When Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, talks about her trip to Cambodia with Arizona-based Peacework Medical Projects, her enthusiasm is infectious.
“It was amazing,” she says of the two weeks she spent as an international medical volunteer in January 2009. “We were very well received, and I think by the time we left, we all wanted to go back. And I believe the community would welcome us back.”
Segal-Gidan is such an eager participant that when she says, “You should come with us next time!” even a nonclinician who fears camping is at least a bit tempted to sign on. Perhaps her experiences, and those of other clinicians, will encourage readers to contribute their professional skills to a worthwhile project.
A Sustainable Model
Peacework Medical Projects (not to be confused with Peacework International) is the creation of Pamela Burwell, MS, PA-C, a woman for whom volunteering has never been a choice; it’s always been something she just does. Her efforts in Ghana and Honduras earned her the 2008 Humanitarian PA of the Year award from the American Academy of Physician Assistants; this year, she added Cambodia to the list of places Peacework visits.
When Segal-Gidan began looking for an organization to volunteer with, she had a list of criteria: it had to be PA-friendly, short-term, and not religiously or politically affiliated. As she says, “The list got pretty narrow pretty fast.” But when she found Peacework Medical Projects on the Web and began corresponding with Burwell, she sensed that she’d found a winner.
“[Pam] works well with the local resources, which is very important, and she’s very respectful of the culture,” Segal-Gidan says. “It wasn’t like, ‘We’ve got the answers and we’re going to come and solve your problems.’ She goes in with the idea of ‘I’m going to see what we can do to help you.’”
Around the same time that Burwell launched Peacework in January 2000, criticism of short-term medical missions began to appear in the medical literature. Editorials and essays in journals such as BMJ and JAMA questioned whether these efforts actually do more harm than good and how clinicians can expect to treat chronic illnesses in a single visit. There have also been queries about whether such “medical tourists” cause disruptions and strain the local communities they purport to help.
Burwell understands the criticism but has worked to develop a sustainable model that integrates as much as possible with the local infrastructure. She has a five-page document outlining the process of putting a project together, from identifying needs and host country nationals with whom to collaborate, to assembling teams of health care providers for the trip. And she never, ever takes a team to a location she hasn’t vetted herself on what she calls her “scouting trips.”
“I think the big—and rightful—complaint about short-term projects is that you go in, you drop a bunch of medicine, and you leave,” acknowledges Burwell. “The way I try to combat that is to create long-term commitments in a given area, and I build health education into the program.”
Focus on Education
Each Peacework volunteer carries about 70 pounds of medications into a country (a fact that slightly concerned Segal-Gidan, until she realized Burwell had done her homework with the Cambodian authorities to ensure that no one would be detained at Customs). Even so, Burwell’s commitment to health education means those medicines “are simply the carrot on the stick that brings so many people to us,” as Burwell says.
Once patients arrive at the Peacework clinic, the focus becomes health education. “We want them to understand the relationship between their own behaviors with personal hygiene and clean water and their own good health,” Burwell says. “We’re not going there and treating long-term diabetes or hypertension. We can treat those things in the short term but more importantly, teach people how not to get them in the first place.”
“If we can teach someone to keep their water clean, it might decrease their chances of being ill 10 times a year,” says Shelley Vaughn, RN, BSN, who is currently enrolled in the family nurse practitioner track at Northern Arizona University.
Something as simple as a five-minute discussion might be enough to improve someone’s life and health; this is part of what keeps Vaughn, who has participated in three Peacework projects in northern Honduras, going back. For example, Hondurans drink a lot of coffee, which contributes to their high blood pressure levels. “Even helping them to understand that if they only had one cup of coffee a day, instead of that being their only beverage all day long,” Vaughn says, might make a difference in preventing or controlling hypertension.
Along with the education, clinicians deliver a sense of respect to the people they treat. Burwell and Vaughn have seen the fruits of that respect in Honduras. After eight years at a location in the northern part of the country, Burwell actually ended her project there (and is preparing to scout a site in southern Honduras) because the people Peacework helped serve have arranged to bring in a government doctor and nurse each month. They have also received a grant from an organization called World Vision to help with their educational needs.
“Now, I can’t say Peacework did all of that,” Burwell says, “but we were there every year, and we convinced these people that they mattered enough for us to show up every year.”
The Good and The Sad
Participation in international medical work is, of course, more complex than just providing health education. For every heartwarming story, there is a heartbreaking one, and clinicians may come away feeling conflicted about how much good they’re doing. Segal-Gidan witnessed both extremes while in Cambodia.
The heartbreaker was the young woman in her last trimester of pregnancy with her eighth or ninth child. She appeared on the second clinic day and was diagnosed with preeclampsia. The Peacework volunteers brought in the local physician to try to convince the woman to go to the nearest hospital, which was about 10 miles away and accessible by public transportation. As Segal-Gidan discovered, the hospital may not have been geographically inaccessible, but for this patient, it was financially inaccessible; her understanding was that the patient would not have to pay for care, but there was an admission fee just to be seen at the hospital.
“I don’t remember the sum, but it wasn’t something that seemed astronomical to us—but to her it was,” she recalls. “And we could not give her the money. Financially, we could, but if we did that … we couldn’t do it for everybody. So that was really difficult.”
Vaughn has been confronted by poverty in Honduras, where she visited a community of about 70 families living in a garbage dump, in huts constructed from plastic egg crates and anything else that comes to hand. “It’s not that they can’t go to a doctor; they can, but it costs money,” she says. “The small amount of money that it costs might be a month’s salary for them. So [health care] is not going to come first. What comes first is trying to put food on the table.”
Burwell acknowledges “it can be rough” but also points out that Americans have something to learn from the quiet dignity and resourcefulness with which people in less affluent countries respond to unfortunate circumstances. “We see the end result of disease that has gone undetected and uncared for. We see congenital defects in children that will not be repaired,” she says. “But what we also see are families who take care of these unfortunate babies, caring for them with such love and in some cases such faith.”
Segal-Gidan, in fact, found some of her patients in Cambodia to be downright inspiring. In particular, there was the man with a spinal cord injury who came to the clinic in a wheelchair, accompanied by his wife and children. Segal-Gidan, who works in a rehab hospital with spinal cord injury patients in the United States, was amazed by the man’s condition. He had no bedsores. He needed to be catheterized for bladder care, but his wife had taught herself how to do that and boiled the tubing that they received once or twice a year for that purpose.
“They could come and teach some people here how to be resourceful,” Segal-Gidan says. “His legs were atrophied; it clearly took a lot of effort from his family to keep him in the condition he was in. And they just did it. It was quite inspiring.”
Many Reasons to Give
Professional and spiritual rejuvenation, in addition to a desire to “do good,” are some of the reasons clinicians may want to consider medical volunteer work. For many, it’s a reminder of why they went into health care in the first place.
“I see a lot of primary care providers who are burnt out about the way medicine is practiced here in the US,” Burwell observes. “They feel up against the paperwork, up against the litigation threat, up against the greed that happens in medicine today. And they forget their original, very good reasons for becoming a doctor or a nurse or a PA.”
For Segal-Gidan, volunteering with Peacework represented a return to her roots. “I chose to go to PA school with the idea that I was going to go and work in the Third World. But when I graduated, the world was not ready for PAs,” she says with a laugh. In the meantime, “life kind of intervened,” and she has followed a much different path—although she’s always had it in mind to pursue that original goal.
Segal-Gidan went to Cambodia with a mix of anticipation and anxiety. She specializes in geriatrics here in the US; Cambodia, because of the atrocities committed by the Pol Pot regime in the 1970s, is a very young country, population-wise. But she found that the health care providers Burwell had assembled truly functioned as a team and did not divide up patients based on their own Western knowledge base.
“What I do [in the US] is take care of people’s dementia; what was I going to do [there]?” she recalls thinking. “But your basic skills stay with you. I could still diagnose otitis media in a kid.”
Vaughn is at the other end of the career spectrum—in fact, part of her interest in becoming an FNP is to contribute more not only here in the US but also in Honduras. As a nurse, she currently handles triage or pharmacy at the Peacework clinics but says, “I would really like to be able to treat the family as a group. Maybe once I’m the clinician, I’ll be able to offer a little more education. That to me is what matters the most.”
Besides feeling that helping the community—at home or abroad—“is part of our responsibility in the health care profession,” Vaughn’s main reason for giving back is her appreciation for the resources available in the US. At the time of her first Peacework trip, Vaughn was a single mom with two young sons who used her nursing sign-on bonus to participate in the project.
“I know that because of the resources we have here, I was able to change what was going on in my life,” she says. “Without those resources, I probably would still be working a $5- or $6-an-hour job and not be able to have what I have now. So I felt the need to share how my life has changed.”
Burwell says volunteers need to be realistic about what they can accomplish on a short-term medical trip. “The very few less-than-satisfied volunteers I’ve ever had were those who had romanticized the projects to the point where they really thought they were going to be saving lives every day and they were going to be welcomed almost like heroes,” she recounts. “And you don’t see change every day, you don’t save lives every day, any more than you do at work here.” (Her list of questions that potential volunteers should ask can be found in the box.)
And while Burwell, Vaughn, and Segal-Gidan come across as pretty extraordinary (not that they’ll tell you so; all three are remarkably humble), “Everybody has something to give,” Segal-Gidan says. “You learn more than you give, but you’re able to give a little, too."