Ethics and Global Health Travel with Judith Lasker, PhD

• Dr. Murphy says Lasker’s book helped give Northwestern University the framework to develop an ethical approach to student and faculty global health travel when the Havey Institute for Global Health was first established.
• Lasker embarked on the research featured in her book after one of her students at Lehigh University expressed concern about whether or not short student trips to poor countries actually benefited the people in those countries.
• As part of her research for the book, Lasker asked staff and researchers in local countries what works and what doesn’t when outside people come to their communities on medical missions. She found that many of the local people feel trips less than three weeks are too short to make an impact and many students are not aware of local customs and languages.
• Other problems include: the expensive cost of short trips, issues with providing medication or care with little to no follow up and the legality of bringing prescription medications from the U.S. to give to people in other countries. She also says it is very difficult to measure whether or not people are helped by these trips. 
• She says before taking part in a trip you should look for red flags, such as programs that don’t require references, only payment for the journey. Lasker notes that trips that promise experiences not allowed in the U.S., such as participation in a surgery or assisting with a child birth should also be red flags. 
• Long-term partnerships with mutual, respectful goals should be key to any global health program, according to Lasker. Virtual training and collaboration with partners in poor-to-middle income countries is also a sustainable way to establish and grow these relationships.

Explore the Brocher Declaration from the Advocacy for Global Health Partnerships website.

Rob Murphy, MD [00:00:06] Welcome to the Explore Global Health podcast. I'm Dr Rob Murphy, executive director of the Harvey Institute for Global Health here at Northwestern University Feinberg School of Medicine. Today, we're talking about the differences between sustainable global health programs and volunteer fly-in medical missions and the kind of questions everyone traveling to another country to provide any type of health care should ask themselves before leaving home. Here to discuss this topic is Judith Lasker, Professor Emerita and sociology and anthropology and Health, Medicine and society at Lehigh University and author of Hoping to Help The Promises and Pitfalls of Global Health Volunteering. Judith's major area of interest are in the field of medical sociology, with particular emphasis on women's health issues and international health. I had the great pleasure of meeting Judith here in Chicago in 2018. She was one of our featured speakers at one of our global health events and subsequently she has started a group called Advocacy for Global Health Partnerships. You can learn more about that at Global Health Partnerships dot org. She's one of the founders of that group. Welcome, Judith. 

Judith Lasker, PhD [00:01:19] Thank you so much for inviting me. I had a wonderful visit back in 2018, and I've been happy to stay in touch with some people from Northwestern and admiring your institute from afar. 

Rob Murphy, MD [00:01:31] So I've been working internationally since the late 90s and I've lived abroad before for a couple of years a year in Germany and over a year in France. I've not lived in a low income country or middle income country, but in 2019, Dean Jameson, here at Northwestern, decided to corral in like, literally, I don't know, three or four dozen global programs of mostly very small and insignificant size and impact and put it into a center. They had found that groups of people were using the Northwestern 501c3 number to raise money. We had no idea what was going on. There were like 85 sites. And he said, I got to get a handle on this. And so I condensed it. We evaluated them. We supported the stronger ones and got rid of a lot of the weaker ones, and we tried to corral people into more sustainable thing. And then along in 2016 comes your book. And finally, something actually made sense to look at the science of this, the social science of this, and it just fit with what we're trying to do. But we didn't have the framework which you provided us. And that's why, you know, when you came in 2018, it was really important for us because soon after that, we advanced to institute level and grew really exponentially. And it's really been the foundation of our growth and our philosophy here at Northwestern to take this thing seriously. And the points that you bring up in this book just makes so much sense. And you gave us the data, the actual scientific argument to make these changes because there was a lot of pushback. A lot of people think, Oh, we're doing a great thing flying an entire ICU over to Kathmandu for seven days and leaving all the equipment there and stuff like that. It's been a rough go, but we've actually found that because of this approach that the students in particular that are doing this and we have one of the highest rates of students taking a foreign experience. It's one of the highest in the country, and we found that there were reviews of that activity are really high and it's one of the highlights of their medical school career. And so it paid off in kind of a soft way. I mean, it's hard to actually, you know, measure that, as you know, but it's really been important to us. I just wanted to thank you personally for doing this because it was really needed and we were we knew what we wanted to do, but we didn't know how to do it. And now I think we know how to do it. 

Judith Lasker, PhD [00:04:14] That is great to hear. I think the spark that got me started on this project, I had a student sitting in my office. I can picture her to this day, saying she had just come back. It was after vacation. Spent two weeks in Honduras on a trip where she had there were a few days of clinic and a few days of going to an orphanage and some tourism, and she said it was life-changing for her. One of the best things she ever did. She had no idea if it did any good for people in Honduras. That's sort of at the heart of what motivated me is that so many people are volunteering and want to help, but they often wonder, OK, did it make a difference? And you know, hardly anybody evaluates this, as you said. 

Rob Murphy, MD [00:04:58] It's not just students. Let me tell you, it's all sorts of people going over there. Oh yeah. 

Judith Lasker, PhD [00:05:04] Oh yeah, church. 

Rob Murphy, MD [00:05:05] Groups and I've been to Nigeria, probably well over 100 times. Wow. Yeah. I would say I know the country very well now, but it took really about 10 or 15 times to really settle in and really feel comfortable. And the people there being comfortable with me, they knew I would be coming back because I was coming back so much and that has made all the difference in the world and same thing in Mali, another country working very closely. And the group here at Northwestern, everybody has the country that they are most familiar with. But it's been a sustainable relationship and it's it's really paid off. 

Judith Lasker, PhD [00:05:45] That makes the difference. 

Rob Murphy, MD [00:05:47] Judith, you began your research career studying health care systems in Cote d'Ivoire in West Africa. Can you tell us about that experience and how it led you to a career, the career that you have today? Like how to it start? 

Judith Lasker, PhD [00:05:59] I think I went into my career of teaching, which included courses on global health with an understanding that whatever policy decisions are being made, whether it be in the U.S. or in Latin America or Asia, you know that they were often driven by the needs of people outside the country or people who had positions of power, rather than the needs of the people in the country. So that was just kind of a general perspective I learned from from working on my dissertation. But when I went into this project, it was really about just trying to answer that student's question Does this do any good? Because I was seeing so many students making these short trips and putting it on their resumes and talking about how wonderful it was and seeing that there was a huge amount being spent on these short term trips. You know, when I started, I didn't think about the environmental impact that became, you know, clear to me over time that all those trips were not necessarily good for the environment. But my real question was, are they good for the people hosting the volunteers and even the language that folks use, you know, when they talk about donors and recipients? It always seems like this one way stream of we help them. And I have seen the problems with that in our own local community and the change in the culture around. How do you do community service that it should not just be? Well, I know something more than you do. I'm well-off and educated, so I can tell you what to do, and I'll just come and do it without even thinking about, Well, what do people really need? So all of that kind of went into the mix, but I really wanted to get a sense of what works and what does it look like from the perspective of the people who are hosting, which is why it was very important to me to interview staff in host countries to say, What do you think? What are the problems? What are the good parts? What do you appreciate? What don't you appreciate? How would you make it different? Fully realizing that as an outsider, a white American outsider, for me to say, So what do you think about us outsiders coming in? People are very polite. So that is why my next step after the book was to have researchers from the countries asking the questions and yeah, the different. The answers are somewhat different. I did my best to find out what they wanted. And these are people who were working for organizations that organized trips, so they had a stake in it, a positive stake in it, and they saw many positive things. But when I would probe for OK, if you were organizing it, if you were doing this, how would you do it differently? And then I compare that to what I learned from my survey of American organizations who were organizing trips to see what their practices are, and there was a gap there. And I think that gap is important. I actually have an article with a one table and like a graphic that says, OK, what do people do? What is it that people in the host countries want? What are the very simple things is the typical trip is less than two weeks, and the whole staff was saying, you know, that's not enough. People just barely get oriented and then they leave and then we get a new group and have to start orienting them again. So they really wanted people to stay longer. One of the issues that's come up in my studies and I've seen it in other people's studies of how staff they really want to be respected for what they know. The idea that students or even very skilled specialist doctors would come to their communities and assume that they don't know anything that they haven't gotten lots of experience and expertise from working there for years. That attitude is probably the thing that bothers people the most. It's like, we're happy that you're here to help. We're happy to learn from you, but acknowledge that you can learn from us and that it's really a two way street, it's not a top down donor beneficiary. This is something that we're now seeing more and more in the literature on. This is the emphasis on mutual equal partnerships where each side learns from the other and appreciates the other for what they're teaching. So the students who go and who are oriented by local staff and who are shown around and have things explained to them and so forth, those local staff are teaching them and need to be acknowledged as teachers and knowledge providers in a way that has not been the case so much in the past. 

Rob Murphy, MD [00:10:47] The thing that kind of hit me over the head when I was at the beginning of this and I had the kind of your philosophy to start with. So, you know, I was getting input and I was training people to do all the work, and everything wasn't me just telling people what to do. But I started reading some of the local literature. That's local history anyway. And I had studied geography and history and everything and was like, Well, the British had this part of West Africa. The French white fathers came into this and it's like all started like around nineteen hundred. And when you read the African version, it's like there's all these other history that came. Then there was the European colonizers and then they got kicked out in the early 60s. Know, so it was very interesting seeing it from their perspective. But I certainly I certainly get it. And I think our discussion is really going in the direction of our next question was what did you actually see in the field to make you write hoping to help? 

Judith Lasker, PhD [00:11:52] I participated in two trips, which by no means makes me an expert. People like yourself who have traveled over and over and over again get to see a lot more than I did, but I was there as a participant observer. I participated, you know, I packed vitamins into the Ziploc bags and that kind of thing, but I was there to really watch. So I saw these incredibly enthusiastic visitors with talents and skills and really wanting to do good, but with no understanding of where they were or of the language. There's one story you may have heard me tell I was in Ecuador with a group and you know, we went to several different villages. You get on this bus and you pack up a lot of stuff and you arrive in the village and they've set up the community center as a place for the clinic. And all of these volunteers get off the bus and they take these heavy bins filled with equipment, and they march into the community center and they set up a clinic. You know, it's quite impressive, but there was a man standing at the door. Very modest. In his demeanor, nicely dressed, wearing a jacket, button down shirt, and he was saying something to the volunteers, each one who came in and they just walked right past him and ignored it because they had no idea that he was greeting them in the local language. So the fact that they had never been told this is what people speak this this who's in charge of this village? This is how you say hello in this language. Here's how you say thank you in this language. They were unknowingly rude. I mean, can you imagine somebody walking into your house and sort of barging by you and not acknowledging that you're there or that you're greeting them? I mean, you don't just don't treat hosts that way. And this is a guest host relationship. I think that image bothered me a lot. The idea that the team was only made up of the Americans and yet all the Ecuadorians who were helping us were somehow not part of the team, just that division. And you know, it's really hard when you're only doing this for a week to learn a language, to integrate with another group of people, of course. But those are things that I think could be addressed somewhat easily. So when I saw that kind of thing happening, I thought, you know, this could be better. A lot of what they're doing seems good. A lot of people are helped, but then we were spending a lot of money to help a limited number of people. And most importantly for me is we don't actually know whether they were helped, right? So when you read the reports of all these organizations that do overseas work and they say we helped three million people, some of them say that we helped 300000 people. All right. Well, maybe they saw some people, they saw a certain number of people and then they extrapolate to their family members or their community members, even if they just tell you we saw 600 patients. OK. Did you help them? Are they better off because you saw them? If you can't show that, then what are you doing? You could be wasting people's time. You could be even causing harm by giving them medication that they can't replace. Or that may not be the right one for them, but you don't know their medical history. Those are the kinds of things that I was impressed by. I think another thing that really impressed me was that everybody I talked to, both in the U.S. and in other countries, and I'd say, Well, so how do you know if this is helpful? They couldn't answer it. They say, Well, we just know people are happy, they smile. They thank us. They ask us to come back. Those are good things. And sometimes very specific. You know, we operate on somebody and they got up and they were better, which is wonderful. I mean, if I were in a place with limited medical care and somebody solved a problem I had, I would be forever grateful. But the cost benefit analysis is not done. There's a lot of expenditure, and the expenditure can partly help people in areas that don't have much medical care or very advanced medical care. But it really also is about helping the volunteers. Your students who say this was wonderful and they're getting a good experience. So are we using people in poor countries for our own benefit? That's another sort of question that concern me as I was doing this work. 

Rob Murphy, MD [00:16:34] Well, you certainly get into that in your book. 

Judith Lasker, PhD [00:16:36] Yeah. If we are using people for our benefit, I mean, I did it. I did my dissertation in West Africa. I took up a lot of people's time asking questions, and I got my degree and I got a career. I totally did it. But if we are doing that, how do we acknowledge it? How do we respect? The contribution that they've made to us 

Rob Murphy, MD [00:16:58] When you're looking at different organizations and their programs, you've evaluated many of them. What are some of the red flags that you look for when considering what's a good program, an ethical program? What are some of the hallmarks? 

Judith Lasker, PhD [00:17:15] So I think one red flag for me is a program that says, send in your fee and you can go. We don't need a reference. We don't need to know that you have any experience. We don't need to know that you're not a jerk. You know, there are a lot of companies that are making money off of this. Oh, sure. And even the ones that are not for profit oftentimes do almost no screening. Many of the ones even that are serious don't do much preparation. If all they do is send you a list of close to pack and visas to get and shots that you need, then they are not preparing you to do this work. And I think that is really not acceptable. 

Rob Murphy, MD [00:18:02] And actually, in our program here, we focus in on about 20 to 24 sites that we've been working with some for 20 years and we make all the relationships bilateral. It's not a one to one thing because we can't afford that. But you know, at our big sites, we always take somebody from that site back here. That's very helpful. And then we know all the players at those 20 sites pretty well. And, you know, some sites com and some sites go and we always looking for nuance. And that's fine. But yeah, it's got to be a deep relationship. 

Judith Lasker, PhD [00:18:41] And that's really the key and I think is at advocacy for global health partnerships. We're increasingly focusing on not the short term trip, but the long term partnership within which there may be some short term trips. But it can't just be. As I've seen with too many organizations, you know, I have a friend who's a teacher in a village and, you know, somewhere and who's invited us to come and spend a week and bring a lot of medicine if it's not part of an ongoing system of follow up. And, you know, continuity of care. The risks are quite quite large. Another thing that I would be very cautious of, and this is something that's been widely discussed in the medical area, is an organization that says. You'll get to do stuff that you're not allowed to do in America. You can go into an operating room and participate. You can attend a childbirth, you know, and those are experiences that students love to get, and it's exciting. But any advertisement that says we can do stuff that you wouldn't get to do back home, I would be very. 

Rob Murphy, MD [00:20:00] Reluctant. Yeah, that's definitely a red flag. We have had issues here, and I'm sure you've heard of them elsewhere, particularly with the and I sort of alluded to the Kathmandu I see U.S. experience that was going on here, but these surgical missions in particular and surgical subspecialties, they've actually put global health kind of guidelines into their their mission and they've got regular sort of regulations about it. But I mean, a lot of those regulations are, you know, related to one and two week trips. And, you know, they have all the like CME type requirements and stuff, all that. But but it's still this kind of short, blunt fly in, fly out. Yeah. Yes. And we go there every year. But what do you think about those those programs, because we find them very problematic, because very few of them are longer than two weeks.  

Judith Lasker, PhD [00:21:02] One of the problems is you mentioned bringing the ICU. There has been a growing effort among NGOs that are involved in product donations to follow guidelines that would eliminate donating old stuff that doesn't work or even donating new stuff that works, but only works as long as you have replacement parts technicians to fix it, electricity going at all times. And you know, if you do a Google Image search for medical equipment graveyard, you find these photos of huge lots in various parts of the poorer countries where they've dumped a ton of really valuable equipment because they can't use the equipment issue is one that's being tackled by some big organizations and big corporations. That's a good thing, and they've been developing guidelines as well. Also, the practice of sending volunteers medicines to take in their suitcases. This is actually illegal in a lot of countries, and it's illegal in the in the United States to be giving out medication. So it's that's really problematic the one or two weeks surgical trips. Again, the biggest problem is complications. Every surgical procedure, as you well know, has complications. And if a person comes to you in a area where they don't live together, surgery and then they go home again, and if they have a complication, who who can take care of it, who would know about it. I think a lot of the surgical groups are now shifting more towards training and working with teams that are in place year round, and they might go one or two weeks a year to say, OK, how do we upgrade skills? How do we introduce some new techniques? But with the idea that the work will be done by the people in the country and not by the outsiders and during the COVID pandemic, with the switch to virtual programs, we're seeing a lot of this telemedicine training online, and there's some real advantages to that. You can reach a lot more people at a much lower expense. Very curious to see if we ever get through this pandemic in my lifetime. You know how many of the programs will switch to that kind of model? I think some of them have already decided to continue it because of the value involved. 

Rob Murphy, MD [00:23:37] Yeah, COVID has really impacted our programs, but I have to say it hasn't ended them and we've done kind of exactly what you said. We've done much more training virtually. It's still, I think, important for people interested in a global health career that they actually get into the environment where they're they're interested in working. But until travel is really opened up, it's going to have to be virtual in many ways. I mean, good, bad or whatever. 

Judith Lasker, PhD [00:24:06] I think for people who want to work in global health, I agree you need the travel experience, but two weeks of travel to a place you've never been and back home again. I mean, it's a taste. It's got to be a longer exposure, more experience. 

Rob Murphy, MD [00:24:21] Well, I think in your book, you you say like the absolute minimum is three weeks and we have the way our student schedules are set up is there's four weeks is a nice block. 

Judith Lasker, PhD [00:24:32] Good for is better than three. 

Rob Murphy, MD [00:24:34] Let me go to a question here from which is in the same vein here. 

Speaker 3 [00:24:38] My name is Mielynn Shi and I'm a second year medical student at Feinberg. When we're working on research projects here at Northwestern, what's the best way to explore how we can apply it abroad? Building off of that, what's the best way to explore how we can apply it locally to an underserved community in, for example, Chicago? 

Judith Lasker, PhD [00:24:55] Some people have figured out that global health doesn't have to be done beyond the borders of the United States. We have a global population in this country. We have people with, you know, who who don't speak English and who have serious medical problems and not good access to care, and they're down the street in many cases. And I know some medical schools have developed programs with immigrant health centers, refugees and so forth or just with low income. I think that you will learn a great deal by working in a center that serves the needs of low income and immigrant populations and probably learn a lot more from that. Doing it over a period of time and getting to know people and understanding what the issues are. I want to address the research aspect that the student mentioned because there are some incredibly. Creative research projects going on in labs across the United States and across the world, where people are coming up with solutions to specific problems, diagnostic problems, water supply problems and so forth. And so the question about how do we apply them is a tough one because it requires really some local partners who are willing to do the collaboration. So the collaboration we've talked about partnerships in terms of clinical care is also really important with research. And there's been a fair amount of attention recently to the unfairness of publications where the research is being done about problems in global south or data in the global south. And then, you know, the North American gets the credit and gets the benefits of publishing it. And the people who did the work maybe get mentioned as a thank you note or something. So again, partnerships around research are just as important. And that means really giving equal consideration to what are their concerns. Are there researchers in other countries that you can work with who are thinking about some of the same questions and maybe have some insights, very likely have insights into ways in which what you're working on may be best applied in another country? There's been a lot of sort of innovative ideas that people have come up with in North America, and then they go to some poor country and say, Hey, try my water filter or try my light source. It's all potentially very good. But what is the local context? You know, there were students from my university who spent years building a water system in a village in Central America, and it weren't technically, but it didn't work culturally and socially, and it just ended up being a big waste of money. They understood afterwards that they needed to have spent a lot more time understanding the local context and the needs and practices of the community before sort of bringing a product. So I'm not sure if that addresses exactly what you're talking about. But again, I urge you to look at some of the literature on global research partnerships and how to make them better. 

Rob Murphy, MD [00:28:08] Now let's we have one other question. We have an audio recording of the question Can we play that? Patrick Driscoll, Masters of Public Health Student at Northwestern concentrating on global health. Can you speak at all towards the intersections of sustainability and ethics in terms of global health program development that you've both witnessed and participated in through your experiences? 

Judith Lasker, PhD [00:28:29] Well, I think we've been talking a lot about sustainability and ethics. You know, is a program ethical if it's not sustainable? All right. It's a one time drop in parachute visit to do something. Is that a good thing if you are the patient who got your cataracts removed on that one trip? It's a great thing, but if there's no training, if there's no continuity, if there's no follow up, it's not ideal as a program. And I want to distinguish those things because far be it from me to say an individual whose health was improved, whose life was improved in any way. That's great. But the ethics here is, you know, how are we expending our resources? And are we doing it? So in a way that is equitable and that makes sense and is a good use of resources so that more people can benefit and benefit in a way that is respectful. And that really is understanding of the needs of a country. It's a tough dilemma. There is nothing better than helping somebody feel better. Right? You fix their hernia, you take out their cataract, you give them a brace for a leg that doesn't work very well and you see them feeling better. It's wonderful. And that's very satisfying. Again, the balance between those individual efforts and looking at the whole picture of what are the best ways to make those experiences available to as many people as possible. And it really has to do with strengthening the overall health care system. This is the World Health Organization now is very focused on universal health care and strengthening health systems. And we can, I think as outsiders with resources contribute to those goals of it strengthening systems in a way that will be much more sustainable than one off visits. 

Rob Murphy, MD [00:30:38] I want to thank Professor Lasker for joining us on this podcast. I wish you luck with your global health partnerships group. I hope people listening to this podcast get involved with that too. 

Judith Lasker, PhD [00:30:50] Take  look at the brochure declaration. We're welcoming other organizations to endorse it and use it, and we're very pleased that a lot of organizations have used it as a guideline for modifying their programs, which is great. I'm really happy that Rob and Northwestern are part of that effort.

Rob Murphy, MD [00:31:08] We're happy to be part. 

Judith Lasker, PhD [00:31:09] Thank you so much.