and expertise are not lending their support, the bottom will soon find they cannot move beyond a certain level. The “outside-in” may be people like us Western physicians who can advocate for the community, support the local specialists and bring an international perspective.
Often, as here at home, we find a disconnect between the top levels of the medical system, for example specialists in the referral hospitals, and the rural health centres with staff that feel isolated and unsupported. Here we think, is another “outside-in” niche—we in Medical Ambassadors approach health from the bottom while connecting at the top, so are able to make contributions at both levels while at the same time advocating for the needs of community health. In this way we take our role as ‘ambassadors’ seriously.
RCI Sees the Big Picture
The Royal College of Physicians and Surgeons of Canada, in an attempt to encourage Canadian Specialists to be involved internationally, has created a not-for-profit arm called the Royal College Canada International Incorporated (RCI). Their stated goal is to “improve medical education and practice globally and to build capacity internationally in specialty medical education and professional development.” They work “alongside peers within government departments and ministries.” By cooperating with the local health departments to build capacity with specialty peers in the receiving country, RCI believes this will “demonstrate positive impact within targeted stakeholders organizations/regions as a result of their direct collaborations […] for sustainable long term success”.
Medical Ambassadors has seen the value of this strategy and believe that both CME and advocating for integration between the “top-down” and the “bottom-up” will accomplish our goal to see human flourishing. And as Christians, we know that when we integrate the spiritual with our efforts to see transformation happen at the individual and community level we are modeling Jesus as the Great Physician.
The Tacloban Story
For many years MAI and MACA have supported a very effective Philippine NGO to train communities in Community Health Education in seven different regions of the country. Then in 2013, Tacloban in Leyte Province of the East Visayas Region, was the topic of world news as a super typhoon unlike any other to date struck their city, bringing a storm surge that washed over homes and brought ships inland for several hundred metres. In the aftermath, much-needed relief flooded in with water, food, help for farmers in replanting and eventually re-building of infrastructure. Churches vied to be partners with the Faith Based Organizations, pastors left their posts to take well-paid jobs with these groups, and the hand-out mentality infiltrated all sectors of society. Carnage may be on more levels than the natural disaster.
There is a positive side too. As facilities like hospitals are seen to be inadequate or affected by the natural disaster, outside help often pours in for rebuilding or refurbishing. The staff desire and appreciate accessing the newest equipment, techniques and IT development that outside expertise brings. The door is wide open with opportunity for international specialists to come and share skills and friendship.
For these reasons we chose Tacloban as the pilot for MAI and MACA to introduce an integrated special project. The newly-built Regional referral hospital which serves six provinces in the Eastern Visayas Region of the Philippines, has a full range of specialties and an openness to outside input. Additionally the Regional administration is seeking ways to improve the communication and service delivery between the referral hospital and the small municipal health centres. They welcomed our input as they see the value of encouraging a preventative community approach in order to fulfill the mandate of their National Health Plan. It has taken time to build relationships but now we see that the ‘top, bottom and outside’ have lined up and value what each brings to the whole.
Medical Partnerships Opportunity
In April of this year we invited two US Obstetrics and Gynecology specialists to come with us to Tacloban. One is the Chair of MAI’s Board and the other a Maternal Fetal Medicine specialist from Stanford School of Medicine. Our Filipino OBGYN colleagues and residents in the brand new EVRMC referral hospital were delighted to have five days with them in teaching rounds, lectures and simple camaraderie around food and conversation. The knowledge was shared in humility and genuine passion, which is very transferrable! They also accompanied our team and three of the Filipino specialists to a rural municipal centre to take part in the training being run concurrently on First 1000 Days with the community CHE trainers. They validated the work of the local midwives, five nurses, and a family physician - the entire health staff for 50,000 people - by touring their facility and discussing their issues. This was a first for the Filipino specialists from the regional hospital and they promised to do it again!
This same Maternal Fetal Medicine specialist continues to keep in touch with those OBGYN physicians and plans to return early next year. He went home excited about his trip and ideas for the kinds of needs that he can follow-up with further teaching next time. This was our hope as the relationship with this hospital continues into other specialty areas.
Sharon and I visited again last month to discuss their priorities, and now look to any of you who might be reading this and feeling the heart tug to contribute in some way to the larger world of medicine.
Not Only for the Retired
The opportunity for retired physicians to pass on the skills and experiences learned over a lifetime is very gratifying. A bigger vision of kingdom purpose is needed in these years after the fulfilling careers we have been involved in. But the same need to live for a higher purpose is true for the semi-retired or someday-retiring physician who wants to look back and feel the warmth of smiles from other parts of the world that have benefited from our years of study and expertise. The future is now for all of us. After all, it is only God’s grace, not our deserving, that has given us the privilege and opportunities Canada has offered.
Medical Ambassadors Canada (MACA) www.MedAmbassadors.com
Medical Ambassadors International (MAI) www.MedicalAmbassadors.org
MAI is a faith-based NGO with 35 years of international experience, now working directly in 40 countries, serving 2.5 million people in over 2500 communities.
Recently rated in the top 10 of ROI Ministry’s most cost effective ministries with proven impact (roiministry.org)
Core values — community ownership, preventative health, integration of spiritual and moral values with physical training and the multiplication effect of peer educators teaching at the home level.
CUPS (Calgary Urban Project Society) www.cupscalgary.com
- Began in 1989 as a response to a need in downtown Calgary for healthcare and social referrals for a growing homeless, addicted and indigent population
- Initially staffed by volunteer doctors through Calgary CMDA Canada network
- Now a much-expanded program integrates healthcare, education, housing, child development and resilience-building programs
- Over 8000 active clients each year and over 40,000 clinic patient visits.
- 2017 and 2018 named in Canada’s Top 10 Impact Charities by Charity Intelligence (charityintelligence.ca)
- Dr. William and Sharon Bieber, Dr. Marilyn and John Kish, along with two downtown church pastors were recognized in 2017 by the Governor General of Canada with Meritorious Service Medals for founding the CUPS centre.