You know who they are: young American students who go overseas, often during the summer months, to participate in community service projects in poor countries where they hope to make a human difference — and, in some cases, beef up their résumés while they are at it. But there are real ethical problems with this model, as explained in the following post by Lisa V. Adams, associate dean for global health and director of the Center for Health Equity at Dartmouth’s Geisel School of Medicine. She is also an OpEd Project Public Voices Fellow and co-author of the 2015 book “Diseases of Poverty: Epidemiology, Infectious Diseases and Modern Plagues.”
By Lisa V. Adams
Global health is the buzz on many campuses today. Students at all levels are seeking opportunities overseas, primarily in low-income countries where they aspire to make a difference. Motivations range from CV-building to a deep commitment to social justice and human rights. In either case, most of them are likely to return saying they got more out of the experience than they gave. We can only hope that their hosts aren’t saying they wish their visitors had never come.
Some have called it a “tsunami of student interest” in global health. The Association of American Medical College’s 2015 survey of medical student graduates reports that roughly one-third of graduates worked in another country during their years in medical school. (At Dartmouth College, where I teach, the numbers of undergraduate, medical and public health students seeking global health opportunities repeatedly outstrip the number of opportunities that we can offer them, and this seems to be a trend at other institutions as well.)
The tsunami metaphor hints at what may happen if students are not well prepared: There is potential for significant damage and clean-up in the aftermath. This is, in part, because these student experiences are fraught with ethical dilemmas. Of course, we do our best to ensure our students become familiar with (if they are not already) the community they will be working with, be active listeners and exhibit cultural humility, not make promises they can’t keep, and clarify their roles as students. This is particularly important in some clinical settings where students are often mistaken for being practicing physicians or nurses.
But it has become clear we need to do more to manage expectations for both our students and our hosts, most of whom are too polite to let us know when a particular visitor is causing problems.
This is why one of my colleagues advises his entry-level students to “first, do no good.” Like so many of us, he has found that successful U.S. students can be so concerned with meeting their project goals or accomplishing something during their time there, they might put the project goals ahead of forming and maintaining good professional relationships. And, like so much in life, it is all about the relationships.
Here’s what I tell my students: The very traits that have served you well to date are those that, in many cases, you will now need to put aside. You have succeeded in your academic careers often because you are assertive, active learners who are not afraid to ask questions or to push yourselves hard and always deliver an outstanding final product. And you have been rewarded for this behavior over and over through teacher praise, stellar grades, and impressive awards.
Now, the challenge is try to unlearn all the socialization that to this point has brought you academic accolades. You must resist the temptation to share every great thought or idea you have. You must switch into listener mode.
Underlying this all is the message that students are guests in the hospital or clinic or community organization where they will be working. And what may look like simple fixes to them on first impression, are typically complicated problems embedded in complex systems that they can only begin to understand in their weeks or months on site. I impress upon them that they are working with very capable and experienced partners – so all the low hanging fruit solutions have already been found.
Many global health programs have measured their success by pins on a (now web-based) map – demonstrating the reach of their programs by the number of sites where they can send students. Unfortunately, this metric confuses quantity with quality. We are so eager to send our students out into the world – and this often catches the attention of potential donors and supporters. But what about the burden this places on our partners who are willing to host our students?
As firm believers in the importance of reciprocity in our global health programs – as in, if we send our students there, we must be willing to receive their students here – we learned about this burden at our own institution. In the first year of our exchange program, the faculty responsible for teaching the visiting students were lamenting the additional work involved with having international students on their team. Their complaints went something like this “They don’t know our medical system, and I don’t have time to teach them all about it” and “Our medical record is unfamiliar to them” or “Their training to this point has been so different from ours.”
I could only smile in response. We think nothing of sending our students there – wherever “there” may be – and yet isn’t this exactly what our partner faculty could say about our students when they arrive, hoping to do some good? At least the students visiting us were proficient in English. That’s usually more than we could say about our students’ ability to speak local languages needed to converse directly with patients (most of the health professionals they encounter abroad are bilingual). At least our nurses, doctors and students aren’t also being pulled from their work to have to translate for students that come to our institution.
Don’t get me wrong: I am a major supporter of educating students in global health, and I spend much of my day advising, mentoring, and preparing students for short (and long) term experiences and eventual careers in global health. I encourage my students to pursue these experiences. I know how it changes them and their outlook and now, the data show, even their career trajectories and likelihood of working with under-served populations in the future. I recognize the work of my colleagues to provide us guidance in addressing these ethical challenges.
But it is clearly time for us to consider our partners’ side of this bargain. Recent surveys of partners’ experiences are encouraging, but we now need to act on their observations and recommendations. And we should be prepared to return the favor and offer similar training opportunities to their students. Reciprocity in educating the next generation is an important first step in leveling the global health-training playing field. Then, we need to make sure our students shed their hopes of solving a community’s complex problems during one neatly packaged summer project.