Breaking the link between colonialism and global medical missions

Rudyard Kipling spoke to the spirit of the age at the turn of the 20th century when he called on newly minted imperial powers to “go send your sons to exile to serve your captives’ need”. Then, the Western popular imagination was captivated by the myth of the intrepid white civilizer setting off to tame the savage wilds. Unfortunately, this fascination did not die out with the empires it justified. We still see ample evidence of it today, “medical volontourism” being a prime example.

            Healthcare professionals from Europe and North America are traveling in increasing number to developing countries for short-term assignments. The effects of most of these assignments range from the benign to the outright harmful; rarely do they offer real benefit to local communities. Volontourists may arrive poorly equipped to deal with their new cultural, linguistic, and even medical milieu. They can end up providing redundant care that undermines nearby healthcare systems and diverts trained in-country personnel to their activities in an “internal brain drain”. There is a constant risk that the lion’s share of the benefits will be reaped by the foreign health workers (and their institutions) who carry back the experience they acquired to their far-flung home countries to decorate their résumés.

            This inequity is a painful reminder of open wounds from a recent colonial past. To the credit of the Western healthcare community, awareness has become firmly established of how problematic medical volontourism can be. Unfortunately, it has yet to devise a solution. The push to professionalize “global health” has hit upon the snag that no one can really agree what the field constitutes. As such, there is no widely-accepted means of weeding out those with a true passion for global health issues from those with only a superficial interest.

            Physician and global health advocate Timothy Laux thinks this role might be played by existing Institutional Review Boards (IRBs). Laux’s case is that, as the only true contender for authority in health science ethics enforcement, IRBs are best-positioned to crack down on medical volontourism.

            Laux acknowledges that, at first glance, IRBs are imperfect candidates for the job. Institutional ethics panels typically confine themselves to review of research proposals and projects in accordance with research-specific regulations and the capacities of the environments they find themselves in. Moreover, they’re frequently overburdened by and understaffed for their workload. Taking the step towards passing ethical judgement on the suitability of individual applicants for volunteer placements—often clinical in nature and on the other side of the world—would therefore be massive. But, Laux asks, if not IRBs, who else?

Well, ethics authorities in the regions where volunteers propose to operate for one. Admittedly, this is easier said than done. Knowledge of bioethical principles, let alone the review boards to enforce them, are likely lacking in many of these environments. A possible solution could be to integrate bioethics into existing health institutions, like local Ministries of Health, who are ultimately responsible for permitting short-term medical missions to take place in developing countries. This would be challenging, as it would require ‘buy-in’ from those institutions, and the cultivation of a cadre of health and other professionals so that they are in a position to inform ministry decisions. But it is not impossible, and local Ministries of Health have a self-interested motivation in maximizing local benefits from these international volunteer initiatives. Or, to be more realistic, they have an interest to at least be in negotiations with initiatives coming from more powerful countries, to minimize the potential for exploitation.     

            All of this is not to say that IRBs have no place in this discussion. They might still be able to take a lead in assessing the merits of students’ proposed projects, a job more in line with their existing competences. But at the end of the day, the final decision makers should always be the communities who themselves stand to gain—or to suffer—at the hands of sons sent to exile.

Gaelen Snell