Global health gap
The current global state of health is one of great disparity: on one end of the spectrum, science and technology is advancing at astonishing speeds; on the other end, infectious disease is consuming the lives of millions of human beings.[1] The 20th century welcomed the application of science and technology to revolutionize the scope of health care, thus improving the quality of life and its expectancy.[1] 

Nevertheless, significant dissimilar­ities remain in health care between developed and developing nations. For example, the gap in life expectancy can be as wide as 50 years, with an average of 80 years in countries such as Canada and 30 years (and declining) in Botswana.[1] 

Diseases such as multiple-drug resistant tuberculosis, HIV, and malaria, to name just a few, are responsible for the deaths of millions of people in developing nations but are virtually unheard of in the Western world. The wide gap be­tween rich and poor has tripled over the last 60 years. It is currently estimated that 2 billion people live on less than $2 per year; this extreme poverty intensifies malnutrition, infant mortality, and disease.[1] 

It is this persistence of health care disparity that continues to attract the attention of various individuals from the developed world. However, we must ask the difficult questions re­garding the ethics of international work. Most importantly, we must consider the benefits and harms of medical students’ involvement in such endeavors.

Ethical concerns
First, one must consider the students’ motives for pursuing an international medical trip. While the majority of trainees aim to make a positive contribution to the health care discrepancy, there remain others who have different intentions. These may include taking advantage of funding resources to travel to a desired country under the auspices of medical volunteering. 

Another hidden motive may include the desire to practise techniques or enhance their technical skills on un­derserved patients, which would not be permitted in Western countries. 

Second, cultural sensitivity issues must also be addressed when considering the potential harm that medical trainees can have on a foreign community’s health. An international med­ical elective may be heavily focused on exposing the trainees to clinical diagnosis and treatment of unique illnesses. However, students may not fully realize the contextual issues that surround a country’s burden of disease. This can include financial, political, and cultural influences. 

Consequently, the learner’s experience will be an incomplete and inaccurate one as it would not take into account societal influences on health and disease.

A third ethical concern that stems from international volunteering is that of the students’ medical competency and the potential harm they can cause to the patients. Due to the structure of the Western medical education programs, the majority of students em­barking on such trips are those in early years of their training. Foreign medical trips are known to involve clinical experiences for these students that are not available in Western hospitals, which have strict regulations and heavier liability concerns. 

Moreover, indigenous physicians of the host community often introduce the student as a “doctor.” Hence, many students find themselves in challenging situations where they are asked to carry out medical tasks that they are not competent in performing. Such circumstances clearly jeopardize the patients’ safety. 

A high demand for medical personnel, an absence of regulations on medical trainees’ involvement in patient care, and a misinform­ed patient may combine and expose the patient to grave harm. Unfortunately, many students will innocently welcome these opportunities to learn, for example, a new suturing skill or new surgical procedure. This may cause serious complications in patients’ care and well-being; moreover, a fatal mistake by a trainee may also haunt his or her future practice in medicine.

Toward ethical volunteering
How can one ensure that these ethical concerns are overcome and the principles of non-malfeasance are maintain­ed? Most importantly, there must be thoughtful preparation by the student prior to departure.[2] A self-assessment of skills and capacity is key to ensuring that medical students remain in the jurisdiction of appropriate care. 

In addition, education about the community is a vital component to ensuring that participation in a short-term international project is beneficial to the community in question.[2] Knowledge about culture, language, medical issues faced by the people, and the possible sustainable interventions are all reasonable pieces of the puzzle to gather prior to embarking on a medical mission.[1,3] 

Moreover, the host community and organization must prepare for the trainees’ involvement. Also, assessment of the project’s goals regarding sustainability of the planned interventions is a vital element of enhancing efficacy and care to the population in question.[1,4]

As global health disparity rises, so should a health care provider’s desire to narrow this gap. As future physicians, we are thrown into the ethical dilemma of wanting to provide care to communities in need, though we may not have the expertise and knowledge yet. Nevertheless, a medical student’s experience in a developing country can be an excellent experience to learn and contribute to underserved communities. 

Thorough reflection and pre­paration are necessary for a foreign elective to be successful for both the students and host community. Most importantly, we must recognize our own boundaries.

References

1. Benatar S, Daar A, Singer P. Global health ethics: The rationale for mutual caring. Int Affairs 2003;79:107-138.
2. Kass N. An ethics framework for public health. Am J Public Health 2001;91:1776-1782.
3. Bezruchka S. Medical tourism as medical harm to the third world: Why? For whom? Wilderness Environ Med 2000;11:77-78.
4. Suchdev P, Ahrens K, Click E, et al. A model for sustainable short-term international medical trips. Ambulatory Pediatr 2007;317-320. 
5. Roberts M. A piece of my mind: Duffle bag medicine. JAMA 2006;295:1491-1492. 
6. Farmer P. Pathologies of power: Health, human rights and the new war on the poor. Berkeley: University of California Press; 2003.

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Ms Wadhwa and Mr Youssef are both members of the UBC Medicine Class of 2012.