Author: Kenneth V. Iserson, MD, MBA, FACEP, FAAEM
Kenneth V. Iserson, MD, MBA, FACEP, FAAEM, is a Fellow of the International Federation for Emergency Medicine and Professor Emeritus, Department of Emergency Medicine, The University of Arizona, Tucson.
Why Global Medicine?
Interest in practicing and teaching medicine and nursing around the world has increased exponentially. Some of our colleagues now have international experience and many others dream of following a path to remote regions. Yet most clinicians are unclear about how to identify and evaluate global volunteer opportunities, what to expect when they travel to remote lands, and how to prepare for their experience. This article, based on The Global Healthcare Volunteer’s Handbook: What You Need to Know Before You Go (Galen Press, March 2014), provides basic information that physicians, mid-level providers, nurses and others in the healthcare field need for these ventures.1
After seeing your sixth uncomplicated viral syndrome during the busy flu season, you find yourself sitting and staring at the little world globe on your desk. You bought it in medical school when you dreamed of traveling to distant lands to help those in need. Time passed, you graduated from school and completed your residency. You’ve been working in urgent care centers long enough to feel comfortable, perhaps too comfortable. Your old dreams of taking time to help others around the world have returned. “If I’m serious about this,” you think, “how do I start?”
The following steps, briefly described in this article, will get you started on realizing your dream:
- Assess your goals for these trips.
- Find organizations with missions consistent with your goals.
- Of these organizations, find out which ones want your services.
- Learn what to expect on assignment.
- Prepare for your assignment.
Assess Your Goals
When trying to make your dream of doing international medicine a reality, the first step is to assess your goals. For most healthcare providers, these generally fall into two synergistic categories: exploring the world and altruism.
Exploring the world. Of course you want to see the world. But, where would you like to go? If you’re like most global healthcare volunteers, you will first consider sites where you can employ your foreign language skill. While that can be a benefit to getting a position, it may not work out the way you expect, because official languages really may not be spoken by most of the population. You also may want to explore sites that relate to your own cultural background. For example, if there are international healthcare projects in a specific country or region of your forbears, you may want to investigate them. Finally, of course, most volunteers would like an opportunity to see interesting and exciting locales (Figure 1: Tigers Nest Monastery, Bhutan (©K Iserson, 2014)).
A vital second question is: Where don’t you want to go? If you answer “somewhere very cold or very hot,” “places with poisonous snakes,” or “locations with lots of insects,” you have eliminated nearly all the world’s populations that need assistance. So, try to be a bit more realistic. Unless you are actively seeking to do disaster work or have a cultural need to work in such an area, you probably will want to avoid working in war zones and areas with ongoing terrorist activity. That still leaves lots of the world from which to choose.
Altruism. “I want to save humanity!” Didn’t you write that on your application to professional school? While you really do want to selflessly assist others and contribute to global health, understand that your activities abroad will have a very limited effect. Don’t despair. Even the greatest luminaries in global health have, in reality, only minimally affected global health. That is why the Bill & Melinda Gates Foundation and the large groups they fund represent the next level of intervention: addressing basic issues, such as preventing malaria, which truly will have a global impact. You cannot do anything meaningful alone, so you will need to be part of an organization’s team (Figure 2: Dr. Iserson seeing pediatric patient in Zambia (©K Iserson, 2014)).
Finding a Position
Now that you know what you want in a global healthcare position, how do you find an organization that is consistent with your goals? To identify appropriate organizations, you can contact colleagues who have international experience, check with the international sections of your specialty organizations, see if any religious groups with whom you are affiliated have international medical missions, and look at annotated lists of global medical organizations.
Colleagues’ international experiences can be useful, but the international organizations they know about may not correspond to your needs. Many of them will have volunteered during undergraduate or medical school, often with organizations dedicated to those student groups. If your colleagues’ experience was during residency, even if it was through their training program, it may guide you toward some interesting opportunities. In my own international work, I have had the opportunity to work and teach at programs under the auspices of five universities.
Take advantage of your professional organizations by checking with their international or disaster sections for any lists of global medical organizations or positions they have on their websites. Not all have such lists, and some (such as the American College of Physicians) require membership to access the information, but it is worth a try.
If you identify with a religion (or even with the general identity of Christian, for example), check with local religious leaders to find out about their global medical projects or organizations. Read the mission statements to avoid getting involved in organizations whose primary purpose is proselytizing, if that is not your interest, rather than delivering or improving international healthcare.
Also look at vetted and annotated lists of global organizations, such as the one in The Global Healthcare Volunteer’s Handbook.1 These can save you lots of time by not only identifying organizations but also providing their mission statements and information on sites where they work, funding opportunities, and the type of healthcare professionals they seek. Not all of this information is generally available.
“How about the Internet?” you ask. Not yet. The Web is loaded with scams and solicitations for money. Wait until you have honed your list and want to investigate individual organizations. That’s when the Web will be most useful.
Meeting Your Needs
Now that you have identified what you want in a position and some organizations that might be suitable, check them out in terms of more specific needs you have for your international experience. Consider matching your needs with both the organization’s mission statement and their rules (Table 1). Both can often be found on their web sites, although you may need to read the fine print carefully.
Organization’s Mission. With what type of group do you want to travel and work? Take a look at each organization’s mission statement and any other descriptive information you can find. You’ll discover that there are big divisions among them, for example, some are secular (non-religious) while others, perhaps most, are non-secular. They also are either for-profit or not-for-profit (generally, non-governmental organizations [NGOs] or government) and usually deal either with acute disasters or work in chronic resource-poor settings, but not both. If you desire to provide the maximum effect for the time you spend, look for either organizations that work in disaster areas or those that strive to make a long-term “sustainable” impact on healthcare by teaching local providers.
Organization’s Rules. Also consider what the organization demands of volunteers. The first consideration must be the time commitment. If you plan to make this your job for a while, you can accept trips lasting 6 months to a year, or even longer. For those trips, you may want to find out about compensation and time off. If, however, you plan on returning to the job you now have, as most of us do, the trip’s length must fit into your schedule. That generally means a month or two, depending on the length of your annual leave and vacation.
There are four types of financial arrangements for short-term assignments. Some organizations pay a stipend and reimburse expenses, whereas others only reimburse expenses, ask you to fund your entire trip, or require that you fund your trip and pay an additional fee. Be careful of the last scenario because that can be used by travel agencies masquerading as suppliers of humanitarian missions.
Consider two other factors when evaluating organizations and missions. The first is the site’s remoteness, which may or may not appeal to you. Urban and remote locations each have positive and negative aspects. Second, will your family be able to accompany you? Some organizations have strict “no family” policies, so beware-especially on long-term assignments.
Match Your Skills
At this point, you can winnow the organizations you have identified by matching your clinical and non-clinical skills with those that they need. Most need generalist physicians, although having emergency medicine experience (generally, urgent care will do) and obstetric training helps. Some groups specifically need clinicians with pediatric experience. Whether your urgent care practice qualifies will depend on the level of pediatric care they need. Some groups, especially those that treat specific surgical issues (e.g., cataracts, fistulas, cleft lips/palates) want only the appropriate surgeons, anesthesiologists, and ancillary staff (operating, recovery room, intensive care unit (ICU) rather than urgent care practitioners.
How about credentials? Most organizations or their on-site hospital will want to see that you have a valid medical license and, most likely, CPR and ACLS training. (In my experience, the American Academy of Emergency Medicine’s Advanced Resuscitation Card has worked as a substitute.) A big question is: Do they accept physicians with D.O degrees? In the past, most generally didn’t. However, things are changing and many global organizations have made arrangements that allow any licensed physician with their group to practice and teach.
Nurses, both RNs and LPN/LVNs, are in high demand, especially if they have any emergency department, pediatric, ICU, or operating room experience. Physician assistants (PAs) and advanced practice nurses (APNs) have a bit more difficulty matching with some organizations because the countries in which they work may not recognize those professional designations and thus may be skittish about accepting such healthcare professionals. Normally, organizations accept nurse-midwives and nurse anesthetists without a problem because those positions exist globally. Other types of APNs, PAs, and other healthcare professionals (and students) will have more difficulty finding organizations to work with-although they do exist.
The primary non-clinical skill that will make you attractive to global healthcare organizations, and that will make their work interesting to you, is having language skills appropriate for the areas in which they work. Even if your clinical skills don’t exactly match an organization’s desires, having needed language skills may make you attractive to them. Be aware, however, that even if a country’s official language is, for example, Spanish, French, English or Chinese, much of the patient population may not speak it. Rather, they may speak their own language or dialect. That can be challenging, and result in frustration.
What to Expect
Working globally will trigger some major changes in your lifestyle and, usually, your clinical practice. Of course, that is part of the allure of working internationally.
Lifestyle. The first thing that you may notice is that your accommodations may not be “of the style to which you’ve become accustomed.” Although you may be housed in a home or hotel, it is just as likely, especially in remote, unstable, or disaster settings, that you will find yourself (as I have) living in a boxcar, tent, ship (at the dock or at sea), hostel, dormitory, apartment, hospital room, or church. In one case, I spent 2 weeks bunked with approximately 250 colleagues on the floor among thousands of constantly operating switches in a telephone company building (Figure 3: The “Compound” for our medical team, Juba, South Sudan (©K Iserson, 2014)). Not only may the living arrangements be unusual, but you also may be plagued by constant light, as well as snoring, sloppy, or discourteous roommates. Carry wax earplugs and a sleep mask to help you get some rest. As for bathing and toilet facilities, be prepared to share, and ask about anything out of the ordinary, such as needing to prime the hot water tank or squatting for the toilet.
Food may be the biggest shock to healthcare volunteers. If the organization does not provide food, you may need to rely on local grocery stores if you have storage and cooking areas available or hospital cafeterias, food stalls, and restaurants. That may be a problem if you are a picky eater or simply paranoid about getting gastroenteritis. While it won’t solve the problem completely, it may help to carry some prepackaged energy bars, drink only bottled (or bagged in some places) water, and always carry loperamide and toilet paper.
Religion, customs, and acceptable behavior may also differ markedly from back home. Try to learn as much as possible about these lifestyle aspects before traveling to avoid surprises. The more you know, the better you will be accepted and the more you can learn. A good policy, however, is to try not to discuss either religion or politics other than, perhaps, asking thoughtful questions.
Clinical Practice. During a global assignment, your practice setting, the available equipment and supplies, and the diseases you see can vary significantly from those at home. You may end up practicing out of a tent, a truck, a schoolhouse, or in clinics or hospitals in varying states of repair and cleanliness. Your local colleagues will generally speak the official language. English, French, Spanish, and Arabic are most common in countries where global healthcare organizations work. The local population will, for the most part, speak other languages or dialects.
As for the clinical challenges of working in resource-poor settings, bring your own stethoscope and headlamp (power outages are common), and be prepared to improvise or substitute for missing supplies or medications.2 As for your fears about the unfamiliar diseases and injury mechanisms you are sure to see, do some reading in advance about the most common medical problems where you plan to go and then carry your “portable brain” along to remind you of what you have read and any unfamiliar medications you may encounter (Figure 4: Jumble of ED medications, Guyana (©K Iserson, 2014)). You can use your smartphone without charge if you keep it in airplane mode and then turn on the WiFi connection. Many sites now have WiFi connections. Remember, though, that throughout the world, common diseases occur commonly. No matter where you are, your patients are much more likely everywhere to be having a heart attack rather than Chagas Disease (Figure 5: World Health Organization 10 Leading Causes of Death Worldwide-2012. Available at: http://www.who.int/mediacentre/factsheets/fs310/en/ Accessed July 6, 2014. Reproduced with permission of WHO, Geneva, Switzerland.).
How to Prepare?
Once you have a position, how do you prepare for it? That involves optimizing your personal health preparations, collecting necessary documents, arranging transportation, ensuring that you will have local and distant electronic communication at a reasonable cost, being able to pay on-site expenses, and preparing for culture shock on your return home.
Personal Health. Allow sufficient time to update all your routine immunizations and to get any additional ones you may need for your site. Some vaccinations require many weeks to be effective (e.g., rabies pre-exposure vaccination, at least 21 days; Japanese encephalitis immunization, 35 days for immunity). Also, get a suitable supply (at least 1 week more than you expect to be gone) of any daily medications, and a supply of malaria prophylactic medications and DEET and sunscreen to apply. Also, don’t forget to take care of any outstanding medical problems and get a complete dental checkup; you may be a long way from a dentist.
Necessary Documents. You will need both professional credentials and personal documents. Once you collect them, carry copies on your phone, on a USB drive, and as hard copies in your carry-on bag. The professional credentials will allow you to practice or teach medicine or to do research at your destination. These include your current medical license, medical school diploma, residency certificates, board certification certificate, and clinic or hospital privileges list. Your personal documents must include your passport (with at least 6 months left and two opposing clear pages), any required visas or “reciprocal tax” document, an official printed airline itinerary (from the airline or travel agent, which you need to enter many international airports), your International Certificate of Vaccination (“yellow card”) or other immunization record, an official letter inviting you into the country (for talks, volunteering, etc., which you can get from your organization), and a letter from the hotel or other accommodations with an address/location (with confirmation number and phone number, if a commercial establishment). It’s also a good idea to carry at least six extra passport photos and, if you plan on driving, not only your home driver’s license, but also an International Driver’s Permit and, in Latin America, an Inter-American Driver’s Permit.
Transportation. Plan for the inevitable travel “hiccups.” My policy is to expect that all transportation arrangements will go to pot, so if they go smoothly, it’s a gift (Figure 6: World destination sign at Heathrow Airport, London (©K Iserson, 2014)). Of course, that also means that you should be ready to make alternative arrangements instantly. As for luggage, assume that it will go missing or be opened, so put all your valuables, including your personal medications, electronics, documents, and personal medical equipment in your carry-on bag. Clearly mark and put TSA locks on your checked luggage. Book flights as far ahead as possible. It will give you the most flexibility, if not the cheapest price. As for the pick-up that organizations usually arrange at the airport, don’t assume that the driver will be there. Make sure that you have the driver’s name and cell number, as well as your local contact’s name and number, so that you’re not stranded.
Electronic Communication. Cell towers and WiFi are ubiquitous, even in of the most remote areas of the world. Using them wisely takes knowledge and preparation if you want to connect with local colleagues and to your family and friends back home. Rent or purchase (organizations sometimes loan) a local cell phone. Alternatively, if you will be doing a great deal of international traveling, you can purchase an unlocked quad-band GSM phone and buy a SIM card in each country you visit. Then you only have to purchase time on the card. Other, more complex but inexpensive options also exist.1 Using your own phone incurs “roaming” charges that may cost you more than your usual monthly salary. To call internationally, connect through WiFi to a voice over IP (VoIP) service (such as Skype). Those calls will be free or very inexpensive.
Finances. As soon as you arrive, you may need to pay some expenses, including taxi fare. If possible, get at least $50 in local currency before you arrive. In many countries, that is not possible, so either change some money at the airport or use an ATM. Carry at least two brands of credit/ATM cards (with no international fee, if possible) and some new, undamaged U.S. dollars or Euros.
Re-entry Culture Shock. You may not expect some of the feelings that arise on returning from a global assignment (Table 2). The way to prevent re-entry culture shock is by reading about it in advance and then actively talking about it with colleagues who have experienced the same thing. It also helps to have your family, boss, and colleagues read a little about it so that they can understand what you’re going through.
Few practitioners take the opportunity to work in global medicine. That’s a shame, since it will not only help colleagues and patients around the globe, but also be the capstone of a successful medical career. Having personally worked or taught on all seven continents, I enthusiastically support all the healthcare professionals who give their time, effort, and funds to assist global organizations and to promote health and healthcare education around the world.
- Iserson KV. The Global Healthcare Volunteer’s Handbook: What You Need to Know Before You Go. Tucson, AZ: Galen Press, Ltd., 2014.
- Iserson KV. Improvised Medicine: Providing Care in Extreme Environments. New York: McGraw-Hill Publishing, 2012.
TABLE 1: Typical Differences between Global Medical Organizations (Adapted from: The Global Healthcare Volunteers Handbook: What You Need to Know Before You Go. Tucson, AZ: Galen Press, Ltd., 2014.)
|Secular Organization||Non-secular (religious) Organization|
|NGO or governmental (Not-for-profit)||Private (Generally for-profit agencies)|
|Big Organization||Small Organization|
|Long-term program intervention||Short-term (sustainable) program|
|Chronically resource-poor setting||Acute disaster|
|Long-term time commitment||Short-term time commitment|
|Paid (generally small stipend)||Vlunteer|
|Expenses reimbursed||Expenses not or minimally reimbursed|
|Fixed clinical sites (hospitals, clinics)||Improvised clinical facilities|
|In-country/on-site administrator||Distant administration|
|Mission: Long-term system growth||Mission: Short-term benefits to local population|
|Family can accompany you||Unaccompanied assignment|
|Remote location||Less remote location|
|Matches your clinical skills||Requires extending your clinical skills|
|Your language skills are needed/can be used||No applicable language skills|
TABLE 2: Ten Symptoms of Re-Entry Culture Shock . (From: Iserson KV: The Global Healthcare Volunteer’s Handbook: What You Need to Know Before You Go. Tucson, AZ: Galen Press, Ltd, 2014; p. 127) (Reprinted with permission.)
- You’re bored by family, friends, and old routines after your excitement and challenges abroad.
- You find that others do not want to hear much about your experience.
- You’re irritated by inane questions about your experience and answer sarcastically.
- You feel that you can’t fully explain your experience or its importance.
- You feel that your experience abroad is distinct from the rest of your life.
- You’re unable to apply your new knowledge and skills to your job, school or life.
- Your relationships with family and friends have changed.
- You think that people misunderstand or see the “wrong” changes in you.
- You feel alienated and experience “reverse homesickness” for your host country.
- You constantly criticize your own culture in comparison with where you’ve been.