So You Want to Go on a Medical Mission

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www.npjournal.org The Journal for Nurse Practitioners - JNP 707ABSTRACTThis article is intended to provide basic information on medical mis-sion trips: what a medical mission trip is, how to find a medical mis-sion organization, and how to prepare both personally and profes-sionally.Keywords: Medical mission tripSo You Want to Goon a Medical MissionCathy S. Chapman707-712_TJNP493_Chap_CP.qxd 10/29/07 2:37 PM Page 707November/December 2007708 The Journal for Nurse Practitioners - JNPMy professional life has been arranged each yeararound a medical mission to Honduras. Somepeople think its strange that I would spend somuch money and time to go to a third-world countryfor a few short weeks every year. How can it make a dif-ference to the health of these people? But many morepeople take me aside and want to know what isinvolvedthey too would like to go.What is a medicalmission? What is involved? And why would one want todo this?There are many reasons for wanting to do a medicalmission trip: the sense of adventure, a chance to seeanother country up close and personal, a meaningfulvacation.When done in the right spirit, medical missiontrips are much more than a vacation, they truly become alife-changing experience. My colleagues and I go onmission trips with the expectation that we are helpingsomeone less fortunate than ourselves. But what we oftenfind is that we are touched and changed by the experi-ence far more than the people that we are there to help.As Ralph Waldo Emerson said,It is one of the mostbeautiful compensations of this life that no man can sin-cerely try to help another without helping himself.Mission trips are usually faith based, but there arenonreligious organizations that sponsor mission trips.Mission trips vary in length, depending on the locationand organization. Most are 1 to 3 weeks in length.If you are thinking about going on a medical mission,you have to do some tough work upfront.The first thingto look at is taking a hard look at yourself.You will bespending 1 to 2 weeks in a foreign country with peoplethat you may not know.The conditions may be primi-tive; the food may be different from that what you areused to.You will probably be working long hours withlimited supplies and equipment. Language and culturebarriers may make your work more difficult. How goodare you at going with the flow? How do you copewhen the unexpected becomes the expected? How doyou feel about cold showers, or worse, no showers? Noelectricity? How well do you do with living in closeproximity with strangers? It is absolutely crucial that youknow what you are getting into and are prepared toaccept it. If you go and do not like it, it will be thelongest 10 to 14 days of your life! You will be miserableand make those around you miserable as well!OK; so you have thought about it and you really wantto do it! The next step is finding a medical mission team.Often finding a team is a matter of looking in onesown community. Many mission teams are faith based, solooking within ones faith community or denomination isa good place to start. If you are not affiliated with or notinterested in working with a faith-based team, sometimesdoctors, nurse practitioners, or other care providers fromthe local health care community do medical relief workthat is not faith based. Check with your local hospital forfurther information on these teams. If neither of theseoptions has proven fruitful, check the Internet.There aremany websites for nondenominational faith-based organi-zations as well as nonfaith-based organizations (Table 1).Once you find a team or a group in which you areinterested, get to know this group as well as possiblebefore you commit to a trip.Try to spend time withothers who will be on your team to get to know thembetter. Be sure you are clear on expectations; knowwhat you can expect from them and know what theyexpect from you. Know exactly what the costs will beand what the cost covers.Ask specifically about before-trip costs: the cost of immunizations and any clothingand supplies that you will need to purchase before leav-ing. Know what additional costs you are expected topay when you are abroad.The first year I did a medicalmission trip, I had not been forewarned of a $25 perperson exit tax. I had spent all my money the previousday to buy gifts for friends and family and had to bor-row money to pay the exit tax!As soon as you commit to going, begin working onobtaining a passport and immunizations, if you do nothave them already.There is substantial cost involved ingetting a passport, and currently there may be a severalmonth delay, particularly if a visa is also required. Contactthe embassy by phone or e-mail of the country you planto visit to learn of visa requirements, time frame for sub-mission, cost.Your organization should be able to tell youwhat immunizations are recommended for where youwill be working.The Centers for Disease Control andPrevention (CDC) website (www.cdc.gov) is a wealth ofinformation on country-specific immunizations recom-mended, information on diseases specific to areas, and tipsPhotos on previous page courtesy of the author: Peoplewaiting in line to be seen at a clinic; and Brenda Deller,RN, of Richmond, Virginia, giving dosing instructions.707-712_TJNP493_Chap_CP.qxd 10/29/07 2:37 PM Page 708www.npjournal.org The Journal for Nurse Practitioners - JNP 709to staying healthy while abroad.The immunization rec-ommendations may vary within a country (ie, mountainscompared with coast, city compared with country), so itis important to follow the CDC recommendations. Butremember, immunizations and preventative medicationsare not 100% effective in preventing diseases, so it isessential that you follow all recommendations for pre-venting illness.You might also consult the US StateDepartment at www.state.gov for any travel restrictions orwarnings about the host country before you leave.When you receive your passport, make a copy to leaveat home with a friend or family member, make a copy foryour team leader, and hide a copy somewhere in your suit-case. One year, my passport was stolen from my pocket ona shopping venture in the city. It was my hidden copy ofmy passport that got me through customs and back home.Table 1. Websites for Medical Missionary Organizations and Medical SuppliesMedical Missionary Organizations URLMissionary Ventures International www.mvi.orgVolunteers in Medical Missions www.vimm.orgPartners in Progress www.partnersinprogress.orgChristian Medical Missions www.christianmedical.orgMedical Mission Response www.mmronline.orgSamaritans Purse www.samaritanspurse.orgMercy and Truth Medical Missions www.mercyandtruth.orgGlobal Frontier Missions www.globalfrontier missions.comMercy Ships www.mercyships.orgInternational Accelerated Missions www.iammission.orgProject Hope www.projecthope.orgMedical Missions Foundation www.mmfworld.orgInternational Medical Corp www.imcworldwide.orgDoctors Without Borders www.msf.orgFlying Doctors of America www.fdoamerica.orgMedical International Rapid Response www.mirr.orgOperation Smile www.operationsmile.orgInternational Medical Volunteers Association www.imva.orgAction without Borders www.idealist.orgRefugee Relief International www.RefugeeRelief.orgDoctors of the World www.doctorsoftheworld.orgMedical, Eye and Dental International Care Organization www.medico.orgInternational Medical Volunteers Association www.imva.orgMedicines and SuppliesMAP International www.map.orgDirect Relief International www.directrelief.orgAmeriCares www.americares.orgInterchurch Medical Assistance www.interchurch.orgProject Hope www.projecthope.orgThis list is intended only as a guide to potential organizations available. It is by no means all inclusive.707-712_TJNP493_Chap_CP.qxd 10/29/07 2:37 PM Page 709November/December 2007710 The Journal for Nurse Practitioners - JNPDECIDING WHAT TO TAKENow begins the daunting task of deciding what to take.Even though the airline allows two check-in bags perperson, most organizations allow only one of those bagsfor personal use.The second bag is used to take medi-cines and supplies. So now you need to fit clothes andpersonal items for 10 days into one bag! Three generalrules can be used for deciding what to take: (1) If youneed it, take it. Do not assume you can save space bybuying supplies when you get there. Some of the per-sonal items we take for granted may not be availablethere. If, by chance, we do find that special facial soap orcontact lens solution, it may be horribly expensive. (2) Ifit is valuable or irreplaceable, leave it at home. Unfortu-nately, theft is often commonplace in areas of greatpoverty.The wet shoes you leave on the porch orclothesline to dry may not be there on your return.Clothes washing is often done by hand with lye-basedsoap that can cause streaking and dulling of coloredclothes. (3) Be sensitive to the poverty that will surroundyou. Now is not the time to wear flashy jewelry or cloth-ing. Many of these people are painfully aware of howpoor they are.You do not need to remind them of thisthrough your attire.Be sure to carry your personal medications as wellas a small first-aid kit in your carry-on bag.Take yourpersonal medications in a small, pharmacy-labeled bot-tle. If you have any medications with street value suchas narcotics,Ativan, Xanax, etc, it is highly recom-mended that you also carry a letter, preferably in bothlanguages, from your care provider that documents theneed for these drugs.The first-aid kit should consist ofa few adhesive bandages, antibiotic skin creams,antidiarrheal and antiemetic agents, and so forth. Evenif you do not get motion sickness here in the UnitedStates, it may be a different story when riding in theback of a diesel van in need of new shocks on bumpy,winding mountain roads! Most third-world countriesare BYOTP (bring your own toilet paper)! Rememberflip-flops for the shower and mouthwash for brushingyour teeth in case drinkable water is limited.Wet wipesand waterless hand sanitizer are invaluable to wash yourhands when in remote areas and can, in times of wateror power failure, be used in place of a bath.Additionalitems may be needed such as mosquito tents that arespecific to your location.Again, the CDC website canhelp with this information.Learn more about the culture of the country that youwill be working in. Is it acceptable for women to wearpants? For men to wear shorts? For women to make eyecontact when greeting men? Are there any hand gesturesthat may have a different meaning? It is important to notoffend the people that you are trying to help. In manycountries, the ok sign that we make with our thumband forefinger means something different from ok! Handgestures do not mean the same thing universally; makesure you know what your hands are saying!Know what the rules of professional practice are inthe country where you are going.Your host organizationshould have this information, but ultimately it is yourresponsibility to be sure you are practicing within thelaws of the country where you are going. Many countrieswant a copy of the health care practitioners licensesahead of time and require that you carry a copy of yourlicense with you as you work.Although lawsuits are notcommon in these situations, it is still prudent to be surethat you are covered either through your own malprac-tice insurance or the insurance of the organization withwhom you are working.Now is time to begin assembling your medical sup-plies.Again, the basic rule is that if you need it, you bet-ter take it. Do not assume that you will have electricity.Take batteries for your otoscope and other equipment.Medicines and supplies are often expensive in third-world countries, the strength of the medicines may bedifferent from what you are used to, and often there areonly a few different medications from which to choose.There may be a few exceptions to this rule, such as medi-ations for parasites or megadose vitamin A that are notreadily available in the United States.These drugs are eas-ily obtained in countries where parasites and vitamin Adeficiency are common.Be sensitive to the poverty around you on mission trips.707-712_TJNP493_Chap_CP.qxd 10/29/07 2:37 PM Page 710www.npjournal.org The Journal for Nurse Practitioners - JNP 711Obtaining sufficient quantities of medicines and sup-plies that you need for 2 or 3 weeks can become costly.However, there are various ways that you can get medi-cines and supplies for free or low cost. Begin with thepharmaceutical representatives that call on your office.Abrief letter about your trip, where you are going, andwhat you will need is helpful.Ask your local hospital fordonations.There are organizations that receive soon-to-expire medications from pharmaceutical companies anddistributors.You can often obtain these medicines for thecost of shipping and a small handling fee. If you have apharmaceutical distributor in your area or a privatelyowned pharmacy, often medicines can be purchasedthrough them at wholesale costs in large quantities.As you begin to assemble your supplies, try to learnmore about the area where will be working.Know whathealth care services are available locally. For several years, Itold people who were experiencing chest pain to go intothe health center for an electrocardiogram (EKG).A localcare provider overheard me one day and told me that therewas no EKG machine at the health center.The nearest EKGmachine was 2 hours away! I also discovered that this healthcenter also did not have a thermometer, a blood glucosemeter, or a blood pressure cuff. I learned not to assume!Find out about the ethnicity of the people. Peoplewho are of native Indian descent or African descent mayhave a higher incidence of diabetes or hypertension.Thiscan help guide your choice of medications and theamount that you take. Common medical conditions seenin third-world countries include malnutrition (both pro-tein deficiency and calorie deficiency), parasitic infec-tions, dehydration, musculoskeletal symptoms, venous sta-tus ulcers, plus everything you see here in the UnitedStates: colds, flu, ear infections, sore throats, and so forth.When choosing what medicines to take, there are afew things to consider. Birth control is not readily avail-able in many areas, and prenatal care, including pregnancytests, are almost nonexistent.Women of childbearing ageshould be considered pregnant until proven otherwise. Ido not use medications such as doxycycline in womenunless the woman has had a tubal ligation, hysterectomy,or is postmenopausal.Consider the environment when prescribing medica-tions.A medicine that has photosensitivity as a possibleside effect would not be a good choice for someone whoworks in the fields under a scorching sun every day. I donot take -blockers because I am not comfortable thatthe patient will understand the need to taper off this medcompared with simply running out and stopping it.Consider taking enough medications for chronic ill-nesses, such as diabetes, hypertension, or asthma, to beable to give each person a years worth of medicine.Often medical mission teams are the only access tohealth care that this patient has.We try to give thepatient enough medicine to last until we or anotherteam comes again in a year.Know the regulations for bringing medicine intoyour destination county. Some countries do not allowany medicines with abuse or resale value. Some requirethat all medications have an expiration date of at least 1year in the future.All medicines should be labeled inboth languages with name, strength, what the medicine isfor in laymans understanding, and the expiration date.PROVIDING CARE IN ANOTHER CULTURERemember that these patients do not have a stockedmedicine cabinet of over-the-counter medications likewe do.They do not have acetaminophen for headachesand fever or ibuprofen for menstrual cramps or antacidsfor occasional heartburn.The lack of availability is com-pounded by a lack of understanding on proper use ofthese medications. Persons often seek treatment for thingsthat seem like minor complaints to us but are significantconcerns to the patient.These patients do not understandwhat is causing their symptoms, they do not know thatthe condition is not serious, and they do not have anymedications to take to resolve their symptoms. Educationon their symptoms and appropriate use of these medi-cines helps them to take care of themselves.Multivitamins are important in third-world countries.Because of their poverty and misconceptions about somefoods, children often do not eat well-balanced diets. Pre-natal vitamins are the exception instead of the norm forimpoverished pregnant women. My group has a workingrelation with a nutritional center for children as well asthe health center in two villages.We take 50,000 childrenvitamins and 50,000 adult vitamins with us each year.Wegive vitamins to all children accompanied by a parent, toall pregnant women and nursing mothers, and to any oneelse who complains of fatigue, lack of energy, heavy peri-ods, or gives a history of documented anemia.We leave ayears worth of vitamins for both children and mothers atthe nutritional center.Any remaining vitamins we haveare given to the health centers.707-712_TJNP493_Chap_CP.qxd 10/29/07 2:37 PM Page 711November/December 2007712 The Journal for Nurse Practitioners - JNPWhen choosing antibiotics, remember that smallgun antibiotics work well in most third-world countries.Because of the limited use of antibiotics, medicationssuch as amoxicillin, Bactrim, erythromycin, and othergeneric antibiotics usually work well.We do not useantibiotic powders for children that require reconstitu-tion with water. Many liquid antibiotics require refrigera-tion; most of the people that we serve do not have elec-tricity, much less a refrigerator.We also found that eventhough we instructed mothers to use pure water toreconstitute the medicine, they were not doing so.Wenow use low-dose crushable or chewable antibiotictablets.We instruct moms to crush the tablet betweentwo spoons and mix with a little sugar and then give tothe child.The child takes this readily, and we are notexposing the child to additional bacteria or parasitesthrough the contaminated water.Keep in mind that illiteracy is high in many adults inthird-world countries.These people usually do not vol-unteer this information unless you specifically ask.Youmay need to give instructions to a child who is able toread who will assist their parent or grandparent in takingthe medicine properly.To help them in taking medicationproperly, we often use a small handout that shows the sunat various positions in the sky to represent various timesof day.We circle the sun that represents the time that wewant the patient to take the medicine.Remember that there is a real knowledge deficit ofthings that we consider innate knowledge: washing ofhands after using the bathroom and before eating, theimportance of covering cuts or wounds to keep themclean, wearing shoes to help prevent parasite infections,not walking barefoot through animal dung, coveringfood to keep flies from contaminating it, and theimportance of pure water.As you treat things such asvenous status ulcers, lacerations, abscesses, or if you doany minor surgery, remember that you will need togive detailed care instructions. Do not assume that apatient with a laceration on the foot knows to keep thewound covered until it heals and knows not to gobarefoot!If your organization has a relation with a health cen-ter or care provider where you are going, consider takingextra medications and supplies to give to them. Fre-quently, these health centers have no medicines or sup-plies to give to their patients and the patients cannotafford to purchase them.TIPS FOR SUCCESSFinally, when you are packing the medicines to takewith you on the airplane, pack them heterogeneously inthe suitcases or containers. If you pack your medicineshomogenously (that is, you put all the antibiotics in onesuitcase, all the vitamins in another bag, and so forth) and asuitcase gets delayed or lost, you have now lost your entiresupply of that medicine. Distributing all the medicationsevenly into all suitcases, lessens the effect of losing a bag.A few last tips for a successful trip include the following: Weigh the suitcases before leaving home.The line atthe ticket counter is not the place to redistributeitems because the suitcase is overweight! Elastic bandages serve a multitude of uses and arewashable and reusable. Do not do anything that you would not do in theUnited States. You are working under less than ideal circumstanceswithout any medical follow-up after you leave, sogive the best possible care that you can. Realize that clean, not sterile, may be as good asyou get. Do not shake your head to anything you do notunderstand. Do not make promises that you cannot keep. Do not give anything away in public places; youwill constantly be mobbed for things. Learn a few words or phrases in the host language:hello, good-by, please, thank you. Keep your eyes and ears open at all times. Smile a lot. Most importantly, HAVE FUN! Cathy Chapman is a certified family and adult nurse practi-tioner at TriState Community Health Center in Cumberland,MD. She just completed her 12th trip to Honduras withMAMA Project and can be reached at chapman.cathy@gmail.com. In conjunction with national ethical standards, theauthor reports no relationships with business or industry thatrepresent a conflict of interest.1555-4155/07/$ see front matter 2007 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2007.08.014707-712_TJNP493_Chap_CP.qxd 10/29/07 2:37 PM Page 712So You Want to Go on a Medical MissionDECIDING WHAT TO TAKEPROVIDING CARE IN ANOTHER CULTURETIPS FOR SUCCESS