Working With International Populations – Abroad or in Your Own Backyard
Finding the right path to pursue international health care requires answering the right questions and choosing the right partners.
Fam Pract Manag. 2013 Sep-Oct;20(5):27-30.
Author disclosures: no relevant financial affiliations disclosed.
Throughout their careers, many family physicians may have an opportunity to exercise their interest in global health by getting away from their current practice lives, if only for a short period of time, and practicing elsewhere. They may be nudged on by a new generation of students and residents, many of whom already have had considerable experience working and traveling in other countries and are looking to carry on with these activities during their medical training. For some this may mean a week, a month, or a year or more working outside of the United States. For many others, the logistics of their lives may be too complicated to allow travel overseas, but travel closer to home may be possible. With more than 25 years' combined experience in international health, we will explore in this article some of the many ways you can pursue your interest in working with needy populations, at home and abroad.
You may first need to answer some very practical questions:
Do personal circumstances and timing allow me to leave the country to work internationally and, if so, for how long?
If I can't leave, would engaging in health issues domestically – whether locally or elsewhere in the country – fulfill my desire to be involved?
What are my goals, and how will I know that my volunteerism is worthwhile?
Will I go with an organization or organize the trip on my own?
Who will cover my practice and other work obligations?
When doing global medicine work, there are several issues to carefully consider.
The ethics of medical work in other countries. As you consider working overseas, consider also the ethical issues that have been raised about the potential effects of short-term volunteerism, including inadequate follow-up, insufficient involvement of local health providers, insufficient involvement of the local community, little to no attention to local needs or the community's perception of its needs, and providing care that you are not licensed to provide in your home country. In addition, if you plan to take pharmaceuticals with you, check with the local authorities to find out the rules on bringing medication into the country and avoid taking medications that are expired or will expire shortly after arrival. Short-term medical trips can certainly fill a gap in global health, but you must proceed carefully to avoid causing more harm than good.
Your willingness to be a learner. There is no question that you have practical and technical knowledge to offer. But you still need to recognize that you are in a different environment and culture and will likely need to adapt your approach from what you do at home. One of your goals for your trip should be learning from local health care professionals, because this will help you connect with them, show respect for what they are doing, and recognize their experience and expertise.
The like-mindedness of your team. If you decide to join a team, make sure the group's mission is compatible with your own goals, if not beliefs. For example, check to see whether they are working on sustainability, working closely with leaders in the community, and attempting to contribute to long-lasting change. If you are planning a trip with a faith-based organization, it may be important to you – and them – to share their religious beliefs, and be aware that many groups proselytize along with their health care activities. The group's religious affiliation may be particularly important when it comes to activities such as reproductive health and HIV prevention.
Consider the following issues as you plan your trip:
Finding time. Finding the time to go is often the biggest challenge for practicing health care professionals. One option is to use vacation time. Another is to negotiate time for global health efforts into your contract before you start working. If your institution allows it, you could also use your CME time or take leave without pay.
Establishing cross coverage. If you intend to go on multiple trips a year or spend a prolonged time working abroad, make sure your supervisor and colleagues support your decision so that you can negotiate your schedule and the care of your patients while you are gone. You may have to see more patients while you are in town to offset the revenue lost while you are away or take calls more frequently to compensate for the time you will be unavailable.
Finding a group. It is unquestionably easier to join an existing team, especially when traveling for the first time, than to organize a trip yourself. Organizations with long-term experience in organizing and carrying out international medical trips will help you with logistics, lodging, documentation, and certifications. They will also have experience with medical evacuation and insurance should the need arise.
There are plenty of organizations to choose from, but finding the right one for you will require some homework on your part, depending on the kind of work you are interested in, the geographic location, and the time of year. Start your inquiries about a year in advance.
For international trips, consider the following:
Where, geographically, do you want to work?
When do you want to go? (What time of year?)
For how long? Short term (two to three weeks), longer term (one to six months), or a year or more?
What type of work (humanitarian, development, public health, clinical, teaching, human rights) do you want to do?
How much money can you spend? And where will the funding come from (personal funds, donations, fund raising, stipend)?
To find a trip that fits with your answers to these questions, you can consult a variety of sources, including globe-trotting colleagues, local residency programs with global health tracks (including your alma mater), local academic medical centers, faith-based organizations, and others. See the list below.
If you have a heart for a particular country and can't find an organization that serves that area, you can always create your own path and organize a trip yourself. This is much more difficult and hazardous, however, as you must establish contacts ahead of time in the country and identify health personnel who will be able to help with planning, preparations, and patient follow-up. You will also have to navigate issues related to accommodations and transportation, security, license requirements, necessary resources to bring, interpreter assistance, and getting oriented to the community and its needs.
More detailed recommendations on how to prepare for overseas work and what to expect when you get there, especially in developing countries, are available in the article “Practical Realities of Working in the Developing World.” A travel checklist can be downloaded here: travel checklist.
Global health in your backyard
For those who cannot go abroad, there are many opportunities in your own communities to care for populations with backgrounds, needs, and challenges similar to those found overseas. Your local community health center may be the best place to start. Here are some other options to consider:
WHERE TO LOOK FOR GLOBAL HEALTH OPPORTUNITIES
SPECIALTY SOCIETY RESOURCES
CRISIS RESPONSE ORGANIZATIONS
GLOBAL HEALTH CONFERENCES OR NETWORKING OPPORTUNITIES
Volunteer at a local refugee clinic. Refugees are people forced out of their own country due to war or persecution for political, ethnic, or religious reasons. In 2012, more than 58,000 new refugees arrived in the United States and were resettled in communities across the country.1 You can easily make a connection with refugee clinics in your state by contacting your state's refugee health coordinator. You can also search the web to find other nongovernmental organizations that are involved with refugee and immigrant work.
Volunteer to work with migrant farmworkers. More than 70 percent of farmworkers are foreign-born, and most are from Mexico.2 Their jobs involve hard physical labor, use of dangerous equipment, and regular exposure to harmful pesticides.3 Health centers throughout the country receive funding from the federal government to provide care to migrant workers. Information about medical work with migrant farmworkers can be found here:
For a list of some migrant worker health clinics by state see http://bit.ly/LAeIET.
Volunteer at an American Indian reservation. The Indian Health Service (IHS), part of the U.S. Department of Health & Human Services, is in charge of providing medical and public health care to members of Native American and Alaskan tribes. IHS hospitals and clinics, in 35 states, serve nearly 2 million individuals. Long- and short-term opportunities to work in one of these settings can be found here.
Become a civil surgeon. Civil surgeons are physicians who have been designated by the U.S. Citizenship and Immigration Services to conduct mandatory immigration medical examinations for refugees according to specific Centers for Disease Control and Prevention guidelines. This is not a volunteer position, and civil surgeons may get paid for their services by the clients or patients they serve. Applicants must be licensed and authorized to work in the United States, be an MD or DO, and have at least four years of professional experience post-residency. Information on becoming a civil surgeon can be obtained here.
Provide asylum medical evaluations. Several organizations have established provider networks to conduct medical evaluations and provide documentation of torture and ill treatment of men and women from troubled spots of the world who are seeking asylum in the United States. Asylum evaluations can be time-consuming, but they are also extremely rewarding. Some organizations offer periodic training. For more information, see Physicians for Human Rights and HealthRight International.
The rewards for spending time in other parts of the world or for working with immigrants, refugees, and asylees domestically are often very different from what you may expect. As anyone who has worked overseas or with diverse populations can attest, the benefits often go beyond just assisting the local population. You will likely learn your strengths and weaknesses, appreciate your limits, test your ability to be flexible and open-minded, and re-examine your short- and long-term goals. You may learn to both appreciate and criticize the U.S. medical system, recognize humanity's resilience, and acknowledge the need for all of us to care and be cared for. You may discover that you can recharge your caring batteries through a challenging experience in a way you had not imagined.
1. FY2012 Refugee Admission Statistics. U.S. Department of State. http://www.state.gov/j/prm/releases/statistics/206319.htm. Accessed Aug. 19, 2013.
2. Findings from the National Agricultural Workers Survey (NAWS) 2001–2002. A Demographic and Employment Profile of United States Farm Workers. U.S. Department of Labor. March 2005.
3. Farmworkers in the United States. Migrant Health Promotion. http://www.migranthealth.org/index.php?option=com_content&view=article&id=38&Itemid=30. Accessed Aug. 19, 2013.
Copyright © 2013 by the American Academy of Family Physicians.
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