Controversies in medical aid to developing countries: balancing help and harm.

Medical aid to developing countries is widely recognized as being an important aspect of global medicine. However, many challenges exist. Medical relief workers are subject to great personal trials. Moreover, the actual medical aid provided may be helpful, may be useless, or may be actually detrimental to the health of recipient country’s people. Medial and other relief workers should be aware of these challenges and accommodate programs and projects accordingly. In 1984, just prior to embarking on my medical education, I participated in a medical and dental aid program with the wellestablished Christian Medical and Dental Society. When I returned home, I wondered, ‘Did I actually help the Colorado Indians of Ecuador?’ I questioned whether the exuberant feeling I had was solely self-serving. This question resulted in a medical school project in which I found most people had similar experience: aid workers personally gained greatly, but were unsure if they helped the people of the country. Now, three decades later, we have a clearer understanding of how to make a positive impact on developing countries. I’m a veteran of four trips to Haiti with non-religious, non-governmental organization, Medical Student Missions, a program focused on both providing medical aid as well as educating medical students on global health. Medical Student Missions provides primary health care and screening under the local rural medical system. Other aid programs exist globally: natural disasters response, surgical teams, immunization programs, education, infrastructure and engineering, research, preand post-natal care and infant care. Some programs are immediate response, whereas others are ongoing for weeks, months and years. Some have a nonmedical primary mission: religious, education, economic or political. All are fraught with challenges: both to the medical relief worker and the projects. We continue to struggle to improve aid programs. Medical aid work can be greatly rewarding. However, the challenges faced by themedical aid worker aremany. Hardships to aid workers do not compare to the living conditions of the peoples of the developing world. Aid workers may find non-potable water, inadequate food, substandard lodging, dangerous transportation, poor communication among team and home, foul weather and extreme climates, microbe-laden insects, rabies-laden animals, civic instability and political unrest. Days may be marked by long hours, with a large daily patient census, in an inadequate facility, with little or no ancillary support. Medical professionals may find unfamiliar medications, different standards of care and need for venturing to the limits of their scope of practice. There may be an overwhelming number of vulnerable and disadvantaged patients, and worse, mass causalities. Aid workers must be attentive to cultural, religious, socio-economic and language barriers. In addition to aid worker challenges, the actual medical relief work can be ineffective or even detrimental. This is not a comprehensive review, but an overview of some examples of howaid trips can be problematic: this can guide readers to further investigation prior to embarking on an aid program. Commonalities for ineffective or less-effective trips are well-documented: trips that are short in duration, function outside local healthcare system, are nonsurgical, vary locations, exclude an education component, lack a supply of durable goods andmedications, lack ameans of improving infrastructure, lack patient follow-up and divert local resources for non essential functions. Medical aid programs can even be detrimental to the local population. For example, an ill and injured aid worker, such as during disaster response, can burden the local medical system, support system and relief team. If aid teams are not selfsufficient, simply providing activities of daily living to aid workers (food, water, shelter, transportation) can tax local resources. Another example, too many unusable donated medical and nonmedical supplies require local resources for transportation and storage. Sometimes, aid groups bring excessive quantities of essential medications, large quantities of unsorted and free sample medications and useless medications.