COMMENTARY

Enhancing the Effectiveness of Medical Missions

Andrew N. Wilner, MD; Lawrence C. Loh, MD, MPH

Disclosures

March 31, 2017

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Andrew N. Wilner, MD: Welcome to Medscape. I am Dr Andrew Wilner. Today I have the pleasure of speaking with Dr Lawrence Loh. Dr Loh is adjunct professor at the University of Toronto School of Public Health. He has also written about medical missions, which I also have a particular interest in. Welcome, Dr Loh.

Lawrence C. Loh, MD, MPH: It is nice to be here. Thank you, Dr Wilner.

Dr Wilner: Thanks for joining us. Dr Loh, how did you get interested in medical missions in the first place?

Dr Loh: I started as a medical missionary, as it were, back in 2005, visiting the Dominican Republic with a friend of mine from the University of Missouri, Kansas City.

Dr Wilner: I read a couple of your papers.[1] Of course, everyone knows it is a great thing. You typically go to what we call a developing nation. Very often we bring medications, sometimes we do surgeries, and we pull teeth. Then we come home and say how great it is. I have been doing that with our colleague who introduced us, Dr Tiago Villanueva, in the Philippines for a number of years.

It has been in the back of my mind that we could do more. You can always do more. There were also some reservations about whether we are antagonizing local physicians or giving the health system there, which should be better, an excuse not to improve. What did you find along those lines?

Dr Loh: There are certainly challenges associated with medical missions. I want to preface my comments by saying that we know that most medical missions and people who participate in them go abroad with the very best intentions. I think that, if anything, a lot of the challenges that are faced by medical missions really kind of play out as a bit of a tragedy, in some regards, in terms of the ones that are less well conducted.

Some of the big concerns usually are around the development of a parallel system that actually competes with the locally established healthcare and social system that exists in these communities and the dependence that is imposed upon them. What happens is you have these missions show up. They bring these free medications. They bring these free surgeries. Then eventually, as all good things come to an end, the question is: What happens when they leave? What happens if they leave for good, and local resources have been diverted to support the coming of medical missions as opposed to developing local capacity?

Dr Wilner: I was very impressed in the Philippines that there is not really a system. In other words, we came to do one of our missions on—well, we go to very remote places. We do not compete with anybody.

Dr Loh: Right, fair enough.

Dr Wilner: We go to where the people live in huts and have never seen a doctor. We work very closely, actually, with the local government so that they are prepared. I would notice that sometimes we would arrive in the town, and there was another mission already there. Then there would be a town 5 km away, and nobody ever went there. There was not a centralized way of scheduling or organizing or prioritizing. Everybody was just on their own agenda; some religious, some not religious. Is this the way it is all over the world?

Dr Loh: I would say that is very similar to our experience in the Dominican Republic. Certainly, that is one of the other concerns around many traditional medical missions—the idea that they focus very much on the provision of care rather than on the overall community picture. It has been shown that some of the best ways to do medical missions are to work with local leadership and address specific local priorities to understand where services might be best used. Also, it is important to ensure that the services that are provided are culturally relevant and appropriate and that appropriate follow-up happens after the medical mission leaves the area.

Dr Wilner: There is also the question of cost. For all of our members, for example, we buy a plane ticket to the Philippines, which is anywhere from $1000 to $2000. There are incidental travel expenses. We usually stay, actually, with the military. That is quite inexpensive. We bring our medications, and we collect some charitable donations.

I remember we had a guest one day who was an ENT physician. He came along with us. He said, "For all the money it cost me, plus the money that I am not earning and the overhead of my office by being here a week, I could have just donated $15,000, and that probably would have gone a whole lot farther than everything we are doing."

Dr Loh: What is funny, though, is that is a typical argument. This is where I actually straddle the middle around medical missions. The evidence actually shows that there is a benefit from having that human connection—that quote by Yeats that, "Nothing ever becomes real till it is experienced." Even in our research, we have identified that people are much less likely to donate something equivalent to the cost of their trip if they do not go to the actual community and experience it for themselves.

Dr Wilner: What do we do to make sure that medical mission volunteerism really does benefit the local communities?

Dr Loh: There are a number of different practices that can be considered. I think one of the most important things is to identify a local partner that can take leadership in terms of directing the nature of the care that is provided. This helps to eliminate a lot of the issues that we see where local partners are almost kind of tourism agencies. Basically, these medical teams show up and say, "We want to go here or here. We do not really know what is going on, but we just want to help." By doing that, working with local partners, it helps to eliminate a lot of the redundancy and waste and helps to integrate the work of these medical missions into the community's existing healthcare structure. That is first and foremost the most important thing to start with.

Dr Wilner: Is there a problem of looking a gift horse in the mouth?

Dr Loh: In terms of?

Dr Wilner: Discouraging people from coming.

Dr Loh: It goes back to a question of whether it is feasible to even do this. I think it is not a question of whether it is feasible to do best practices, but the reality is that "more is better" is not a philosophy that seems to work in a lot of places anymore. You have inappropriate care being given. I am not saying that all medical missions do this. By virtue of having so much variation in the way medical missions are conducted, there are bound to be some issues that arise in terms of redundancy and waste and inappropriate care.

Dr Wilner: You work with another organization, 53rd Week. Tell us about that?

Dr Loh: The name actually refers to the idea of collaboration behind medical missions. The idea that in 1 week, it is very limited what a medical mission can accomplish. If you take a year's worth of trips and have them coordinated appropriately towards a local goal, you might get something better and bigger than the ordinary. The whole focus of 53rd Week is about responsible volunteering abroad and the mechanism and frameworks by which we can actually do that.

Dr Wilner: How does one interface with this group?

Dr Loh: You can check us out online on our Twitter and Facebook accounts, so if you Google "53rd Week," it will come up. We have a number of videos online as well as publications for people to check out.

Dr Wilner: Dr Loh, I want to thank you very much for speaking with me about medical mission work and how we can do it better. I think there is always more that we can do. That is what makes it exciting and satisfying.

Dr Loh: Medical missions are some of the greatest opportunities we have to change the world. It is all about making sure we do them in a manner that is right and responsible.

Dr Wilner: I am Dr Wilner. Thank you for joining us at Medscape. If you have any comments or questions, please write them in the space below this video. Thanks for joining us. Thank you, Dr Loh.

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