Good Intentions, Good Works?

Every year, says Judith Lasker, as many as a million Americans travel to developing countries hoping to help less fortunate people by giving of their time, their energies and their talents.

These volunteers represent businesses and nongovernmental agencies, churches and nonprofits, hospitals and universities. Some work in medical clinics and orphanages, some build schools and drill water wells. Some pick up college credits, and some spread the gospel of their faith. Even tourist agencies are sending people on international service projects. The phenomenon has given rise to a new word: "voluntourism."

"Nearly every time I mention my research," Lasker writes in her most recent book, Hoping to Help: The Promises and Pitfalls of Global Health Volunteering, "someone has a personal experience to recount or tells me about a family member or close friend who has volunteered. That was not the case only a decade ago."

A debate has sprung up over the motives and effectiveness of international volunteers. Supporters say volunteering can benefit the lives of volunteers as well as the people they help. Critics say some programs are culturally insensitive and self-serving, lack preparation and follow-up, and can have negative economic and health effects on host communities.

"The developing world," Somalian blogger Ossob Mohamud wrote in the British newspaper The Guardian in 2013, "has become a playground for the redemption of privileged souls looking to atone for global injustices by escaping the vacuity of modernity and globalization."

Mohamud elaborated: "Voluntourism almost always involves a group of idealistic and privileged travelers who have vastly different socioeconomic statuses vis-à-vis those they serve. They often enter these communities with little or no understanding of the locals' history, culture and ways of life."

"'Voluntourists' they may be," countered Sam Blackledge, a reporter for England's Plymouth Herald, "but their work can have a huge impact on their own lives and the lives of those they help."

Blackledge added a proviso: "No approach is without its flaws, but it is vital that people do not group charities doing this well with companies who are putting very little into the developing world. Charities that invest in the developing world need keen, energetic, ambitious people to help them along."

How can international volunteers serve effectively, and know they are doing so? How can they turn good intentions into good works while avoiding the appearance of condescension? Lasker, the National Endowment of the Humanities Distinguished Professor of Sociology, attempts to answer these questions in her book.

"Although short-term international volunteering is a massive and growing enterprise," she writes, "there is very little information about what volunteers do, where they go, who is sponsoring them, and what they accomplish."

Her primary concern, she says, is "whether the investment of billions of dollars of resources in the short-term volunteering enterprise can be justified by the results in terms of improvement in health, reduction in health disparities, or other measures of value to the host communities.

"I hope to contribute to making [volunteering] more effective and valuable to all concerned."

Hoping to Help has received high marks from the media since it was published earlier this year by Cornell University Press.

“Many scholars have discussed the theory behind global aid and the various perils in its execution,” said a review in The New York Times. “Dr. Lasker…delivers instead a straightforward, data-driven review of a small health-related fraction of the enterprise…Anyone contemplating a volunteer stint is likely to be interested in [her] results, which amount to a sort of de facto best-practices manual.”

A writer for the Daily Beast said, “Dr. Lasker has come up with not only a comprehensive description of how this field operates, but a list of recommendations for how it could be better.” A reviewer in Forbes magazine wrote, “Although she scrutinizes short-term health volunteering programs in particular, many of Lasker’s insights and critiques can be applied across the universe of international volunteer projects.”

In a book review for the British Dental Journal, A.E. Jones called Hoping to Help “…a triumph of social analysis and commentary which rigorously appraises and summarizes the existing body of evidence on the topic…overall it is a deeply compelling read that will give you plenty of food for thought, and perhaps change your plans, practice or even your life. I would wholeheartedly recommend it.”

A life-changing experience

In conducting research for Hoping to Help, Lasker and her assistants interviewed 119 people: 55 host-country staff members in Ecuador, Ghana, Haiti and Niger, 15 volunteers, 27 officials with American sponsor organizations, 15 people from the United States and France who work full-time with volunteers in host countries, and seven global health experts.

The group also conducted an online survey of 177 U.S. organizations that send volunteers overseas for short-term health programs. And they collaborated with the Catholic Health Association on a survey that received responses from 152 organizers of short-term medical missions and 205 volunteers who served with the missions.

Four of Lasker's former students played key roles in the research: Ana Arteaga '12, now a pre-med graduate student at Hawaii Pacific University; Sirry Alang '08G, assistant professor of sociology at Lehigh; Joe Rendon '14 '15G, an education specialist with AgSafe; and Caroline Kusi '11, the East Africa coordinator for the University of California at San Francisco's Preterm Birth Initiative in Rwanda.

Arteaga spent three weeks with Lasker in Haiti and interviewed several dozen Haitians about the effectiveness of international volunteers.

“The hosts really only had positive things to say about volunteers,” she says. “It was actually very difficult during interviews to get people to honestly critique the volunteers and/or the services rendered.”

Her work in Haiti, says Arteaga, changed the course of her life.

"The experience rocked me to my core. It was horrifying to see how people just a short flight away from the United States could live such radically different and impoverished lives. After Haiti, I knew I had to get into the medical field. It wasn't just a passion for medicine that arose, but an overwhelming desire to provide physical relief to those who suffer."

Arteaga's advice to prospective international volunteers is to find an organization that has a long-term partnership with a host community.

"I think the focus should be on the host community and their needs, not the volunteer. It's important to understand what their needs are first and foremost, and then see if your particular skills and talents fit those needs.

"Also, if you're going to provide unskilled labor or work that could be easily done by almost anyone, I'd advise you to stay home and instead donate [your] money—I think that would be a better use of resources and time."

On the scene in Ghana

Alang spent three weeks in Ghana, evaluating the efforts of 20 volunteers employed by a medical technology company.

At a nursing school, the company's employees sought to improve the training of nurses. At a clinic that provides maternal care and treats people with infectious diseases, the employees trained birth attendants in modern hand-washing techniques and in record keeping. They also built a medical waste disposal facility and a K-12 school.

Of all the company's efforts, says Alang, the construction of the school was the most productive.

"A group of men built the school," she says. "They had to make bricks from scratch, but after a couple of days, the volunteers figured out what to do. They worked with and learned from the Ghanaian builders. They finished the building in two weeks. Of all the volunteers, they were the ones most appreciated by the Ghanaians. And they probably had the most fun. They had a chance to get to know people and bond with them."

The efforts of the other volunteers were often undermined, says Alang, by insufficient knowledge of the Ghanaians' abilities and experiences.

The company, says Alang, "really did not know what the skill level of the Ghanaian healthcare providers was. They had not learned, before arriving in Ghana, what the people already knew.

"The volunteers did not leverage community resources. They did not pay attention to the way things were being done, especially to the resources the Ghanaians already had. The volunteers were almost dismissive of that.

"If you want to interact with a community in a meaningful way, you have to know where it's at so that you can leverage the skills and resources people already have."

Likewise, said Alang, the company had given little thought to the aftermath of its employees’ visit.

“In two weeks,” she said, “you’re not going to change infrastructure or make long-term change. That takes time. [The company] did not really focus on the sustainability of a project. They didn’t ask, how will people continue with this project when we’re gone, how will they maintain medical waste disposal machines. If there’s a problem, who will fix the machine?

“The clinic where I observed had one computer. Explaining to people how to keep records on a computer takes a lot of time. What if that one computer crashes when you leave?”

The failure to appreciate and work with cultural differences was perhaps the biggest obstacle to success for the company's employees, says Alang. This became apparent during discussions about the rights of women in Ghana.

"If there's no context within another culture for people to practice certain rights," says Alang, "then there's no point telling them what rights they have. We might say to Ghanaian women, 'You have the right to go a hospital' or 'You have reproductive rights,' but a husband might not let this happen.

"Ghanaian men might think, 'These white women are coming here to tell our women to be stubborn.' These men want their wives to give birth safely, so we shouldn't treat them in a way that risks alienating them.

"If women depend on men for these things, we should leverage men's influence. Don't make it a point of contention; make it a benefit. You cannot get people to engage in things that will be beneficial to them if you bring to the process your own attitude of cultural superiority. This shows a lack of cultural humility. You have to learn about their culture and get to know people in context of their culture."

Volunteers who hope to implement long-term change or develop a new system should spend at least two months in a developing country, Alang says.

“It might take one month to learn the people’s level of skill and their rationale for the current system before you can figure out how to improve it,” she says.

“If you’re a doctor performing surgeries, that’s a different thing. So is building a school or clinic. Both of these are one-time projects. Your primary purpose is not to transform a system or train people—these require long-term change.”

Her time in Ghana, says Alang, has helped her think more critically about her own work as a community volunteer.

“It has made me try harder to acknowledge the resources and talent every community has and to work with a community as a partner. It has helped me to identify what not to do, and to be more strategic and more respectful.”

Nine tips for responsible volunteering

In the final three chapters of her book, Lasker lists nine ways for international volunteers to be more effective. One recommendation is for volunteers to spend more time in host countries. Lasker says volunteers and their sponsors should also:

• Foster mutuality with host-country partners by regarding them as equals from whom volunteers have much to learn. Some scholars, Lasker writes, advocate "for university-community partnerships that view the community as possessing knowledge and assets, such that the university and community can work together to [create] solutions to social problems."
• Maintain continuity of programming. "A program is valuable if the results last beyond the initial visit," Lasker writes, "or if it [helps strengthen] local institutions that can continue to provide services into the future." A team of American pediatric neurosurgeons, she says, trained Peruvian surgeons during three one-week visits. The Americans then reviewed the records of Peruvian patients for five years to evaluate the success of their counterparts in Peru. "Even tracking results over time from a distance can be a valuable form of continuity," she writes.
• Seek the host community's advice in assessing the community's needs. This increases the validity of information that is gathered and improves a mission's effectiveness. Conversations should be held not just with health officials, Lasker writes, but with other community leaders and organizations as well.
• Evaluate the outcomes of their work. Lasker acknowledges the difficulty of evaluating social and educational programs and cites her own teaching career as an example. At the same time, she was surprised at the number of sponsoring organizations that had never measured the success of their efforts. She concludes that volunteer organizations should set goals, gauge results over a long period of time, and include their hosts' perspectives in their evaluations.
• Focus on prevention. While medical volunteers understandably want to cure sick people, Lasker writes, they can accomplish more in the long run by also working with hosts to tackle the causes of illnesses, from malnutrition to parasites to lack of clean drinking water.
• Offer integrated and diverse types of health services. Providing comprehensive care is more expensive and logistically challenging than offering selected types of care such as cancer screenings or simple surgeries, says Lasker, but a holistic approach, especially one that includes dental and eye care, is worth pursuing. Coordination among the providers of different specialties can make this goal easier to achieve.
• "Capacity building" has become a buzzword in the jargon of medical volunteering, says Lasker. At the least, this means the training of local staff and the construction and follow-up maintenance of labs and other facilities. Ideally, it should also ensure that volunteers not do work, such as teaching classes or interpreting, that locals can do.
• Spend more time preparing for overseas projects. Many, if not most, programs, Lasker writes, "provide grossly insufficient preparation for volunteers when it comes to the history, culture and language of the country they will be visiting." At the least, volunteers should learn the basic greetings in a country's language, something of its culture and history, and how to act "with a sense of cultural humility." Also, returning volunteers should share what they've learned with new volunteers.

In her conclusion, Lasker notes that some organizations have begun to question and even limit the number of short-term trips they sponsor. Some faith-based groups warn that "an avalanche" of short-term volunteers can reinforce a sense of dependency in a host country.

Lasker says the benefits of short trips to host communities "remain to be documented more systematically," but argues that it would be "unfair to discount completely the many examples of volunteers' contributions—the thousands of individuals regaining sight or being able to work or go to school or avoiding future cancers or having pain alleviated or feeling cared about.

"The emphasis needs to be on maximizing these effects in the most responsible manner possible. In pursuit of a more just world, can we accept anything less?"

This story appears as "Good Intentions, Good Works?" in the 2017 Lehigh Research Review.