More than 150,000 people live in Cape Coast, Ghana. On any given day, most of them are out on the street frying donuts, balancing bowls of eggs on their heads, tending market stalls with neat stacks of biscuits and loaves of white bread piled high, and climbing in and out of crowded vans called tro-tros. On the second day of a two-week service-learning trip, two colleagues and I lead our University of Missouri students into the throng to join a group of traditional drummers and dancers who, trying their hand at health education, have invited the students to join them. The last-minute invitation was short on details but we accepted anyway, thinking that at the very least the students would learn something about Ghanaian culture. The ostensible theme of the program we are participating in is malaria and HIV prevention. The form the program takes is a parade.
We assemble on Rasta Row, so named after the dreadlocked proprietors who sell drums, clothing, and art to tourists in the shadow of Cape Coast Castle. On side streets, people are washing clothes or children, stirring cooking pots over open fires, lying on pallets outside shops, and stepping over open gutters and around free-roaming chickens and goats. Children run toward us, dragging younger siblings by the hand.
With the drummers and dancers—one in a bright orange wig—at the head of the loud procession, we begin to make our way toward the center of town. Children run up and grab the hands of our 25 jet-lagged undergraduates, who are studying health sciences, nursing, human development, and journalism. All of the students belong to a cohort—dubbed the “Millennial Generation”1—for whom Facebook and YouTube are tools of daily life rather than miracles. Although many have never been outside Missouri before, technology has given them a sense of the world as an ever-shrinking place, and they are eager to make their impact. According to the Pew Research Center, technology has also made them inclined to reach for “quick-fix information nuggets.”1 I lead short-term service-learning trips in part to counter that impulse. You may be able to ask Siri any outlandish question you can think of—what to do with a dead body, for example—and get a reasonable response, but global health problems are not so easily solved. Service-learning programs can benefit the cause of global health by providing opportunities for students to think deeply about the reasons for the disparities that they cannot fail to notice while abroad.
On this morning, however, our students are ready to begin educating. The idea that informing people about risky behaviors will lead them to change their behavior makes sense in developed countries like the United States, where the burden of disease tilts toward chronic conditions with identifiable behavioral risk factors. It also fits with a general belief among Americans in the power of individuals to control their own destiny.
However, the literature on the social determinants of health suggests that what people have (or don’t have) tends to trump what they know.2 In a rural village a few days later, the students are confronted with this fact. When a student suggests as part of her presentation that covering water will help keep it clean, a village elder asks, “How are we to cover the river when it is so large?”
Before I take students to another country to try to help change the health behaviors of people whose lives they know very little about, I ask them to name the top cause of death among people their age in the United States. They correctly identify motor vehicle crashes. I ask whether they are persuaded that talking on a cell phone while driving increases the risk of a crash, and they reply that they are. However, when I ask if they talk on the phone while driving anyway, almost all of them say yes. We then discuss how hard human behavior is to change, even with sound strategies and adequate resources.
Unfortunately, the drummers and dancers have neither. A local clinic treating erectile dysfunction has donated a stack of photocopied leaflets, which are given to the students to distribute along with a stack of glossy pamphlets on world population growth, also donated. These resources end up in the road or in the hands of children who pluck them from the ground like wildflowers.
Midway through the parade, a student pulls me aside to ask, “Is this even effective?”
If her question has to do with educating U.S. students about public health, the answer is yes. A Web site could never convey the importance of literacy with the urgency of the gentlemen asking a blushing nursing student to read the erectile dysfunction flyer to him over the sound of drumming.
However, the student asking the question is not thinking about her own education. What she means is, Will this activity prevent malaria and HIV?
Service-learning programs, particularly in Sub-Saharan Africa, are expanding rapidly because young people from the United States and other developed nations long to serve.3 Yet, even when these programs work with the more experienced nongovernmental organizations (NGOs), there is often a divergence between participating students’ expectations and their actual contributions—which in this case may turn out to be serving as the first step on the drummers’ and dancers’ path toward learning how to plan educational programs and manage volunteers. This mismatch, particularly in health-care-focused programs, has important implications for universities as they embrace the goal of educating global citizens.
In my view, the way to address this contradiction is to focus less on service and more on the student experience—specifically, to emphasize educating students in matters of health equity, universality, and the social and economic determinants of health. It is important to remember that providing health care is not similar to brick laying or ditch digging. Health care involves unique issues of human dignity, privacy, and equity.
While differences in resources and access require us to consider these issues particularly closely when students from the United States and other developed countries travel to developing countries, they also offer a starting point from which students can gain understanding of how such disparities affect health status around the world. It is for this reason I believe that medical, nursing, and other health professions students should be encouraged to spend time abroad learning public health, with an emphasis on the upstream social conditions that influence the health of future patients, rather than exclusively participating in clinical activities.
This may seem paradoxical. Why take health professions students to underresourced countries and have them focus on the things they don’t know, rather than contribute the things they do? In my view, an overemphasis on service too early in the education of a health care professional threatens to short-circuit the very learning that supports effective lifelong engagement in global health.
In the days that follow the parade, our students attend HIV-testing clinics set up by our regular NGO partners. The students’ role is to share information about prevention. One afternoon, though, a miscommunication results in a friendly Missouri undergraduate—not a nurse—delivering positive test results to a Ghanaian man about his own age.
In retrospect, it is not difficult to see how this occurred. I suspect that from the point of view of our Ghanaian partners, our students had more than enough formal education to assist in the short-handed environment of the rural clinic. Nor is it surprising that the student said “yes” when asked to help, despite his discomfort. How could he fail to see that many people in Cape Coast went to heroic lengths to address the needs of their community, with limited training and resources?
During that evening’s discussion, we ask the students to consider what basic services people are entitled to regardless of where and in what circumstances they live. Does insisting on developed-world standards for people living in developing countries merely ensure that no services will be offered to them? What value should a visitor place on community norms? How do you judge whether a community representative can speak for those at risk? In my mind, I add a further question: What is owed the Ghanaians who assume so much of the burden in educating these young Americans? In my view, the more profound the early learning that occurs on these trips, the greater the obligation of the sending institution to the communities in which the learning occurs.
We make it clear that the students should not deliver test results in the coming days, even if asked to by the NGO staff.
“Why not?” presses one student. I ask her to consider how she would feel walking into a clinic at home and getting the news that she’s HIV-positive from someone with her background and training. After a long moment, she replies, “Then what are we doing here?”
What I believe we are doing is raising that question and others like it with students who will perhaps go on to have careers in global health. We are digging deep into our own cultural and ethical assumptions for answers. While in Ghana, the students work in hot dusty fields, share bathrooms with intermittently working plumbing, eat unfamiliar foods, and get homesick. But it is during this evening discussion of ethics that another student reflects, “This is so much harder than I thought it was going to be.”
To ensure that the students’ struggle to learn is met with appropriate attention to the needs of the communities that they always find so hard to leave, I propose the following:
- Pretrip preparation for service-learning programs should include discussions of universality and equity. Students should understand that clinical duties they are not permitted to carry out in their home country are also prohibited abroad.
- Programs for medical, nursing, and other health professions students should devote a significant portion of the experience to activities that take place outside clinics and focus on the social and economic determinants of health status.
- Universities should acknowledge the limits of student service—and the role of local NGOs in educating students sent abroad—by contributing additional resources to aid in the development of local partners. These might include tuition credits or waivers for preceptors and/or assistance with research or training. Ideally, this would represent consistent support on the part of the university over an extended time.
At a temporary rural clinic a few days after our evening ethics discussion, an elderly man is diagnosed with hypertension and takes advantage of his time in the clinic’s plastic chair to detail the sorrows of his life. “There is no one to cook for me,” he says, “and I have no meat. All of my old-age friends are gone.” He does not mention that the nearest permanent clinic is depressingly remote, as is the money to pay for the medicine he now knows he requires. His needs go far beyond education about diet and exercise—they include access to health services, a financial safety net, and even well-maintained roads that he might travel to get to work or a clinic. These are precisely the kinds of things that many people in the United States seem increasingly disinclined to pay for, even at home, with serious consequences for the health of vulnerable populations. For students on this trip, some of whom may never leave the United States again, this experience—if it leads to insight into issues of equity and the social and economic determinants of health—should also inform their approach to U.S. health policy.
Missouri is still far away on our second morning in Cape Coast, however, and in an empty lot overlooking the sprawling city, the castle, and the sea, the parade pauses for a final dance. A handful of students see the ocean for the first time ever off the coast of Africa, and the sense of its vastness is just one of the things they will experience and learn in the days to come. They will learn that they can negotiate for a taxi ride, buy plantain chips through the window of a tro-tro, and survive for two weeks without constant access to the Internet. It is my hope that the question that drove so many of them to board the plane—What can I give?—will soon be joined in their minds and hearts by two further questions: How did this come to be? And, even more important, What ought I do?