Reflection and Understanding

Introduction

Through this training, we have put forth many definitions and theories about best practices in global health and volunteer abroad programs. While we hope that you found the material interesting and helpful, know that you won’t feel the full effect until you are on the ground, living the realities and complexities of international community development.

The realization of Unite For Sight’s goal—to improve eye health and eliminate preventable blindness—is highly dependent on the willingness and ability of volunteers to take to heart the significance of social entrepreneurship and grassroots empowerment in successful community development. You are an essential component of this vision. You bring your own unique set of interests, academic history, personal experience, and passion—all qualities that have the potential to dramatically enhance the impact of Unite For Sight’s partners. As seen in many of the vignettes put forth in the training modules, Global Impact Fellows have the power to do both incredible good or incredible harm.

To help you tie in all that you’ve learned throughout this training experience, consider the vignette below involving a volunteer in a challenging situation. Read the summary of her challenge, and then think about how you would have responded in the same circumstances, keeping in mind the lessons from the training modules. Then, compare and contrast your response with our recap of how the situation should have been dealt with.

The Situation

Madeline is at an outreach and sees that hundreds of patients are waiting to be seen. The staff placed Madeline at the medication and eyeglass dispensing station today with George, who is another Unite For Sight volunteer. Madeline sees that a bottleneck to patient flow is accumulating at the patient intake station. Disgruntled about the backup of patients, Madeline thinks, “If the community translators had arrived today on time, we wouldn’t have this problem.” Madeline is accustomed to the daily routine enough that she feels like she can get started taking patient histories on the dozens of individuals lined up. Madeline also has an ophthalmoscope that she brought from medical school, and decides that today will be a good opportunity to practice looking at the retina for each patient as her own learning opportunity. “My hospital advisor back home would be so proud to hear that I am taking what I’ve learned in the States to a developing country,” she thinks. Although she doesn’t have a translator to assist her, this is not a deterrent—she has picked up enough words in the local language to hold a basic (albeit somewhat broken) conversation. Besides, as Madeline said, “Unite For Sight had high aims to reach the greatest number of people possible, and eliminate preventable blindness, and I want to contribute my skills to this goal.”

One older woman she sees tries to tell her something with very emphatic hand gestures and quick, incomprehensible speech. Since Madeline cannot completely understand, she records the few tidbits she can interpret, assures the woman that she has gotten everything down, and moves on to the next patient. “What does one crazy woman’s babbling matter anyways? The doctors are the experts. They’ll solve her problems when they see her.” The additional patient intake station that Madeline created is not part of the standard station flow that was set up by the ophthalmic nurses at the start, and the patients rotating through Madeline’s intake station are skipping the visual acuity station and walking directly to the ophthalmic examination and diagnosis station. The ophthalmic nurses are confused about how today’s setup is causing so much chaos amongst the patients, and they need to take extra time to redirect the patients to the visual acuity station. The patients are also telling the ophthalmic nurses that they were already examined. By the time the ophthalmic nurses notice that Madeline set up another patient intake station and is looking at patients’ eyes with an ophthalmoscope, she had gotten through dozens of patients.

Discussion: Lessons to Remember

What are Madeline's errors, and how should she have acted in this situation?

1. Madeline should have remembered that timeliness is not a universal value. It was good that this didn’t change her habit of arriving to work on time. However, she still became frustrated when the translators arrived late. While different countries may have varying perspectives of time, volunteers should assume (unless told otherwise) that just because patients or supervisors periodically arrive late does not mean that volunteers can show up any time they want.

2. Further, Madeline practiced beyond her abilities and responsibilities when she began examining patients’ retinas. There are two main issues with her decision. First, while she was justified in wanting to utilize her background as a medical student, it is absolutely unethical to relax patient care standards in any setting. In his book Pathologies of Power, Dr. Paul Farmer discusses the deplorable “ironies of inequality” perpetuated by some development agencies and research universities who transport their unproven procedures to developing countries.(1) Madeline should have been prepared to provide the same standard of care to the villagers as she would expect in the United States. Using the villagers as educational guinea pigs was a presumptuous and disrespectful decision. Second, Madeline’s incorrect belief that “something is better than nothing” has ongoing consequences for the health of the entire community. Because of Madeline’s inexperience and inability to communicate, the patients who saw Madeline expressed dissatisfaction with the way they were treated. Many felt under-valued due to the linguistically complicated and terse encounter. Some of them never returned to the clinic for their surgeries or subsequent consultations. Furthermore, they also told fellow villagers how poorly managed the outreach was, discouraging even more people from coming forward to access quality care from the local eye care professionals. Thus, even though Madeline’s decision may seem like a small mistake, it forever changed the attitudes of several locals about eye care. Even patients who did return were still reluctant to accept everything the doctors recommended. Hence, Madeline inadvertently created new barriers to care: fear and skepticism.

3. While independence, drive, and resourcefulness are championed in the States—and can be useful with proper regulation—Madeline’s behavior was in fact disruptive to the outreach activities. Her supervisors interpreted her actions as overly bold, abrasive, and disrespectful. Unite For Sight takes great pride in the fact that outreaches are led and managed by the local eye care professionals. Madeline subverted the local professionals’ authority by making a unilateral decision about her tasks for the day. She should have inquired as to whether it would have been a good idea to set up an additional patient intake station. If her superiors had found this suggestion useful, they could have then directed Madeline to a more strategic spot. Instead, Madeline brazenly disrupted an already efficient system by placing herself in a location that caused patients to skip the visual acuity station.

To avoid Madeline’s mistake, volunteers should enter any foreign situation enthusiastic about humbling themselves enough to realize just how little they know. Madeline did just the opposite—she was excited to show just how much she knew. Again, while Unite For Sight does not want you to suppress your skills, we do want you to use them appropriately, with the permission of both cultural norms and supervisor approval.

4. Lastly, it is important to consider Madeline’s interaction with the elderly patient. In his book Illness Narratives, medical anthropologist Dr. Arthur Kleinman makes clear the importance of carefully recording and interpreting all of the meanings behind a patient’s illness as determined by the patient’s description of his or her interaction with sickness (its perceived etiology, physiological repercussions, and effects on social relationships).(2)(3) Because individuals perceive and respond to bodily abnormalities in ways connected to deeply cultural webs, the practitioner’s role is “the sensitive solicitation of the patient’s and the family’s stories of the illness, the assembling of a mini-ethnography of the changing contexts of chronicity, informed negotiation with alternative lay perspectives on care, and what amounts to a brief medical psychotherapy for the multiple, ongoing threats and losses that make chronic illness profoundly disruptive.”(4) Madeline should not have been so quick to dismiss the woman’s explicit communication of distress. The use of an interpreter, and deeper investigation into and understanding of cultural beliefs, would have helped Madeline record the woman’s concern more accurately and compassionately.

Conclusion

Much of this training asks that you, as an international volunteer equipped with an exceptional understanding of the rules for successful community development, abandon your preconceptions and defer to the authority of local cultural norms. While there is much to be said about the power of humility and sensitivity, this does not mean that you have to abandon what makes you you—your experiences, your personality, and your passions. While you are asked to be an “ethical” volunteer, we also hope that you are able to learn and grow from your experience by asking questions, applying your unique, invaluable academic and experiential background, and taking time for reflection and introspection. When contemplating what you witness each day, ask yourself the following questions:

Do discrepancies still exist between my expectations and the reality of this community?
Am I still clinging to preconceived notions about the culture or people?
What are patient-perceived barriers to care, and how can I help to eliminate these barriers?
Does this patient understand why and how they should use their medication?
Am I acting with humility and empathy in all of my interactions?
Am I respectful when observing the local doctors during patient exams and surgery?

Sometime throughout your participation as a volunteer, you are going to experience confusing or frustrating emotional responses to certain events. Embrace these moments as opportunities to better understand your worldview. As Scottish author Robert Louis Stevenson said, “There are no foreign lands. It is the traveler only who is foreign.”(5) If you are ever struck by curiosity, perplexity, astonishment, or even repulsion, remember that the local people may be just as perplexed by you. Practice cultural reverence, humility, and, ultimately, self-awareness. As long as you value and harness these traits, your volunteer participation will be educationally informative, personally enriching, and immeasurably rewarding.

Footnotes

(1) Farmer, P. Pathologies of Power: Health, Human Rights, and the New War on the Poor. (University of California Press, 2005): 128, page 200-201.

(2) “Arthur Kleinman, Professor.” Harvard University: The Department of Anthropology. http://www.fas.harvard.edu/~anthro/social_faculty_pages/social_pages_kleinman.html.

(3) Ibid.

(4) Ibid.

(5) Stevenson, R. “Quotation.”http://thinkexist.com/quotes/like/as_the_traveler_who_has_once_been_from_home_is/173153/4.html.