Advice for Aspiring Volunteer Physicians

Before packing one's bags and flying off to some exotic locale to do medical mission work, a physician should address a variety of factors to ensure a worthwhile experience.

First of all, rarely do physicians volunteer services abroad without working through a sponsoring organization. A physician should try to join with a group that offers the type of experience he or she wants. For example, some organizations send teams of physicians, with their own equipment and support staff, to treat a specific population. Others send physicians by themselves with the idea of teaching local practitioners through observation and example. Still others send physicians to areas where emergency relief is needed, such as in war-torn countries or those devastated by natural disasters.

The following directory of organizations includes some of each sort; those contemplating volunteering should ask the group of interest for details. This is the sixth such directory to be published in JAMA; the last appeared 3 years ago (JAMA. 1996;276:355-359). Any group that wishes to be listed in the future may send the relevant information to JAMA's Medical News section.

Scott A. Norton, MD, is a dermatologist and a lieutenant colonel in the US Army stationed at Walter Reed Army Institute of Research in Washington, DC. Norton has been on about 15 overseas medical missions around the world. He estimates that he's practiced medicine for about 2 years outside the United States in some sort of international assistance capacity. He has written articles such as "The Dermatologist's Baedeker: Preparation for Medical Assistance Missions" (Dermatol Clin.1999;17:187-208), and in a recent interview Norton offered ideas to ensure a successful mission.

"I think that one should realize that as a volunteer, we gain a lot—our lives may change," he said. "But the motivation should not be to change our lives. It should be to assist others."

To prepare for those efforts, Norton recommends that prospective volunteers learn about the country in which they will serve—including its history, traditions, social conditions, current political climate, health care delivery system, and local diseases.

"It's also important, philosophically, to understand the cultural norms of the society for which you're volunteering and to adapt or integrate oneself appropriately," he said. "It's important to not jeopardize the social framework of that society. Their physicians and health workers have devoted their lives to working in those environments. It would be catastrophic for a volunteer, an outsider, to ignore their dedication, understanding of the community, and the ways they've adapted to this medical environment."

Norton also warned against providing state-of-the-art medicine for chronic conditions—offering a month's worth of drug samples, otherwise not available, to relieve temporarily a chronic condition that will relapse once the volunteer leaves and the samples run out. Instead, one should consider treatments that can be continued without the physician, or medication, present.

There are also other, nonmedical, factors to take into account.

"Physicians should be aware that there may be exchanges of gifts," he said. "Some of the most dispossessed people can maintain some self-respect and want to give something of meaning to a person who has helped them. Learn in advance what the appropriate response should be. Declining a gift or failure to reciprocate may be considered ill-mannered."

Personal safety must be considered.

"Know what precautions to take to avoid foodborne, waterborne, or vectorborne disease," Norton said. "You or your organization must find out about the climate and terrain to plan your transportation, shelter, communications, and resupply." He also reminds physicians to consider their physical and sexual safety as well.

Medical mission work isn't for everyone. Norton said physicians should be physically and mentally fit and not volunteer to "find themselves." Successful volunteers are those who are adaptable and don't become frustrated easily. Excessive idealism may be a liability.

"Several studies have shown, in humanitarian assistance, the people who have an innocent or naively altruistic sense are often the most disappointed or frustrated from their experience," Norton said. "One should not expect to arrive among destitute and bedraggled people and become Mother Teresa. And if one is hoping for that outcome, then one needs to learn more about health and society in developing nations."

But while there is much to learn and prepare for before going overseas, Norton believes the experience is worth it.

"Many American physicians have so many demands in their practices that they've often lost sight of an aspect of our profession that is extraordinarily fulfilling, and that is to serve people who need help the most," he said.

Tables listing service opportunities abroad. Table 1, Table 2, Table 3, Table 4, and Table 5

Iquitos, Peru—Eugene Pflum, MD, always wanted to travel the Amazon River to see the natural wonders and beauty of the rain forest.

Because of that dream, one morning in June the orthopedic surgeon found himself aboard a three-wheeled motorcycle taxi stuck in traffic, surrounded by noise and exhaust fumes, headed for a hospital in a South American city of 350,000 people. He was in Iquitos, which sits near the junction of several rivers that merge to form the Amazon, because of another of his wishes—to perform medical mission work.

"I've had a lifelong desire to see the Amazon and help people who needed care," the 55-year-old Pflum told the JAMA reporter who accompanied him. "I also wanted to provide knowledge to physicians who weren't lucky enough to be born in a country with all the equipment we have."

Pflum's journey to the edge of the Amazon began last year in San Francisco, where he attended a scientific meeting and came across the exhibition booth of Health Volunteers Overseas (HVO) (see Table 2). A private, nonprofit organization "dedicated to improving the availability and quality of health care in developing countries through training and education," HVO had a program for orthopedic surgeons to serve 2-week missions in Peru.

Pflum signed up and found himself flying down to Lima, Peru's capital of 7,000,000 residents, where he was met by Gaston Barnechea, MD, an orthopedic surgeon and HVO's liaison in the country. Barnechea has a private practice but sees most of his patients through EsSalud, the Peruvian national health plan that covers certain types of workers and their families, about 25% of the nation's 26 million people.

Barnechea is a tireless worker dedicated to improving the health care system in Peru by bringing volunteer physicians from the United States to train local EsSalud physicians. These Peruvian practitioners then go on to train others after the volunteers leave.

"I'm playing pool, making balls bounce," Barnechea said, explaining his methods.

He also insists that the volunteers write letters to the leaders of EsSalud, noting which supplies and equipment are lacking at the various hospitals in their system. Barnechea hopes letters from US physicians will reiterate the needs claimed by physicians working in EsSalud hospitals.

"Gaston is a natural politician," Pflum said of the efforts.

It was important for Pflum to work in Iquitos because EsSalud is a referral-based system with most of the complex cases being treated at one of the five "level 4" hospitals centered in Lima and a few other cities. Level 4 hospitals are Peruvian state-of-the-art facilities.

Technically, procedures such as hip prostheses and total joint replacements should be done only at level 4 hospitals and not at level 2 institutions such as the one in Iquitos, said Osweldo Pretell, MD, the hospital's director. The problem is that Iquitos is so isolated that it can be reached only by air or by boat travel up the Amazon, making referrals to Lima hospitals too costly for the cash-strapped system that bills the local hospital for patient care.

"We want our physicians to learn these procedures because, from an economic point of view, it costs us less money if we can solve these problems locally instead of sending them to Lima," Pretell said.

Finally, after 5 days in Lima teaching orthopedic surgeons the latest techniques in procedures such as arthroscopic knee surgery, Pflum flies to Iquitos on a Friday night and spends the weekend with Barnechea eating local delicacies such as paiche (a fish) and heart of palm. The two physicians also visit villages where natives sell their wares to tourists. The merchants complain when Pflum refuses to bargain and pays full price.

"I just can't haggle with people who have so little while I have so much," he says. "The quarter I could save is worth much more to them."

It is after that weekend that Pflum finds himself stuck in morning traffic on his way to set an 86-year-old woman's hip fracture. Iquitos is an active port town and traffic, made up mainly of motorcycles and minibuses, is stopped because trucks are entering the road after picking up cargo from the river ships. Finally, Pflum gets moving again, passes the naval base and food markets, and arrives at the 70-bed hospital.

Pflum keeps asking the English-speaking Barnechea about what equipment will be available and what prep work has been done to ready the patient. He meets Ricardo Campos, MD, who will assist and translate during the operation, then both physicians enter the surgical unit and begin to work.

Pflum is a bit concerned because the woman fractured her hip 12 days earlier, and some of the muscle may have atrophied and need to be removed. But that hasn't occurred, and the procedure is completed routinely.

Pflum spends the rest of the week operating and lecturing.

He learns some new techniques as well as teaching, and is reminded that the rest of the world operates differently than the United States.

"Most of the patients treated in EsSalud hospitals have jobs, but they can lose those jobs if they're laid up," Pflum said. "So a lot of the outcomes are compromised because they go back to work before they fully heal. You have to modify the surgery to fit their economic needs and lifestyles. We in the United States have a lot of money for rehabilitation, and time isn't as important to us as it is to them."

Pflum also enjoyed teaching and sharing his knowledge with his Peruvian colleagues.

"They would be doing something that most of us had not done for 20 years, so the things we take sort of for granted they find new and novel," he said. "The physicians were very anxious to learn."

But Pflum also gained from the first-time experience.

"I went into medicine to be appreciated for doing a service and not to be a technician just doing a job," he said. "In the US, many times patients pay the bill and don't even say anything. The physicians and the patients in Peru show appreciation for the services you provide."

Once his medical work was completed, Pflum spent the following weekend taking a journey down the Amazon fulfilling his other lifelong dream: to see the sights along the storied river. He highly recommends the entire experience.

"This revitalized me," he said. I'm happier now.

The refugees I worked with were so kind and caring toward each other, so willing to help, they taught me that humanity can survive in such a situation," Mary Lightfine, RN, an emergency room nurse from Florida who worked as a volunteer with Doctors Without Borders (Médecins Sans Frontières) in the northern Macedonian camp of Cegrane, recounted recently.

A seasoned volunteer, Lightfine has worked in war zones around the globe, including Somalia, where she was shot at, threatened, and held at gunpoint. She arrived in Skopje, Macedonia, aboard a 23-year-old cargo plane on April 8 and spent several days in different camps, including Brazda and Raduchia, and then moved on to Cegrane, where she helped set up the medical program and staff the clinic. She said many of the people who live in the village of Cegrane are ethnic Albanians, as were the fleeing Kosovars, and they were very receptive to the refugees.

The locals and refugees were eager to volunteer to work in the clinic, said Lightfine. In some ways, the kindness of the refugees made the work more difficult, she said, because, through the translator, she heard such sad stories from them and felt how horrible it was that the war had happened to such nice people. "The more stories they told, the more I could envision their villages, their lives," she said.

The traumatic stories also indicated how important mental health services were and will be for people who experienced human rights violations, such as forced expulsions, separation from family members, and witnessing destruction and murder.

In addition to patients with psychological stress, Lightfine saw manypatients with chronic illnesses, such as high blood pressure and diabetes, who needed medication. There were patients who were receiving dialysis, patients with cancer who had been receiving morphine regularly, and patients with indwelling catheters. She saw patients arriving on stretchers from nursing homes and hospitals, which were emptied out when the crisis began.

Drew Fuller, MD, a volunteer who worked in the Senekos camp, another northern Macedonian camp run by Doctors of the World, said he, too, was impressed by the dignity of the Kosovars he worked with and treated. "What stood out most was how people could go through such a tragedy, endure such great losses, yet maintain their humanity," he said.

Fuller, an emergency physician in the Baltimore area, said a strong desire to participate in international health activities and an advertisement Doctors of the World (see Table 2) placed in JAMA led him to lend his services to the effort in the Balkans. When he arrived in late April, he said, only about 2000 refugees were in the camp, but by the time he left in mid May, the numbers had ballooned to around 9000. He remarked that the calm mood of the camp, where children played ball and jumped rope and people socialized in tents, stood out against the backdrop of airplanes buzzing overhead and bombs exploding just over the border.

Working in the camp's clinic, Fuller said he saw a relatively healthy population who came in primarily for upper respiratory infections and, in children, diarrhea. "I really did feel that everybody in the camp rotated through the clinic at least once," said Fuller. He noted that many of the people needed to tell their stories, which they did through interpreters. Fuller said the experience emphasized the point that it is his job as a physician "to cure when I can but to comfort always."

Lisa Adams, MD, a physician who worked for a number of years in Kosovo and who is now on the advisory council and board of directors of Doctors Without Borders, said the willingness to listen to these patients is important. When she talks to volunteers preparing to work in the refugee camps, she stresses that many of the patients they will be treating will have experienced terrible traumas, but because they are from a stoic culture, they are not going to come into the clinic just to talk about what happened to them. Instead, they may come in with minor complaints, such as back or knee pain, and then begin to talk. Volunteers should be willing to spend time with these people and let them talk, she said.

Having served as medical and project director of a tuberculosis program run by Doctors of the World in Kosovo from September 1994 until December 1996, and also being of Albanian descent, Adams is familiar with the region, its people, and the historical background against which the recent crisis occurred. Although she was not able to return to Kosovo this spring, she was there in March 1998 when ethnic Albanian Kosovars were fleeing to protected areas in the country after the Serbian military began its first round of massacres in the Drenica region.

At that time, Adams said, she felt that commitment to the nonviolent resistance movement, which Kosovars had been following for 9 years, was fraying. "People were starting to say ‘I'm ready to die for my country because this is no way for my children to be living.'"

The plan for the next few months, said Adams, is to keep the Senekos camp open and 24-hour medical services available until the last refugee has left. One of the most important issues for humanitarian organizations, she said, is to develop mental health programs that offer help to refugees returning to a country irrevocably altered. "I really do feel that part of the mental health issue is rage," she said. "While this is a normal human emotion, there need to be outlets that allow people to cope with this.

"Memory can redeem the past, it can transfigure history, however painful, into another pattern."—T. S. Eliot, Four Quartets

Chicago—Escaping a homeland poisoned by war and ethnic cleansing, Bosnian refugees arrived in the United States in the early 1990s to forge new lives. But not all terrors were left behind. Concealed amid their few belongings were traumatic memories of displacement, combat, concentration camps, and rape.

In the wake of such horrific experiences, survivors need access to adequate mental health services, but care must fit the people's needs and circumstances, said Stevan Weine, MD, a professor of psychiatry at the University of Illinois at Chicago College of Medicine. Much remains to be learned about ways to help people who've been through such terrible experiences, he added.

Weine has delivered mental health services in collaboration with the Heartland Alliance to Bosnian refugees in Chicago for 4 years. A city with a large immigrant population and a well-developed infrastructure for refugee resettlement, Chicago is home to about 16,000 Bosnians. Through the Project on Genocide, Psychiatry, and Witnessing, which Weine cofounded with Croatian-American psychiatrist Ivan Pavkovic, MD, he conducts research to explore new ways of providing help to this refugee population. And as Kosovar refugees begin to arrive in Chicago, his group is preparing to provide services tailored to their needs.

Evidence from his work with Bosnian refugees suggests that two out of three are suffering from the mental health consequences of trauma, said Weine, but only about 8% of Bosnians in Chicago have sought out services. "While we were able to help people who came in for help, we were struck by all the barriers that kept refugees from coming into a clinic."

The challenge is to address the needs of refugees who are suffering but not seeking services, those unwilling to be identified as patients. said Weine. To do this, he and his colleagues focused on the social realities of Bosnian life. They are now working within the context of families and communities to make the families stronger.

Because Bosnians faced with a problem turn to their families to solve the issue rather than seek out psychiatric services, he said, "Making the family, rather than the individual, the central focus of intervention seemed to make sense."

In this population, the problem with an exclusively clinic-based approach, focusing on the individual, said Weine, "is that it makes the assumption that individuals come to us because they are distressed or have a mental health problem. There is a lot of stigma attached to that for everyone, but this is especially true for Bosnians. We proposed to develop and study an intervention with Bosnian families that would fit this different way of thinking." By focusing on the family as a target of intervention, Weine's group places greater emphasis on supporting family strengths than on identifying individuals with disorders.

This research is being carried out through a project called CAFES: Coffee and Family Education and Support for Bosnian Families, which is funded by a grant from the National Institute of Mental Health. CAFES is not family therapy but a structured discussion group aimed at building on family strengths. A CAFES group consists of a half-dozen Bosnian families who meet informally for nine sessions over a 15-week span. The program encourages greater communication within the family and also helps families connect with other refugee families, said Weine. The CAFES program helps address issues of preventing problems and access to services. Families who participate learn about the possible psychological consequences of living through the experience of war and genocide and will also get information about mental health services.

While the program is not intended to replace other kinds of mental health services for refugees, it is an important addition. Weine emphasized that refugee families are "healthy families who have passed through hell," and said similar work has been done with multifamily support groups for patients with cancer, chronic illnesses, and other adversities that can devastate a normally functioning family.

Aida Mujagic is a Bosnian who recruits families to participate in the CAFES project and also serves as a facilitator in the groups. She said the response to the meetings has been positive, and members are pleased to have a place to come and talk about their insecurities about being in this country and trauma they suffered in the war.

In the first group she worked with, Mujagic said, by the end of the sessions most members realized they could benefit from mental health or other health services. "One woman who had a stroke knew a lot about health services and she helped others find services to meet their health needs." Members of this group, who were initially unemployed, also helped each other find jobs. By the end of the 15 weeks of meetings, everyone was employed.

Although many Kosovar refugees taken in by neighboring European countries are returning home now that the bombing has stopped, those who journeyed to the United States may remain in this country for a number of reasons, said Weine. Not only have these refugees traveled a greater distance, they have been offered the opportunity to resettle here permanently.

Kosovar refugees have had similar experiences and have many of the same mental health issues as Bosnian refugees, said Weine, and organizations working with this group face comparable challenges in terms of access barriers and of making services relevant to needs. But the groups are far from identical, said Weine, and it will be important to understand what their needs, problems, and strengths are in order to help them.

To gain insight, Weine went to Germany a few weeks ago to interview more than a dozen Kosovar families and conduct ethnographic and testimonial interviews, something he has done with Bosnian refugees.

From these interviews Weine learned that family ties among Kosovars are as strong as those of the Bosnians. "People, especially from the country, are part of large clans where you have three or four nuclear families, with three or four generations, combined," he said. "One man is the head of the clan. They tend to be gender-rigid and authoritarian. If you want to do anything in that family you have to talk to the head. He's the arbitrator of what anyone in the family does with anyone outside the family." He said that while Kosovar families were very friendly and willing to talk, it was clear that the head man was in control.

This situation has many implications for delivery of services, said Weine. "You have to negotiate with the clan leader—or in a nuclear family, the head of the family—and explain to them in a very straight way what you're interested in doing, how you think you can help. If you skip that step, you're going to hit a wall."

Weine's group is learning about the needs of Kosovar refugees in this country by sending trained personnel into Chicago communities to meet with newly arriving Kosovar families. Dzana Huseni, RN, a psychiatric nurse born in Bosnia to Kosovar parents, has visited several Kosovar families who have recently arrived in Chicago. Because she is also a refugee, she said she knows how they feel.

As she listens to these families, she hears that many are undecided about whether they will stay in this country or go back to Kosovo. "They are depressed and traumatized." Some have missing family members and they do not know whether they are alive or dead. Huseni said that because the Albanian Kosovars "are not like American people who can talk in front of other people about their problems," it seems better at this point to work with individual families alone instead of in groups. "Maybe after they feel a little bit better, we can work in the groups with them, but not now because they are not so open."

An important component of Weine's refugee work involves helping survivors of violence process their stories of trauma through the psychotherapeutic technique of testimony therapy. Not only can this method contribute to an individual's recovery, it is also a means of bearing witness to the historical and social realities of political violence.

In his book of narrative nonfiction, When History Is a Nightmare: Lives and Memories of Ethnic Cleansing in Bosnia-Herzegovina, which will be published this month by Rutgers University Press, Weine looks at the role testimony can play in helping society and the individual deal with collective memories of trauma. His book also explores the Bosnian value of merhamet, meaning forgiveness or generosity, which provided a glue that held society together but was not enough to protect them from the violence of Serbian nationalists.

The importance of addressing issues of collective memory can be illustrated by what happened in Bosnia after World War II, said Weine. "In Bosnia, every family has memories of somebody being killed or surviving atrocities from World War II, but after the war in Tito's Yugoslavia people were not permitted to talk about these memories except in a very narrow, state-scripted way. While it is true that Serbs, Croats, and Muslims lived together and were neighbors and friends, I make the argument in the book that there was a great silence at the center of this experience of living together."

What this means, he said, is that the society did not meaningfully process the memories of atrocities during World War II, nor did it develop the structures of public life that would help a society contain and deal with those kinds of memories and resist nationalistic attitudes.

Documenting the stories of the Bosnians and Kosovars will provide an important human record of a defining experience of their cultures, said Weine. It also may help survivors realize the risk intolerance carries for hate and vengeance, since, he notes, "we know that today's victims are always at risk of becoming tomorrow's aggressors. We want to help survivors contain and absorb these memories within the context of becoming a peaceful and democratic open society and not tomorrow's nationalists, tomorrow's crisis.