Personal views: So who's teaching whom?
Authors: Liz Smith
Journal: BMJ (2000)

VSO (Voluntary Service Overseas) sends skilled men and women to work in partnership with people in developing countries. The organisation has seen a dramatic surge in inquiries from health professionals interested in working overseas—figures released in February 1999 show that applications from the health sector have gone up by 55%.


In the wake of the Stephen Lawrence report the health service's capacity to deliver care to multicultural Britain is under scrutiny. Cultural awareness and sensitivity are at a premium, yet the skills of health workers who have worked overseas remain undervalued. 


My colleagues still find it difficult to communicate how they have developed



A widely held assumption that volunteering is a one way learning process rather than an exchange of ideas, skills, and information means that a large proportion of my colleagues still find it difficult to communicate how they have developed professionally from their experience.

I spent two years in Zambia with VSO as a nurse tutor. My aims and motivation were misunderstood by many from the outset. Most colleagues saw the trip as a mercy mission. True, I went to help, but I had much to learn before I could do so. Trained in the West, I was no specialist in African medicine overseas. I also refreshed a lot of my basic skills, such as the use of sterile techniques. Having trained on the cusp of the prepackaged era, I had not been using these skills back in Britain. My Zambian colleagues were highly adept at these procedures. We have become unduly complacent about infection rates in Britain, where more people die of hospital acquired infections in a year than die on the roads.

I took up my post as health network coordinator at VSO two months after my return in 1997. The network enables health professionals who have worked overseas to share their ideas to the benefit of health care in Britain. At the time the debate about cultural awareness in the NHS was just gaining hold.

Putting my ideas into practice has been an exciting process. Together with colleagues from different communities and professions I designed Bedside Manners, a learning pack that helps NHS staff explore multicultural issues and test their own awareness. I am struck by the students' insistence that it is the first time that they have been asked to reflect on even the most basic principles of cultural identity covered in the pack.

Other returned volunteers have been equally innovative. Jon, a health promotions specialist working in the Midlands, has designed an information booklet to help his colleagues distinguish between the different needs of Muslims, Sikhs, and Hindus. It had become acutely apparent to him on his return from overseas how handicapped a health worker can be by cultural ignorance.

Throughout my training the buzz word was always individual care, but for some reason the individual and his or her culture were never seen as one by tutors and staff. This meant that a “one size fits all” philosophy reigned. The unspoken rule was that the need of every patient could be understood from a Western cultural perspective.

There are specific lessons that we can learn in the NHS from the Stephen Lawrence inquiry about tackling institutional racism. Foremost among these is that attitudes and understanding count at every level of organisation. The importance of cultural awareness extends to a general practitioner counselling a Catholic family in family planning; a health visitor planning to visit a family over the Muslim festival, Eid; and doctors in obstetrics and gynaecology assigning Muslim patients to male staff. NHS trusts should be encouraged to widen the number of leave of absence schemes to make it easier for staff at every level to work overseas, and they should afford the same staff greater recognition on their return.

With the extension of the Race Relations Act to NHS trusts there is a greater pressure to reform attitudes in health care. And it will take more than just words, guidelines, or policy to effect real change. The only way to change attitudes is to involve people in questioning their own values and assumptions.

When I was a student nurse my colleagues and I would laugh at families who brought strange food in for their families. When I was ill with malaria in Zambia the two Bangladeshi doctors who stayed with me used to bring me curry. All I wanted was tomato soup. I just couldn't face the curry even though it was given with the best intentions. This example sums up the problem. For too long we have been doing things with the best of intentions. The old adage, “treat people as you would like to be treated,” has a major flaw—we are not all the same.