Less than 4% of the world's population younger than 19 lives in the United States.1-2 Most children in the world have absolutely no access to a pediatrician or to any medical care that approaches that provided in the developed world. In developing countries, children die of illnesses that are considered preventable or treatable in the developed world, including dehydration, measles, malaria, AIDS, and acute respiratory infections. These are the areas where pediatric intervention may have an effect through education, immunization, and access to even basic medical care.
International health also takes form in the immigrant and adopted children who continue to arrive in the United States in increasing numbers, bringing with them medical problems not commonly seen in this country as well as cultural issues that affect their medical care. Learning something about common medical problems in developing countries and having an awareness of various cultural issues enables pediatricians to provide better care to these international patients.
There are a number of other reasons pediatricians are attracted to international health. In working globally, even in volunteer positions, pediatricians can be strong advocates for children and children's rights in other countríes. By working alongside our international colleagues, we also can support them, learn from them, help educate them, and validate the often heroic work they do in caring for children using limited resources. International volunteer work also is a way to "give back" in a very concrete way, by offering one's time and talent to children who do not usually have access to pediatric care.
Volunteering pediatricians also broaden their own educational horizons through international work. The clinical scenarios often are very different, and the language and culture offer fertile opportunities for learning. For many, such work satisfies a desire for adventure and an interest in learning and working within a new land and culture.
International volunteer work probably is not for everyone. The pediatrician working in global health needs to exhibit some idealism and hope; the lack of resources and the great clinical need at many sites is almost overwhelming. A certain level of resiliency is essential, along with flexibility, an open mind, and the ability to improvise. Long-distance travel and busy schedules in new environments generally require significant energy levels and good health. Sensitivity for cultural differences, humility, and the ability to work with people whose language and culture may differ greatly from one's own are very valuable attributes. Another fairly essential quality is a good sense of humor - smiles and laughter often transcend cultural barriers.
Pediatricians contemplating international volunteer work must consider a number of basic logistical factors such as their own families. Being away for even brief periods of time may be challenging for the family and the volunteer. Juggling work schedules and shuttling children to and from activities is obviously more challenging for the family if one parent is halfway across the world. Families of volunteers may be concerned about safety during travel and in a developing country. However, some opportunities allow volunteers to bring a spouse or children along, and the experience may be enriching for the whole family.
Working in cooperation with colleagues in home environments also is important, and the logistics of pediatricians' practices may dictate how long and when they may be away. One may not engender good feelings if one decides to be gone for the month of January, leaving colleagues to deal with the respiratory syncytial virus or influenza season. Especially for an employed physician, the issue of time off must be addressed. Volunteer work often may be used as educational time (category 2 credits), because the pediatrician is both teaching and learning. Duties may include attending on a ward or in a clinic; teaching students, residents, nurses, or other colleagues; or learning the structure and details of an entirely different healthcare system. Many pediatricians, however, may need to use personal or vacation time or take a leave of absence to do volunteer work.
Finances, unfortunately, also must be addressed by anyone volunteering internationally. Increasing financial pressures in today's healthcare system have made it more difficult for pediatricians to be away from practice and not "producing." Monetary losses from a trip abroad may include lost income and the cost of travel, as well as food and housing while abroad. If one is working with an organization, the group may partially or fully support the pediatrician. In addition, there are grants and scholarships available to help with funding. A number of volunteer organizations encourage and guide physicians in fund-raising to support this kind of volunteer work.
One's own personal health and safety must be taken into consideration when volunteering abroad. A significant acute or chronic medical problem may be much more difficult to deal with when traveling and working in areas with limited resources. Availability of medication and access to medical care must be considered, especially for women who are considering volunteer work during pregnancy. Many volunteer opportunities may entail work and travel that is much more physically demanding than usual workdays, with added challenges of extreme climate or altitude. Exposure to infectious diseases, as well as safety issues including motor vehicle accidents, violent crime, natural disasters, and war may pose additional significant risks. Although these factors may seem like significant obstacles, good health, reasonable caution, and common sense allow volunteers to work safely and securely in a wide variety of sites.
One of the first things to decide when planning volunteer work abroad is how to get involved. Taking into account all the factors mentioned previously, how can pediatricians best spend this limited time to use their skills in a way that will have some positive effect on the children and healthcare workers they will meet? Many pediatricians choose shortterm volunteer opportunities. Numerous organizations accept physicians willing to donate 1 or 2 weeks of their time (Sidebar 1, see page 701). Most groups ask for credentials, and some may require certification in cardiopulmonary resuscitation, pediatric advanced life support, or neonatal advanced life support. In addition, some groups may require foreign language ability.
If considering a longer term placement, larger nongovermental organizations, government agencies, or universities may be good contacts. For most practicing pediatricians, a long-term commitment very likely could mean a leave of absence from practice, or possibly a career move in a new direction.
Volunteer positions abroad may entail several different kinds of work. Some opportunities are strictly clinical, such as examining and treating children in a hospital, often with other volunteer medical professionals or with local physicians and nurses. Pediatricians may work in facilities that are staffed and run by nongovernmental organizations or in locally run clinics or hospitals. Other positions involve teaching, either in the form of more formal lectures or using more hands-on teaching in clinic or hospital settings.
A number of teaching sites may invite pediatricians to attend or coattend on an inpatient ward or clinic. Some positions involve work in research settings or in more public-health-oriented programs, working in or helping to develop educational or healthcare programs in a community. Obviously volunteers need to draw on their own experiences and training, but international work may also offer an opportunity for professional education and growth.
In addition to looking at the type of work, there are other factors the pediatrician working abroad should consider. Opportunities may involve traveling and working as part of a team (eg, running a clinic, surgical trip, educational group), working independently with only local staff, or working with visiting medical staff from a number of different countries. Each of these makes for a very different type of experience; some volunteers may enjoy the shared sense of accomplishment that being part of a group fosters, whereas others may be more comfortable working independently. Religious groups support many volunteer medical organizations, and the pediatrician should consider the effects of this aspect on the experience.
Once one decides on the type of work and the site, it is important to prepare adequately for the trip. The first step is to understand the job description. There may be specific duties, or duties may be decided by the volunteer. What is most needed where the volunteer is going and what resources he or she will have to work with should be researched. Job elements that volunteers should consider include the length of the work day, whether there will be any time off, and who will be assisting. It is good to know what medical procedures will be performed, to remain within any specialties and to know if any specialized skills are required in case updating or recertification is necessary. Learning the range of medical problems in a clinical situation is important, as is information about potential students and their levels of medical education. It is also worthwhile to learn as much as possible about the resources of the hospital or clinic where you will be working - whether they have a pediatric ward, what the facility is like, and what laboratory, x-ray, and medications might be available. Connecting with previous volunteers at the same location is often the best way to find accurate information.
Geographic Area and Indigenous People
In addition to learning about medical facilities and duties, it is important to learn as much as possible about the geographic area. If they do not speak the local language, volunteers should determine whether translators will be available. If even a few phrases of the language can be learned, they can go far with patients and staff alike; these efforts will be met with smiles and appreciation. A few timely comments, such as "hello," "please," "thank you," or "delicious" may be great icebreakers. Try to learn about local geography, history, and culture in order to determine if there are specific ethnic groups that will be encountered and any forms of traditional healthcare they may use. Reading travel guides and writings by local authors from a country or region can give great insight into a people and their culture. Other factors to consider are weather (season), travel logistics, food, and lodging. Access to computers and the Internet is variable in some areas, but may be an important resource for a volunteer working in a developing country.
Packing, Supplies, and Travel Requirements
Once a site is picked and dates and travel arrangements set, trip preparations may be started. Volunteers must consider what type of equipment and supplies to bring, which depends on the type of work being performed, the local resources, and space in baggage. For most clinical sites, basic tools such as a stethoscope, otoophthalmoscope, and blood pressure cuff are needed. Ear curettes and tongue depressors also may be helpful. Only supplies that are useful and do not require advanced technology to be maintained should be taken. If volunteers are providing clinical care, supplies to consider bringing might include disposable gloves, masks, gowns, and eye protection; antiseptic handwash; HIV prophylaxis kit; N95 masks, especially in areas where severe acute respiratory syndrome has occurred; containers for dispensing medication, such as plastic bags and small plastic bottles; transformer for any electrical equipment because voltage may be different; and code cards or Breslow Tape for emergencies. Many volunteers bring medications as well, because access to medications is a perennial challenge in much of the developing world.
When choosing medications, volunteers should keep in mind the range of medical problems at the site, ease in storing and administering the medicine, and the amount each volunteer will be able to supply. It is often possible to obtain donated medications, either through donor programs at pharmaceutical companies or non-profit organizations that handle donated medications. Medications obtained in small sample quantities may be helpful but are often not easy to transport because they may require a fair amount of luggage space and add weight. Volunteers should never bring expired medications to sites. Medicines most commonly needed in clinical settings include antibiotics, antipyretics, and analgesics. Depending on the site, iron supplements or multivitamins also may be useful, as will emergency medications such as epinephrine and atropine. Medications that are not really useful, such as cough and cold medicines, should be avoided, and new medications that may not be familiar to local healthcare staff, should be used with caution, especially if they have significant side effects.
Pediatricians working abroad also may want to take some reference materials. Books are heavy and difficult to transport, but a Harriet Lane handbook, a basic pediatric text, and a book on tropical medicine all could be helpful. References on infectious disease and nutrition or language texts for healthcare professionals also may be very useful.
Personal travel preparations cannot be overlooked. Obtaining a passport and visas takes longer because of increases in security since September 11, 2001. Volunteers should make and bring copies of all important documents and check the Centers for Disease Control and Prevention Web site3 or a local travel clinic to help decide if any vaccinations or medications are needed before departing. Volunteers also should have adequate supplies of any personal medications, including sunscreen and insect repellent. Many healthcare settings in other countries have dress codes, so these standards should be checked, and appropriate clothing should be packed.
Cultural and Professional Preparations
If the work will entail teaching, appropriate preparation is important. It is good to know who will be taught (eg, medical students, local physicians, nursing staff) and what kind of teaching will be required (eg, bedside rounds, formal lectures, discussion groups). Availability of equipment such as slide or overhead projectors may be limited, so preparations should be made at home for handouts or learning materials. Teaching volunteers may have topics they are already comfortable speaking about, but it is good to ask what those at the site are most interested in learning.
While working at the site, attention to cultural issues cannot be overemphasized. The local beliefs and customs regarding medicine and the medical community should be examined, as well as the role of physicians compared to traditional medicine providers and the level of education of the patient population. Language issues are particularly important. Appropriate terminology should be used for the local population; therefore, only appropriate and useful translators should be used. Pictograms should be considered as instructional tools depending on language barriers or patients' literacy levels.
Cultural re-entry after volunteer work abroad may be very challenging. Returning to the "opulence" of a western medical setting only emphasizes for volunteers the relative lack of care and resources in the developing world. Patients and parents may seem overly demanding here at home, and pediatrician volunteers may be both physically and emotionally drained after such a trip.
Sharing of experiences may not be easy for volunteers once they return home. Most people do not really want to know too much about their experiences, and it may be very difficult to communicate experiences; criticism of the home area may not be well received. Volunteers may, however, direct the energy and enthusiasm such a trip evokes into useful projects at home, such as giving talks or slide shows about their experiences to colleagues or students. These projects may encourage others to get involved in international child health activities by working with colleagues, students, or residents to consider becoming involved at the planning or administrative level. It may be easier to discuss experiences with colleagues who have been on similar trips.
CONTRIBUTIONS WITHOUT TRAVEL
For many pediatricians interested in international health, a trip abroad to a developing country may not be possible or may be something that needs to be postponed for a few years until family or financial issues are more conducive. There are, however, several ways to be involved in international child health without ever leaving the country. Donated books, journals, and medical supplies are greatly appreciated by colleagues in developing countries. The American Academy of Pediatrics Section on International Child Health has an on-going program to donate pediatric books (Sidebar 2, see page 704). Another program called REMEDY, started at Yale University, helps organize the recycling of medical supplies for use in local hospitals in developing areas.
Obviously, pediatricians do not need to travel to care for children from the developing world. International adoptions have increased dramatically in the past few years, and many larger medical centers have developed international adoption clinics, run by pediatricians who have special interests in these children. As mentioned previously, even in a small practice, an interested pediatrician can become a resource for screening and caring for children adopted from abroad. Many areas of the country also have large numbers of immigrant children, many from developing countries. These children often arrive with medical problems, and they, too, need adequate screening and care that is culturally sensitive.
Another way to be involved is to sponsor or work with colleagues who are visiting from abroad. Physicians or nurses from other countries may benefit greatly from short-term stays here in the United States, and they can, in turn, educate their colleagues in their home nations.
Children, especially in developing countries, cannot speak for themselves; they need the strong voices of educated pediatricians who have greater access to legislators. We can urge leaders both at home and abroad to support initiatives that advance the health and welfare of children. Pediatricians can speak out on issues such as child labor, child soldiers, land mines, and lack of healthcare access for children. We can encourage our own government to ratify the United Nations' Convention on Rights of the Child. As individuals or as part of activist groups, we can encourage our government and those of other countries to support issues that prioritize child welfare.
The Internet has opened new doors for pediatricians in developing countries. Although access to the Internet varies, pediatricians in the United States can now more easily share new medical information with our colleagues abroad, and "e-mentoring" and clinical consultations across the globe can occur very rapidly. Several organizations have developed or are in the process of developing telemedicine programs with institutions abroad, and more pediatricians may work with colleagues in developing countries via simple e-mail communication.
Work in the realm of international child health offers many gains for practicing pediatricians. Whether at home or abroad, the amount one can learn about clinical medicine and healthcare systems is astounding. These experiences also generally make one more flexible, innovative, and much more appreciative of the resources we have in the United States. Experiences in international child health also tend to "recharge one's batteries" and rekindle one's enthusiasm for pediatrics. Often in settings abroad, pediatricians can just practice medicine - taking care of children the way they have been trained, without the many hassles and paperwork that sometimes can overwhelm them in their own practices.
Pediatricians are given special gifts in the opportunities they have to touch the lives of children. Pediatricians who work in other countries know it is wonderful that, thousands of miles away and in vastly different cultures and lands, they are entrusted with the parents' most precious possessions - their children.
1. Global Population Profile: 2002. International Population Reports. US Census Bureau, Population Division, International Programs Center. March 2004. Available at: http:// www.census.gov/ipc/prod/wp02/wp-02.pdf. Accessed September 7, 2004.
2. Profile of General Demographic Characteristics: 20O0.Census 2000 Summary File 4 - Sample Data. Geographic Area: United States. US Census Bureau. Available at: http://factfinder.census.gov/servlet/QTTable? _bm=y&-geo_id-D&-qr_name=DEC_2000_ SF4_U_DPl&-ds_name=D&-Jang=en. Accessed September 7, 2004.
3. National Center for Infectious Disease Travelers' Health [Web site]. Available at: http://www.cdc.gov/travel. Accessed July 30, 2004.