This essay was originally published in Chapter 8 of Barefoot Global Health Diplomacy.
The year 2000 brought a wave of health programs answering the call of the Millennium Development Goals. The early campaigns took aim at a single disease, such as HIV/AIDS. The international goals for addressing all factors that affect health, including the social determinants, have since matured to prompt efforts to strengthen entire health systems, widening their scope to corral badly needed resources to combat noncommunicable diseases that cause the majority of deaths worldwide.
The number of programs built to address these Sustainable Development Goals has exploded, created and supported by nongovernmental organizations (NGOs), governments, and universities. The workforce deployed, many times by high-income countries to low-income settings, can involve researchers, medical students, nurses, or physicians, to name just a few. Yet no matter the years of experience, even the best trained health worker sometimes does not fully appreciate the health system, societal, or political context in which they are about to work. This can have a detrimental effect on the worker, on the host system or university, and on wider diplomatic relationships between programs and even countries.
I have accumulated experience working and teaching in East Africa, in both rural and urban settings, in NGO and government-funded initiatives, and alongside academics, physicians, medical students, and medical residents. These posts have introduced me to, and made apparent the need to confront, one of the most disturbing personas I have come across: the “global health” martyr.
The “Global Health” Martyr
I arrived on the packed open-air medical ward to meet my new colleague. He was exasperated. There was a medical ward full of 72 patients to be seen and the medical officer interns were nowhere to be found. There had been three deaths overnight and he had not received a single phone call. The nurses had his local mobile number – why hadn’t they called?! He had been there in the East African country for a year. His well-rounded training as a physician in the US had prepared him well to take care of patients in any setting, but his own physical signs of burnout were apparent. Seemingly on the verge of tears, he was defeated – not just by the daily preventable loss of life, but also by the exhaustion of staying on call every single night since he had arrived last summer. If he wasn’t going to show up to help these patients, “who would?,” he thought.
In a neighboring country, the new wave of health volunteers arrived from the States. A group of red-eyed nurses, physicians, and midwives grabbed their luggage and jumped into vans waiting to take them to the hotel. They were welcomed by one of the nurse volunteers from the same program who had already been in the country for two years. She would serve as their main host and the one tasked with orienting them to their host culture for the next year. Over instant coffee the next morning, she told about the work she had undertaken during her time of service. The volunteers were welcomed by various Ministry leaders and oriented by their program’s staff for two weeks before separating into the different towns where they had been assigned. The nurse volunteer gradually appeared reluctant to collaborate with newly arrived colleagues at her institution. She seemed hesitant to share materials from previous projects or even PowerPoint slides she had used for lectures. It became apparent she had not built positive relationships with other local NGO workers, or even ward nurses. In fact, it sounded like she was working on projects strikingly similar to those from other organizations in town, but she did not seem to be aware of their work. The small pet projects of hers looked great to the American organization that sent her, but no one else knew much of the details of her successes or failures. What had she accomplished over the past two years? Only she knew, and in fact, that seemed to be her goal. If she was indispensable, she could secure funding to keep her in the country another year. She did not appear eager to return home to work in the US.
In each of these locations, a desire for service, glamorized by The Last King of Scotland, or worse, an older, more paternalistic or even colonialist model, had transformed, perhaps unconsciously, into a self-serving and destructive mission.
The Martyr, defined
Historically, a martyr is one who gives up their life for a cause, many times with religious underpinnings. Their belief in a dogma bigger than themselves drives them to suffer and to make the ultimate sacrifice, giving their life to further the quest for others. In health care in the United States, the metaphorical martyr has been glorified. Displaying signs of martyrdom – the cranky surgeon barking orders in the operating room, the fatigued nurse working 4 night shifts in a row, the drained medical resident who has been on call once every 3 nights for a month – has been revered by superiors, commanding a badge of courage.
But society is shifting and this behavior is increasingly becoming unacceptable. Many have come to openly recognize that it is unsafe to be exhausted while taking care of patients. Medical resident work hours in the US now carry restrictions. And it is not okay to shout at teammates in the hospital. Verbally abusive colleagues are being reported and held to account.
If the martyr is not welcome at home, why then should expatriate health workers be allowed to export this model abroad? That mantra ought to be at the front of our minds whenever working outside of our home culture: if it is not okay at home, it should not be okay here.
The Martyr’s impact
The first physician I met could feel himself breaking down. But he was unaware of the ripple effect emanating from his intense desire to help. He was raising his voice to nurses and even to his boss who was, as he saw it, unwilling to hold the interns accountable for showing up to work. During lectures and bedside teaching, his tone of voice discouraged soft-spoken (common per local custom) students from speaking up or asking questions. He was simultaneously losing credibility within the department and isolating himself.
The results were damaging to him personally, to the health system, and to diplomatic goals of his program and even his country. Personally, he was suffering from exhaustion and demoralization, which were compounded by witnessing avertible death on a regular basis. Post-traumatic stress is many times written about in military circles, but he was setting himself up for a challenging return home. On the system level, his actions were harming the education of those around him, as he abruptly corrected or dismissed students, and worse, his condition was preventing him from making sound patient care decisions and this was apparent to colleagues. His boisterous presence at daily rounds even seemed to encourage the local attending physician to justify regular absences, potentially obstructing medical students from locally relevant teaching and patients from locally appropriate care. Finally, at a higher level, he inevitably stood out as an expatriate. On top of obvious racial differences, stylistic differences and cultural insensitivity caused uncomfortable discussions about him amongst local staff. Everyone at the hospital knew which program had sent him and he was unavoidably a representative of his home country.
Perhaps this was just an unfortunate case of a servant ground down by limitations in their work. Poor accountability for local health workers to show up for work, local hospital corruption with regard to the new wing being built, and leadership failures within the Ministry of Health were largely foreign to him. This judgement, though, was driven by source country expectations built up over lengthy medical or research training at home. The failure to fully understand the local context is a wider problem faced potentially by anyone funded by efforts to reach international health goals with expatriate workers.
If not the Martyr, then who?
The global health martyr can also take the form of the self-important NGO representative who’s carved out a little section of work that only that volunteer understands, that seemingly only that worker can carry out. This is inherently antithetical to commonly stated NGO goals of coordination amongst other parties carrying out similar work, thus at times creating confusion with local health staff. There is plenty of work to be done in these settings and a true leader would be working to build on previous successes or knowledge in the area and to pass on tasks to local stakeholders rather than the next generation of foreign servants. At the very least, sharing with potential local collaborators could prevent duplication of efforts and further progress towards achieving stated health goals. In a neocolonialist fashion, cooperation failures serve as a barrier to what ought to be the ultimate “global health” goal: no longer relying on international workers. Unfortunately, this martyr can effectively erase any potential collateral gains of a well-intentioned program.
Preventing the Martyr
Achieving health goals worldwide will require a hard look inward at universities, in NGOs, and within governmental programs; at all three levels of the aforementioned implications. Within each volunteer, there must be an intrinsic motivation, but this must be harnessed for good and not allowed to overshadow the needs of the intended recipient of program benefits or donor resources. Health workers must be prepared for the context in which they will serve; be supported throughout their work with close feedback and access to psychological or other required services; and return with a repatriation plan. In fact, shorter-term volunteers may require more cultural and contextual preparation to contribute safely and with respect in a brand new societal environment. The sending organization or funding entity must equip itself to monitor the performance of their volunteer and ensure their resources are being used effectively. This would include frequent iterative evaluation regarding the organization’s fit, program appropriateness, and success at meeting true stated needs of the population they wish to serve.
Finally, the diplomatic implications for the source country, programs, and institutions, must be considered more intentionally. Cuba has sent health workers abroad for several decades, with the intent of improving their stature as a country in areas around the world. The thought is that if one has been taken care of by a Cuban physician or nurse then they will likely think favorably of all Cubans. This sort of approach can be to our benefit or it can seriously backfire. If American health workers are seen as part of creating a hostile work environment, adding stress on top of that which already exists due to limited resources, how will local health workers view all future American (or other expatriate) health workers who come to work alongside them? If NGO workers are not fostering a collaborative, interdisciplinary approach employing productive communication tools, then how will health delivery programs in low-resource areas be encouraged to maximize efficiencies to eventually no longer require external assistance?
Unfortunately, these toxic personas can prevent our ability to partner effectively with key stakeholders and thwart a system’s ability to grow its capacity to serve its population. When does the “global health” martyr serve as a barrier to progress rather than a catalyst for health?
Global health interventions are not unlike other forms of international involvement. Several decades ago, we armed Pakistani military partners and did not bolster that with a plan for the resulting regional security fallout. In 2003, we invaded Iraq first, then belatedly prepared for reconstruction and a multilateral approach to stability. In health diplomacy, we are deploying and repatriating workers built for service, but we are again lacking foresight: we are missing opportunities to truly partner with local colleagues and respond to their expressed needs as part of a larger strategy to sustainably improve their systems to a stage at which they no longer need the expatriate health worker, and openings to improve international relations.
The unwitting transformation of an idealistic, altruistic health worker into a martyr can be prevented. Every time the martyr emerges, however, we run the risk of torpedoing our progress towards reaching the goal of universal health coverage, and worse, perpetuating actions that are antagonistic to both external donors’ and local governments’ stated and broader goals. The goals themselves are laudable, but a toxic approach or representative can render a hospital, an organization, or even a university, incapable of working towards the end of improved health for all.