[Review] Hoping to Help: The Promises and Pitfalls of Global Health Volunteering

Global health volunteering — medical missions, health brigades, "flying" surgeons — is a huge and growing enterprise. An estimated two hundred thousand Americans engage in such activities each year, and their time is valued at more than $750 million — not including the hundreds of millions of dollars in direct costs such as air travel, administration, and supplies.

Despite this enormous investment of resources, very little is known about the actual benefits of short-term volunteer service trips, of which the vast majority last less than two weeks. Volunteer trips are seen as opportunities to "make a difference" or to "give back," and most people who engage in such activities intuitively believe they accomplish some measure of good. Yet whether these efforts actually benefit the host communities, how those benefits are measured, and what other objectives are involved are rarely discussed or considered.

As they have grown in popularity, such activities — often grouped under the heading of "voluntourism" — have become a target of criticism. In a scathing critique in the Guardian a few years back, Somalian blogger Ossob Mohamud wrote: "Voluntourism almost always involves a group of idealistic and privileged travelers who have vastly different socio-economic statuses vis-à-vis those they serve. They often enter these communities with little or no understanding of the locals' history, culture, and way of life. All that is understood is the poverty and the presumed neediness of the community, and for the purposes of volunteering that seems to be enough."

Judith N. Lasker engages this debate with her latest book, Hoping to Help: The Promises and Pitfalls of Global Health Volunteering. A professor of sociology at Lehigh University, Lasker examines the landscape of short-term volunteer trips; the benefits and drawbacks of such activity from the perspective of the sponsoring organizations, the volunteers, and the host communities; and what can be done to make such activity more effective, particularly for the latter. The research on which the book is based includes a national survey of a hundred and seventy-seven U.S.-based sponsor organizations, more than a hundred interviews, and participant observation by the author on two short-term trips.

To assess effectiveness, one has to identify program goals, and in the case of voluntourism that ends up being more complicated than simply saying "improving the health of host communities." Indeed, sponsoring organizations — which include churches, universities, hospitals, and NGOs, as well as large corporations and other profit-making companies — often state that providing health services and building public health capacity in underresourced communities is one of their primary goals. However, organizations oftentimes have other, competing interests, including their ability to recruit talented professionals and their own financial sustainability. "[E]nhancing the organization's reputation" and "promoting volunteers' personal growth," writes Lasker, "are often considered just as important [as any benefits created for the host community], raising questions about whether a focus on them might reduce the effectiveness of a group in promoting health."

Many sponsoring organizations argue that short-term service trips inspire volunteers to become more charitable — and more likely to donate to or fundraise for the organization in the future — as well as more culturally aware, leading them, in many cases, to become advocates for more broadly distributed social justice. Volunteers themselves often refer to their short-term experiences as being transformative and, sometimes, as altering the trajectory of their careers. Lasker notes, however, that the evidence for these assertions is sparse, and cites a UK study of medical students that found "little solid evidence for claims that the experiences provided a wide range of potential benefits to the students in the areas of clinical knowledge and skills, attitudes, global perspective, personal and professional development, and institutional benefits...[and] little systematic effort to create such an impact."

For Lasker, the ultimate test of a program’s effectiveness is whether the program improves health outcomes in the community or communities in which the volunteers serve. But again, the evidence on which to base such an assessment is scarce; most organizations don't even attempt to gather evidence of their impact, Lasker writes, and organizers of such activities often seemed surprised when asked the evaluation question. Indeed, when asked about the challenges they face, organizations surveyed by Lasker indicated that evaluating impact was not a top concern and cited, instead, funding, coordination and logistics, and managing the expectations of volunteers and hosts as more pressing challenges. In a telling detail, when asked how they evaluate their programs, two-thirds of the organizations surveyed said they conduct a follow-up survey of volunteers, while only 41 percent evaluate the benefits to the host communities. In other words, without rigorous evaluation of program outcomes, the "[v]alue [of these activities] is assumed."

To be sure, Lasker's own research found that short-term volunteers are valued by local organizations for the extra manpower they represent; the critical surgical procedures they provide; for the medicine, equipment, and supplies they bring with them; and for helping to build the public health capacity of local communities, whether it’s training local staff or making improvements to infrastructure (e.g., rebuilding clinics). They create non-health benefits as well, including contributing to the local economy and a feeling of solidarity and engendering a sense of caring. Indeed, "[i]n many cases," Lasker writes, "the health benefits contributed by short-term volunteers clearly improve and even save lives."

Still, poorly managed projects often do more harm than good. And where volunteers engage in tasks for which they have insufficient training or certification (think medical students seeing patients and prescribing medications), there is great potential for harm. Lack of continuity and predictability of care also can create problems — for example, when medications prescribed for chronic conditions are distributed on a one-off basis, leaving patients worse off when their supply of the medication runs out. In other situations, volunteers may compete with, or even displace, local professionals, as was the case in Haiti after the 2010 earthquake there. Volunteers also require a great deal of time and attention from local staff, whether it's coordinating the logistics of their travel, explaining organizational processes and procedures, or responding to their needs and expectations. When that detracts from local staff members’ medical responsibilities, Lasker writes, it becomes harder to justify the value of the services being volunteered.

To address these and other issues, Lasker offers nine principles for short-term volunteer programs: foster mutuality between organizations and host communities; maintain continuity in programming; conduct needs assessments; evaluate processes and outcomes with host community input; focus on prevention; integrate diverse types of health services; focus on building local capacity; strengthen the preparation of volunteers; and extend the length of volunteers’ time in country. The last, in particular, is important. Or, as a former director of Timmy Global Health puts it: "If the best way to provide health care to low-income communities was through short-term trips, then you and I would be going on short-term trips to get our health care."

Alas, few organizations follow Lasker's principles, and the number of short-term global health volunteer trips continues to increase. Yes, a number of respected organizations, including Partners In Health, have begun to limit such activities to longer-term missions. But that is not enough, Lasker argues. Because of the investment of time, money, and resources required — not to mention the real harm well-intentioned but badly managed efforts can cause — all such programs should be systematically and rigorously evaluated to ensure they are providing maximum benefit to the host communities "in the most responsible manner possible." In pursuit of a more just world, Lasker asks in closing, "can we accept anything less?" For this reader, the answer couldn't be more obvious.

Grace Sato is a Knowledge Services manager at Foundation Center.