BOOK REVIEW
Laura M. Montgomerya
a PhD, Dean of Global and Experiential Learning, Professor of Anthropology, Wheaton College, United States of America
Keywords: Short-term medical missions, humanitarian volunteerism, service learning
In Hoping to Help: The Promises and Pitfalls of Global Health Volunteering, Judith Lasker seeks to go beyond the simple question of whether short-term medical volunteer opportunities do more harm than good to answer “... a larger ethical question: whether the investment of billions of dollars of resources in the short-term volunteering enterprise can be justified by the results in terms of improvement in health, reduction in health disparities, or other measures of value to the host communities (p.16).”1 She gathers information from a survey of 117 organizations that sponsor opportunities for short-term volunteer medical missions or brigades, and interviews 119 individual volunteers and staff of both sending and receiving organizations from around the globe. She also participates as a volunteer in programs to Ecuador and Haiti.
The strength of Hoping to Help is that it provides the reader with an overview of the heterogeneity of organizations, stories of volunteer motivation and experience, and information on the effects on host communities of numerous efforts to provide health-care through short-term efforts to underserved populations in the Global South. Lasker makes clear that understanding global health volunteering requires avoidance of simplistic generalizations. Her extensive use of quotes from survey data and interviews illustrate the commonalities and differences in the perspectives of program leaders, volunteers, and hosts. The organizations range from churches, educational institutions, faith and non-faith-based non-governmental organizations, to corporations. In some cases, these opportunities spring from the initiative of a single individual who felt a need to respond personally to circumstances encountered during a sojourn in an underserved area. Volunteers express many and often mixed motivations for their participation: a desire to help, self-actualization, improved educational or employment opportunities, religious convictions, or a sense of “giving back.” Likewise, the perspectives of receiving organizations reflect both positive and negative assessments; the most positive often relate to longer-term projects that focus on training. Lasker also draws attention to the disparities among these organizations in the selection and preparation of participants, and the quality of care provided. In the final chapters, she offers nine practices based on her research findings that, if followed, may result in efforts more likely to yield positive rather than negative outcomes. The appendix provides both recommendations and cautions to those considering participation in health-related volunteer opportunities. She concludes that long-term programming is probably a better approach especially if focused on capacity-building.
In Hoping to Help, Lasker rightly points out that the voices of host communities are often unheard in assessments of short-term, health-related volunteer efforts. She explains, “It is crucial to know what people in the host communities — the Global South — think...” which is the rationale for “... devot[ing] so much space... to recounting what they have to say (p. 15).”1 Unfortunately, she commits the same omission. She relies heavily upon the perspectives of host-country staff or health-care providers to describe or evaluate the benefits to host communities. These individuals may or may not be members of or the appropriate spokespersons for the communities or populations served. With reference to the effects on host communities, Lasker does reiterate a basic principle of healthcare: “First, Do No Harm”, and points out that “harm” is not limited to medical harm but includes the potential to undermine local practitioners and host organizations, and to consume their time and resources in addition to challenges regarding continuity of care. A more descriptive title of the section on host communities would have been “host providers or organizations.”
Apart from rare examples, however, we do not hear the voices of those on the receiving end of the care provided by global health volunteers: the patients. We learn little about their experiences or perspectives regarding the effects on their health status, access to health care, or implications for their daily lives. Those served by volunteer groups are often from vulnerable populations such as the poor, the educationally disadvantaged, or victims of disaster. Vulnerable groups often incur proportionately higher costs for transportation, lost wages, and long waiting times when seeking health care than more affluent patients. Health care provided by volunteers should not add to these burdens, whether from prolonged or unclear communication due to lack of skill in the local language, affront to dignity caused from cultural ignorance, stress created by the need for assessments or tests done by untrained individuals to be rechecked, unexpected costs incurred from complications or side effects of free care or medications, or other inconveniences which affect these populations but are often invisible or incidental to others. To do otherwise is to exploit their vulnerability. More importantly, who provides compensation when a patient is harmed, permanently disabled, or dead from the care received from volunteers? Certainly, careful attention must be paid to the challenge of soliciting candid responses from those who may perceive their access to health care as dependent upon positive reports of their experience. Nonetheless, patients’ accounts of their own needs, perspectives, and experiences must be heard directly and weighed heavily in any analysis of the ethical or practical worthiness of global health volunteering. The book’s weakness is the paucity of data from persons served.
The major contribution of Hoping to Help is that it compiles and organizes information gained from many organizations, volunteers, and hosts, and summarizes problems and concerns discussed in the academic literature in an accessible narrative. In this respect, it will be a helpful resource for those unfamiliar with global health volunteering or those organizations and individuals who would like to examine their own efforts within a broader context. Nonetheless, the book’s general findings and principles have been long noted in the scholarly literature; the book offers little new information.2,3,4,5 Prior work has identified the lack of evaluation or recognition of its importance as a significant barrier to assessing the efficacy or appropriateness of global health volunteering.2,4 Greater attention to the body of research on Christian short-term missions in general would have provided the author a broader context to interpret the comments and perspectives of leaders and participants in faith-based health efforts.6,7 Similarly, previous research has addressed issues that Lasker claims are undocumented or understudied, such as the significance of religious motivation or affiliation, effects on charitable giving, influences on the “global perspectives” of participants, or benefits to the local community — issues common to most short-term humanitarian efforts even though additional research is warranted.6,7 The nine practices identified as keys to improve the efforts of organizations or individuals engaging in short-term medical volunteering are those that scholars have described over the last few decades for short- or long-term humanitarian or community development efforts.8,9 If these principles were heeded, global health volunteering would be more likely than not to reduce its drawbacks and increase its benefits, but employing them properly requires high levels of expertise, deep cultural knowledge, language proficiency, and long-term knowledge of communities. Organizations in long-term community development or health projects find them difficult to implement, especially when compounded by the pressures of donors or governments to produce quick results. For these reasons, Lasker’s expectation that organizations or individuals with a short-term focus might incorporate these practices broadly is overly optimistic.
In summary, the primary question posed by Hoping to Help is left unanswered. The book fails to provide the empirical evidence needed to assess whether the significant investment of money and effort is justified through measured improvements in health status, reductions in health disparities, or greater access to health service beyond mostly anecdotal accounts. Even the information that leads Lasker to conclude that longer-term capacity building may provide some measure of value to the host communities is not clear-cut. Granted, the data required to draw a more definitive conclusion is complex and may be difficult to gather or may even prove elusive. Nevertheless, clearer evidence is needed urgently given the great health needs of much of the world’s population, the staggering amount of financial and personnel resources consumed by these efforts, and the potential for great harm to vulnerable populations. We need more than a “maybe” coupled with the hope that with the right structure, motivations, and preparation the answer is more likely than not to be, “Yes.”