Thousands of global health volunteers, most from the United States, travel to Africa every year. These volunteers come from diverse backgrounds and have varying levels of experience. They include surgeons, anaesthesiologists, nurses and medical students. They arrive with the ambition to improve health outcomes in Africa and learn about "global health".
In my research I have studied the impact of these volunteers in Zambia. Between 2014 and 2016, I conducted research at a rural hospital where medical volunteers from the US provided various forms of medical care, including eye surgeries, caesarian sections, and treatments for malaria, tuberculosis and HIV.
In my latest research paper I examine how the presence of these volunteers affected the lives and relationships of people in Zambia.
My key finding is that the presence of medical volunteers caused damage to the relationships between Zambian health professionals and patients.
I identify this as a kind of "relational harm".
These findings are important because relationships are central to the delivery of effective healthcare. Clinical care requires material infrastructure: power, water, hospital beds, medical gloves and technical devices. But it also requires strong relationships of cooperation, trust and mutual recognition.
I conclude from my findings that academics, volunteers, and global health organisations should pay more attention to the "relational harm" that volunteering can cause in under-resourced settings where privileged volunteers work amid extreme inequality.
The impact
Drawing on long-term ethnographic research and interviews with Zambian health workers and patients, I found that local opinions about global health volunteers were divided.
At the hospital where I conducted my research, patients were often enthusiastic about their presence while many Zambian health professionals were critical.
Patients regularly praised volunteers and described positive encounters with them. One Zambian patient described a medical volunteer as having "a heart for patients ... he doesn't look at who he is dealing with ... he can be there for anyone."
To many patients, it seemed that volunteers often provided a higher quality of care than Zambian staff members.
But this was, in part, due to differences in wealth, status and privilege between American volunteers and Zambian health workers.
While American volunteers could focus entirely on their hospital work, Zambian staff members had families to support, social events to attend, and school bills to pay. This meant that they could not spend as much time at the hospital or offer patients gifts, including small payments (known as "transport money"), that volunteers often offered to patients.
This was noted by Zambian health workers, such as Matthew, who told me the following:
Most {patients} will say that {the volunteers} will help with transport money and {the patients} get back home and then they share with their friends that they got transport money. But sometimes this is at the expense of local staff who then get called bad.
In addition, Zambian health workers felt that their hard work and expertise were being overlooked. As another staff member explained:
These international {volunteers} ... they really look like they are better and even patients start to see a big gap. But it is not that Zambians are worse.
This staff member was pointing out that volunteers were often able to provide care that appeared to be "better" because they could work for longer hours, offer transport money, or even use newer technologies and medical devices.
In this context, staff members felt that they were judged negatively by patients because of the presence of volunteers.
When patients expressed a preference for white volunteers - particularly those with less expertise - it often negatively affected Zambian health workers. As an experienced Zambian health professional told me:
When somebody comes in and says they want to be treated by a white student, then you feel like a stranger in your own country.
The presence of volunteers therefore strained the relationships between staff members and patients, creating new forms of anxiety, resentment, and division.
Staff members and patients were concerned that these tensions would continue to affect their relationships in the future - even in the absence of volunteers.
What can be done
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These findings can contribute to growing debates about the benefits and risks of global health volunteering.
Critics have argued that medical volunteering reinforces inequality and paternalism, as well as causing direct harm through medical negligence. Supporters of medical volunteering argue that these risks can be overcome when medical volunteers are responsible and informed.
Focusing on the impact of medical volunteering on local relationships offers a new perspective.
In the future, global health volunteers and the organisations that promote volunteering should reflect on whether their work is damaging relationships in healthcare settings. In under-resourced contexts, these relationships are often particularly fragile, as researchers working in Sierra Leone in the aftermath of Ebola have shown.
Those who decide to volunteer should consider whether they are leaving these relationships in a better or a worse condition than they found them. If their aim is to improve health outcomes, they should ask how they might use their resources to strengthen these relationships instead of undermining them.
James Wintrup, Senior Researcher, Chr. Michelsen Institute
