We made it! Our first short-term healthcare missions trip. Triaging, examining, praying; we dispensed and filled hundreds of prescriptions. We were wonderful...
Then as we looked at the faces of the smiling children, we realized the next outbreak of flu or diarrhea could claim many of their lives. Were our efforts of any value in the grand picture? Were our short-term healthcare missions meeting the community's needs?
Dispensing thousands of dollars worth of pharmaceuticals in a community with limited health knowledge seemed a questionable practice. This led us to ask an important question: Can healthcare missions potentially be harmful to the communities we are called to serve? We began discussing healthcare missions with local providers, Peace Corps staff, and leaders in developing communities. Based on numerous case reports, we came to the realization that similar to healthcare in developed settings, there is great potential for harm from healthcare missions. The more we examined short-term healthcare missions, the more it became clear that not enough regard is given to patient safety.
We, in the medical/healthcare missions community, can rationalize our lack of regard for patient safety by saying some help is better than no help. However, this type of thinking has resulted in well-intentioned Christian healthcare teams contributing to complications and even deaths of children in developing communities. The following two cases are but two of many reported to the authors by local health workers and missionary staff in Central America. These cases demonstrate how the neglect of patient safety can have tragic consequences.
Case 1. A general healthcare team was serving a village community in Central America. Maria*, a 29-year-old mother of five, arrived at the clinic pharmacy to receive medications after having her entire family seen by one of the physicians. Maria had three prescriptions for herself, and each child received prescriptions for parasite medications and vitamins. In addition, three of the children were febrile; two had been diagnosed with otitis media, and one with strep pharyngitis. Each of them also received antipyretics (Tylenol) and antibiotics. Dosages were carefully explained to Maria—for the 12-year, 6-year, and 6-month-old children. Less than a week after the team left the country, Maria's 6-month-old child was brought to the public hospital with acute liver failure and died. Maria had mixed up the dosages of medication and had been overdosing her baby with acetaminophen.
Case 2. A hospital ship docked in a Central American country and performed surgeries daily; primary care clinics were conducted in the surrounding villages. The outreach continued for 3 months as scheduled without apparent problems. The ship left to serve in other countries and was planning to return to the first country in 12 months. After contacting the government to arrange for the ship's return, leaders were informed the ship and organization were barred from their country. The government explained two problems that occurred with the last outreach. First, medications were left with a nonlicensed village health worker. (One of the translators begged a physician for the medicine to help her people.) This resulted in the overdose of nonprescription cold medicine of a 5-year-old child. Second, when authorities inspected the medications left behind, many were past expiration date. The medications were short-dated and expired after the ship's departure. After diplomatic maneuvering the organization was able to return to work in the country.
UNDERSTANDING THE POTENTIAL FOR HARM
Unfortunately, common healthcare missions practices can be harmful. Physicians and nurses report obtaining sample medications or surplus unused medications from family, friends, and other patients, or purchasing medications in quantity from a pharmacy. They describe, "pill popping parties" (their words) to consolidate unit dose medications into plastic baggies that combine batch numbers and/or eliminated expiration dates. Furthermore, the mission outreach pharmacy can be considered a place where nonhealthcare personnel are assigned to package and dispense medications. Inadequately labeled plastic bags have been used in lieu of safe childproof containers in efforts to save money.
Many problems occur because short-term healthcare missions tend to be pharmacy-focused and pharmacy-driven. The mission team will set up in a church or school and with a truck load of pharmaceuticals. The entire community lines up for the clinic because of free care and medicines. Most come as family groups with mother and three to five children. Minor complaints often are treated with medication. Hence, one mother will receive multiple medications for each child and herself. Prescriptions are taken to the clinic "pharmacy" where nonhealthcare volunteers fill them under the oversight of a nurse or paramedic. Multiple medications for each child can be dispensed to the mother, who may have a second grade education or less. Verbal instructions for each medication are given through a translator, with a crowd of a hundred also waiting for medications and while the young mother is trying not to lose her five children. The multiple medications she receives for each child may be in plastic baggies. Handwritten instructions are included for each medication but the mother seldom is able to read so, she must rely on her memory as she uses the medications. She takes the multiple baggies to her one-room adobe home where there is no place to secure the medications from her children.
Local healthcare providers in developing countries report not enough thought is given to health education or helping the young mother develop strategies to maintain the health of her family in her complex life circumstances. Teams rarely know of, let alone receive training on World Health Organization (WHO) or United Nations Children's Fund (UNICEF) standards of practice for developing communities. Medical records are rarely kept; weights, heights, and immunization status of children are rarely documented. When this type of information is collected, few attempts are made to connect the data to local health systems or utilize data in long-term health programming efforts.
Medications are expensive, and the intent to be good stewards of resources is commendable; but there are double standards of care between what is practiced on short-term healthcare mission trips and legal practice in developed countries. WHO and other organizations have set some standards of practice for the donation and importation of pharmaceuticals and their use. Mission groups should follow these standards and obey host country laws related to importing pharmaceuticals.
Missionary physician Arnold Gorske, working with the Best Practices for Global Health Missions, has identified multiple reasons why patients are at much greater risk of serious harm from pharmaceuticals in the short-term missions (STM) setting (Table 1). A quick examination of these reasons brings the problems associated with pharmacy-driven missions into sharp focus. To avoid potentially tragic consequences from medication distribution in healthcare mission settings consider the following recommendations:
- Education before medication! Health education should be the focus rather than prescribing medications.
- Standards for patient safety that exist in developed countries must be applied in developing countries.
- Medications should be prescribed only when absolutely necessary and dispensed in child-safe containers. Attempt to limit the number of prescriptions for each family.
- Know and respect the country's pharmaceutical dispensary laws. Ideally a local pharmacist, or team pharmacist, should oversee the dispensing of medications.
- Medications need to be dispensed and instructions given by licensed personnel only (pharmacist, nurse, physician); unlicensed staff should never package, label, or dispense medications.
- Private pharmacy consultation areas should be established so medications can be dispensed and instructions given according to WHO standards.
- Know and adhere to the WHO/UNICEF standards of practice for child health in developing countries.
- The mother of children prescribed home medication must (for each child): verbalize the medication instructions, demonstrate measuring the dose of medication, and administer the first dose of the medication under the supervision of a licensed provider. Each child treated should have medication dosages labeled with each child's name and age along with instructions for administration.
- No expired medications should be taken into a country. This is unlawful and some countries have restrictions on the use of short-dated medications. Know country standards. Some countries send a health inspector to the airport to assure no medications coming in are less than 12 months from expiration.
- No sample or unlabeled medications should be used unless a complete dosing regimen can be given. Packaging should remain intact.
- A detailed inventory of pharmaceuticals (with expiration dates) and/or medical supplies should be with the healthcare team at all times. This facilitates customs transfers and can avoid potential legal problems.
- Surplus medications should never be left with unqualified/unlicensed healthcare personnel.
- Pharmaceuticals should be carefully secured throughout the mission.
- Never attempt to sneak medications into a country. This is punishable by imprisonment in most countries. Often, medications can be purchased at a very low cost in local pharmacies, which helps develop relationships with local pharmacists.
Many underdeveloped countries served by short-term healthcare missions have a different understanding of what causes disease and suffering. For animistic cultures, disease frequently is thought to be caused by broken relationships such as an offended ancestor or someone who has put a curse on the patient. In Hindu cultures, disease may be considered bad "karma." Some cultures see suffering as "God's will" and inevitable. Missions that practice healthcare from a western scientific worldview can be misinterpreted by the host culture as some sort of magic or interfering with destiny. What western cultures see as compassionate care and providing medicine may be interpreted as something totally different than intended.
Cultural beliefs can and often do impact a patient's understanding of pharmaceuticals. For example, more is better, so if a one pill helps, three pills should be more effective. The color and size of pills can be interpreted to disclose what the pills are for, such as red pills are for blood, small pills are for children, and big pills are for adults. In addition, instructions given from a western perspective may be interpreted entirely differently in another culture. Telling a patient to take a medication with meals could be very different from what we consider breakfast, lunch, and dinner times.
It is critical to assess whether the patient can read and comprehend instructions, and what the instructions mean to him or her. Because medicines are free or low cost, patients often deny they are taking any medicines or have medicines at home in order to be certain they will receive medicines from the clinic. Furthermore, the frequent use of traditional medicines (i.e., herbs, potions) increases the risk of adverse drug interactions. Finally, consider how treatment by a short-term provider can affect patients' relationships with their local provider, or how they may already be using the best drugs available in the community for their condition (Gorske, 2009).
THE PROMISE OF HEALTHCARE MISSIONS
Short-term healthcare missions hold significant promise to build capacity and help communities respond to their own health needs. We have only begun to explore the vast potential for short-term healthcare missions to engage in health education and prevention. Many causes of child mortality have proven sensitive to health education interventions. For example, studies show that better feeding practices alone could save 800,000 lives per year. Micronutrient supplementation has been shown to have notable impact on both long-term development and mortality of malnourished children in developing communities. Vitamin A supplementation can reduce mortality by up to 23%. Iron supplementation has been shown to impact child development over age 2, and zinc supplementation shown to reduce diarrhea incidence by 18% and pneumonia incidence by 41% (Vesel et al., 2009). Most short-term healthcare teams can provide parasite medications and vitamin supplementation. Presently, WHO recommends that vitamin A supplementation programs work alongside health promotion and communication activities (Hill, Kirkwood, & Edmond, 2004).
COMMUNITY HEALTH FAIRS
One of the most effective methods for delivery of health education is the community health fair. The community health fair is a model widely utilized by U.S. and Canadian public health departments. Health fair outreach is a balanced model implementing both health promotion and curative care components. Some common purposes are to promote health awareness, educate, and perform basic screenings and primary care. Health fairs can be open to all or be population specific, such as a children's or women's health fair. Organizations such as Health Education for Developing Communities, Hesperian Foundation, and Teaching Aids at Low Cost have teaching materials on the health, hygiene, and nutrition problems that plague developing communities. Many of these materials are open copyright and can be used to develop posters, presentations, and handouts.
York (2006) has identified key concepts for designing a successful health fair based on reemerging patterns found within the development and implementation of health fairs:
H—Help build a sense of community.
E—Educate families about child health and available resources.
A—Advocate for the health of children and families.
L—Listen to the needs of families and look for the support mechanisms within or around communities to meet the specified needs.
In developing communities support mechanisms may be limited. Often, however, there are more resources than is assumed by short-term volunteers. Local pastors, health workers, teachers, Peace Corp workers, and missionaries are excellent sources of information on what resources are available, and at what distance.
Important health fair components include the following:
Community health assessment
In their work on designing a successful health fair, Dillon and Sternas (1997) explained health fairs have two components: education and screening. In international health fairs there is a third intrinsic component: community assessment. Short-term healthcare missions frequently see an entire community or specific population group within that community. Health data gathered during a mission outreach can be invaluable in identifying needs and developing population-specific health strategies.
Growth monitoring and nutrition program
Regular charting of the weight and age of children on a graph is an important assessment tool for determining the level of malnutrition in a community. Such monitoring done on a regular basis can help to determine progress. Combined with appropriate nutrition education for the culture, this can be an effective means of improving the health of a community. Many books set forth teaching strategies to combat malnutrition in limited resource settings. This basic data should be gathered in all primary care outreach models along with health teaching.
Community health home visits
Home visits provide an opportunity to learn about living conditions in the local community. When safety permits, no greater opportunity for ministry and health teaching exists. Teams of three or four persons can be sent to each home in a community along with a local community health worker, missionary, and/or translator. Under their guidance, an assessment of living conditions, hygiene, nutrition, and socioeconomic circumstances can be undertaken. Weights, heights, and immunization data can be obtained for all children. This assessment data can be used by the community to develop strategies for physical and spiritual health. Many teams conclude their home visit with prayer for the family and the presentation of a family Bible.
Healthcare missions exist to facilitate and encourage physical, emotional, and spiritual health. As such, we must work to facilitate permanence and continuity of health services. God has blessed healthcare professionals with the knowledge to alleviate and prevent much suffering, but patient safety must not be neglected. God intends for us to use our abilities to care for the poor and underserved in a way that respects the human dignity of our patients and local healthcare providers. We recognize that God cares deeply for those he has called us to serve. They are created in his image, and deserve the very best there is to offer. Community health fairs may require more effort, planning, and coordination with local health systems, but a well-done health fair can represent some of the best help available.
- Best Practices in Global Health Missions—http://csthmbestpractices.org
- Health Education for Developing Communities—http://www.hepfdc.info/index.html
- Hesperian Foundation—http://www.hesperian.org
- TALC-Teaching Aids at Low Cost— http://www.talcuk.org
Dillon, D. L., & Sternas, K. (1997). Designing a successful health fair to promote individual, family, and community health. Journal of Community Health Nursing, 14
Gorske, A. (January, 2009). Why patients are at much greater risk of serious harm from drugs in the short-term missions (STM) setting
. Retrieved March 29, 2010, from http://csthmbestpractices.org/resources/Harm+from+Drugs+in+the+STM+Setting+Jan09.pdf
Hill, Z., Kirkwood, B., & Edmond, K. (2004). Family and community practices that promote child survival, growth and development: A review of the evidence
. Geneva: World Health Organization.
Vesel, L., Bahl, R., Martines, J., Penny, M., Bhandari, N., & Groupe, B. K. (2009). Infant malnutrition assessed using new WHO child growth standards and its relationship with mortality and exclusive breastfeeding. Publication: Bulletin of the World Health Organization
World Health Organization. (2005). Handbook: IMCI integrated management of childhood illness
. Geneva, Switzerland: Author.
York, K. (2006). Designing a child health fair. Nursing BC, 38
*Name of patient has been changed to protect identity