Reframing Short-Term Medical Missions

Posted Jan 31, 2020

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: 

Patient safety‭. ‬

Integration and collaboration with the national healthcare system‭. ‬

Facilitating health development‭. ‬

Community empowerment‭.‬

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. ‬

More Information

Medical Ambassadors Canada‭ (‬MACA‭)‬

Medical Ambassadors International‭ (‬MAI‭)‬

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 (‬‭) ‬

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)‬

(Photo Credit: Sgt Johanie Maheu, Rideau Hall, OSGG)
  • 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 (‬‭)‬
  • 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.‬