Voluntourism and Global Health: Preparing Dental Students for Responsible Engagement in International Programs

Voluntourism and Unintended Consequences

Voluntourism, an emerging trend in international volunteering, is defined as a combination of volunteering and tourism.⁷ Mission trips, outreach expeditions, and other short-term (several weeks or less) global health-related activities fall under this definition. Oftentimes, such trips are expensive for students, and agencies taking care of practical arrangements charge significant fees. A variety of factors may motivate students to participate in voluntourism, including previous international travel and increased media coverage on global health issues.¹ Being aware that many populations lack access to adequate oral health care or that it is expensive and unaffordable for many in need also encourages some students to make a contribution by addressing these inequalities.^8–10 As dentistry has a long tradition of volunteering, students may simply have a desire to give back,^1,8 inspired by the charitable history of the profession.¹⁰

Additionally, students may be seeking adventure and exposure to new and exciting encounters. They may expect that voluntourism will combine excitement and the opportunity to address oral health needs, an experience they may feel will bolster their resumes. Despite positive intentions, these motivations are extremely short-sighted, are mostly fulfilling self-interests, and are violating principles of professionalism. These include adhering to the principle of doing no harm, patient autonomy, using sound clinical judgment, and practicing within one’s scope and level of training.¹¹ A growing amount of evidence demonstrates that all too often the intentions of volunteers do not match their impact on the local communities they visit. The nature of such activities does not provide adequate time to ensure alignment with the local health care system or for students to develop a deeper understanding of their host community’s resources, needs, and expectations. Frequently, the sending organizations also lack planning, preparation, and a proper strategy for integration with the local health care system.^10,12 Due to lack of broader understanding and knowledge of basic public health principles, volunteers may not see the dangers that lie in their activities.

The provision of service from high-income to low-income (or low-resource) countries often competes against rather than compliments the host community’s health system, which is often fragile and weak. Donating technologies, services, and materials that a community cannot procure or sustain on its own creates unrealistic expectations, promotes dependence,¹³ and fails to address the cause of the problems. Furthermore, it may even devalue current practices being conducted¹⁴ or negatively impact the income of local providers.³ As a consequence, a number of governments, such as Guatemala for example, make it illegal for foreign NGOs to implement programs without government coordination and alignment in an attempt to avoid duplication, contradictory efforts, and wasted resources. Unfortunately, a number of NGOs continue to practice illegally, often unknowingly, due to lack of awareness of local policies and practices.³

Additionally, voluntourism is limited to short-term and sporadic treatments—i.e., “band-aid” approaches—rather than investing the time necessary to address the underlying causes of the problems.^3,15 One example might be childhood caries treatment and extraction camps in areas without access to healthy foods low in sugar, not to mention clean water with appropriate levels of fluoride. The focus on curative and emergency care alone neglects the important determinants and risk factors of oral diseases and often fails to include preventive activities and long-term capacity building, including community-based mechanisms such as appropriately designed school programs integrated with other hygiene-related programs and advocacy for healthy public policies in all government sectors.^3,16 Such efforts are thus not sustainable, meaning once the volunteers leave, the efforts cannot be maintained. Furthermore, there are simply not enough volunteers worldwide to adequately address the oral health disparities that exist.^15,16 The cycle of voluntourism based on clinical treatment “missions” keeps communities dependent on charitable donations, often impeding their progress and chances for development in the long run.¹³

Principles of Global Health

Although a variety of definitions exist, there is growing consensus on the meaning of global health and several guiding principles. The World Health Organization (WHO) defines health as a “state of complete physical, mental, and social well-being and not merely the absence of disease.”¹⁷ Based on this definition, global health refers to the “scope of problems, not their location,” meaning global health addresses local determinants of health and disease as well as those that cross national boundaries.¹⁸ The guiding principles of global health include the underlying, upstream, common risk factors for disease,^15,19 allowing for the fusion of population-based prevention and individual patient care.⁵ Also, they encompass collaboration with local community partners through a social contract^11,19 when designing and implementing an intervention, as well as taking a multidisciplinary approach to incorporate not only health but also education, economics, and politics.^{5,15,18,20,21} By operating under these guiding principles, the aims of any global health-related activity are not determined by merely being based in an international locale or a low income region, but rather address health through ethical soundness, sustainability, local empowerment and leadership, and evidence-based, prevention-oriented approaches²¹ wherever the needs are located.

Voluntourism contradicts many if not all of these principles, so students must be encouraged to critically reflect on global health activities so they learn how to avoid the unintended consequences of voluntourism. A sole motivation for adventure and travel should be discouraged altogether; rather, motivations should be cultivated to align with the above principles of global health. This can be done largely through defining global health objectives and subsequent curriculum development. This approach is not new, even in dental programs,²² and many schools have implemented educational activities.⁵ However, the trend towards dental voluntourism is still on the rise. We believe that a disconnect exists between curriculum objectives and impact of actual engagement of students in global health-related activities.

Most likely, the explanation for this disconnect is that students pursuing voluntourism are in clinical training programs designed around treatment-centered competencies and board examinations focused on patient-based approaches. Dental programs are training students to become competent in traditional clinical skills, such as examination, diagnosis, and treatment of the individual patient. It is, therefore, not surprising that students are most comfortable with service- and treatment-oriented activities that are in line with their training.⁸ Educators need to facilitate the required switch from patient-centered background care, which is the major part of the dental curriculum, towards a culturally relevant, population-centered way of thinking. Students must be given a mechanism they can use to connect their patient-oriented mind frame to a population-based approach, focusing their ambitions on a more reflective and critical evaluation of volunteering. Such an approach will allow students to better match their global health-related motivations and interests with the objectives of global health.

With these problematic areas in mind, it should be noted that there are numerous positive effects on students as a result of working abroad.¹⁰ These include, among others, an improvement in skill level, greater cultural sensitivity, and a deeper appreciation for public health issues.²³ While these benefits have been reported for students, more research is needed to determine if the programs are having long-term positive effects on the communities visited.

Pilot Workshop on Ethical Volunteering in Global Health

In spring 2012, in conjunction with a leadership course in dental ethics and as part of the emerging global health curriculum, Harvard School of Dental Medicine developed and piloted a Workshop for Ethical Volunteering in Global Health. The workshop was designed as a discussion-based, interactive program that included lectures, small-group activities, and personal reflection. It focused on volunteering according to global health principles in any location, whether locally or abroad. The aim of the workshop was to provide students with a systematic approach to ethical volunteering, providing ways for them to critically reflect on motivation and attitudes related to traditional models of volunteering and facilitating alignment with principles of global health. The workshop was mandatory for all third-year dental students. The objectives are outlined in Table 1. The workshop compelled students to reflect on and think critically about factors that should be known about a community prior to undergoing any activity, especially in the form of voluntourism. The workshop also addressed how to avoid possible unintended negative impacts and included overarching themes such as sustainability and local empowerment.

Students participated in an anonymous, written survey at the start and close of the workshop. Results were then compared in order to track the impact of workshop messages. Students were asked to rate the importance of various components of volunteering on a scale from 1 to 5 (1=not important, 2=somewhat important, 3=important, 4=very important, 5=extremely important). Volunteer work components on the survey consisted of the following: A) bringing donated supplies; B) providing hands-on emergency clinical care; C) seeing as many patients as possible; D) providing oral health education; E) providing preventive measures such as fluoride; F) working with the local government; G) participating long term (more than a few weeks); H) volunteering with a well-established organization; and I) learning all about the community, including local customs and culture. We considered components A, B, and C as conventional, more traditional components of dental volunteering similar to voluntourism. Components D and E were also considered conventional but could be included in new volunteering models if done as part of ongoing efforts. Components F, G, H, and I were considered the new standard for ethical volunteering in global health. These considerations were not directly communicated to students when the surveys were distributed, but rather were conveyed through the workshop learning objectives.

Thirty students submitted surveys, both before and after the workshop, that were evaluated for this study. Ordinal data scores were compiled and weighted according to frequency distribution and magnitude. Numerical summary measures for the volunteer components addressed in the workshop are shown in Table 2. This study was assigned CHS number M22633-101 and was granted the status of exempt by the Harvard Medical School Human Subjects Institutional Review Board. According to the survey results, 97 percent of the students reported that they were very likely or extremely likely to volunteer in the future, whether locally or abroad. After workshop participation, the mean scores of importance for all conventional concepts decreased, and the mean scores of importance for all new components increased. All of the students reported that the workshop influenced the way they viewed volunteering in dentistry.