Volunteering abroad: Choices, challenges, dos and don’ts

Donating time to serve those in need by volunteering abroad can be a personal life-changing experience as well as a meaningful contribution to the health and social well-being of disadvantaged communities.

However, it is important to understand one’s own motivation, be prepared, choose wisely, and be open to listening and learning.

“Reflect on the question: What are my goals? Are they in alignment with the goals of the in-country ophthalmologists?” Susan MacDonald, MD, co-founder and president of Eye Corps, a nonprofit in sub-Saharan Africa, said.

Ophthalmologists with a long experience of volunteering abroad can be a precious help to those who want to embark on a volunteer trip but do not have a clear idea on how to get involved, what is needed, where their skills may be best spent and how to get equipped. In addition, they may have fears and doubts holding them back.

Choosing a destination

According to MacDonald, the first important step when considering volunteering abroad is to follow the rules of the country. Practicing medicine in another country requires licensing and registration. Next, it is important to connect to the in-country ophthalmologists and get a better understanding of their goals.

“That’s really important from an ethical perspective,” she said. “When working with a vulnerable population, I find it helpful to make sure I understand our outreach goals and remind myself that I am volunteering to serve my fellow man — that I have an obligation as a physician to do no harm and protect the patient.”

“The poor are a vulnerable, protected population, and mixing research with humanitarian care is a slippery slope. I would be very cautious about participating in those projects,” she said, warning against joining groups that partner with companies doing first-in-human testing or using the outreach as a personal surgical training opportunity.

When choosing to volunteer, it is important to ask what is needed. The choice of where to go should be based on the skill sets one can offer because cataract surgery rather than diabetic eye care, ocular trauma or glaucoma surgery may be prevalently needed in specific areas of the world. However, everyone should be prepared to do anything to move the outreach program forward, MacDonald said.

“You really need to be a team member, which does not mean you’re just going to be doing doctor work at all times,” she said.

It is also important to research local diseases. Trachoma, for instance, is endemic in some parts of the world, and ophthalmologists from Western countries have no direct experience with it.

“When I went to Africa the first time, I had to learn how to treat trachoma and what to do in case of a trachoma outbreak in the community. I was also seeing a lot of corneal diseases that I would not normally be treating in the U.S. I had to expand my repertoire and find out what treatments were available in the local pharmacies,” MacDonald said.

Make inquiries, listen, ask for help

All the diagnostic equipment an ophthalmologist is used to may not be available in another country. MacDonald’s advice is to bring along some basic instruments.

“I would bring my loops, my 90 D and my 78 D lens, my indirect ophthalmoscope and any instrumentation that I really would be dependent on because I am not likely to have an OCT to diagnose cystoid macular edema or diabetic retinopathy,” she said.

Reaching out to the outreach leader or the doctors who are already working at the destination site will help an ophthalmologist understand what may be needed.

“Have a Zoom call and ask them how you could be helpful. If you are coming in with equipment, ask about the voltage level and power outlet. Be humble, listen, ask questions and give the opportunity to answer. Have a nice dialogue,” she said.

The same humble attitude of listening, asking for help and learning will be the key to a rewarding experience onsite. Remember that teaching is more powerful than treating. If your goal is to improve the care in a region, invest in the local ophthalmologist, teach, mentor and donate equipment.

“Do not get over your skis. Take it slow. The first time you are there, you may just want to assist rather than operate. I was on an outreach trip with a doctor who was unprepared to manage one of the typical difficult cases you encounter there. He didn’t ask for help until he was too far along and ended up with significant complications. He was devastated by what happened, so he packed up his bags and left the next day,” MacDonald said.

There is nothing wrong with asking for help. MacDonald recalled coming across an untreated retinoblastoma bigger than she had ever seen. She immediately stopped and asked for the help of the host doctor, looked at what he was doing and learned from him.

Learn the local language and social skills

Learning some basic phrases in the local language will greatly help with patient communication and help gain patients’ trust.

“The most wonderful moment is when I’m speaking Swahili, and I’m making mistakes, and a group of little old ladies that are listening to me are just cracking up laughing. We laugh together, and that’s a bonding experience of trust,” MacDonald said.

In addition, social skills must be learned. When meeting the local doctors, it will be important to ask about their families, inquire about their health and engage in some friendly personal conversation before dealing with work and professional matters.

“Compared to most cultures I have been exposed to, we tend to be more businesslike in the United States. Inquiring about patients and work schedules without getting to know each other first would be considered unpolite,” MacDonald said.

It is important to be committed to respecting local cultures, taking into account that inappropriate behaviors reflect on the reputation of the entire project.

“Women should really be careful about how they dress and not go out alone. Don’t think this is the time to party because you are really there to work,” she said.

Empowering the local workforce

Training local doctors and nurses is a priority of international eye care organizations.

“Empowering the local manpower means making the service sustainable,” Nelson Swai, MD, a third-year ophthalmology resident at Muhimbili University in Dar es Salaam, Tanzania, said.

Earlier during his residency, he was engaged in a collaborative project between his university and Eye Corps, organizing online lectures and setting up a surgical skills lab. He was also given the opportunity to undertake outreach work with the Eye Corps team in Lindi.

“It was by observing us residents struggling with surgery in the outreach that Dr. MacDonald thought there was a need for establishing a surgical skills lab. We already had a plan at Muhimbili, but it was not yet implemented. Her team joined the effort to renovate the room, supplied furniture, equipment and surgical consumables, and then we started practicing,” Swai said.

During his outreach experience, he had intensive training in biometry first. Then he was able to observe surgeons in the operating room, practice with supervision under the microscope on an artificial eye and finally have hands-on experience in manual small-incision cataract surgery (MSICS). He is now a skilled surgeon who is involved in training local junior residents.

“Having local ophthalmologists who may act as role models to the juniors is very important. I saw during my undergraduate training that the students who aspired to be eye doctors were very few, and I think it was because of the lack of role models,” Swai said.

In 2019, there were only about 70 ophthalmologists in Tanzania to cover the needs of more than 60 million people. Since then, the number has nearly doubled, but not all of them are practicing.

“Due to lack of equipment and several other reasons, some end up doing administrative jobs in hospitals, and that affects their clinical skills. Most ophthalmologists work in city hospitals, but the rural areas of Tanzania have scarcity of ophthalmologists,” Swai said.

By empowering local surgeons and engaging them in outreach services to remote, underserved communities, Eye Corps is helping in the development of long-term, sustainable eye care and boosting ongoing government strategies to increase the number of surgeons.

“The Eye Corps project may be everlasting, but we need to become independent at some point. Take an example of scenarios like the COVID-19 pandemic in which travels were restricted. It is therefore important for us to have local eye health care resources and surgeons who can perform their job competently across the country, follow up the patients regularly and train other eye surgeons at a country and regional level,” Swai said.

Glaucoma, for instance, whether medically or surgically managed, needs local specialists who can monitor the disease on a long-term basis. Due to the scarcity of trained glaucoma surgeons in Tanzania, patients who need surgery are often treated medically, leading to poor pressure control and disease progression.

“Empowering the locals to become glaucoma specialists is essential,” Swai said.

Teaching and learning

Orbis International and its Flying Eye Hospital (FEH) have a strong focus on education and training, spanning across several continents.

“Our FEH is a fully equipped teaching hospital onboard a converted aircraft that travels globally. It serves as a facility where local eye care professionals receive hands-on training and mentorship,” Malik Y. Kahook, MD, board director and chair of the medical advisory committee at Orbis, said.

Orbis has also created Cybersight, an innovative online telemedicine platform offering e-consultations, live surgical demonstrations and educational resources. This allows eye care professionals in remote areas to access expert advice and training.

“I started with Cybersight work in 2016 and then increased my commitment by going on a FEH program to the Caribbean. This was a hugely impactful experience where I had hands-on teaching sessions in the airplane surgery suite and also completed several teaching cases in a local hospital,” Kahook said.

Over the years, he has steadily increased his involvement and said that the time he dedicates to Orbis is one of the most fulfilling parts of his working life.

Every time he joins a program, he comes back home feeling he learned just as much as he taught.

“Volunteers are able to impart surgical pearls and tips for best practice, while locals can share how they overcome different barriers to delivering care in under-resourced areas as well as specific clinical needs that might be different in any given population,” he said.

Ophthalmologists, ophthalmic nurses, anesthetists and biomedical engineers with at least 5 years of experience are welcome to volunteer and can find detailed information about current opportunities and the application process on the Orbis International website. Selected volunteers often undergo an orientation and training process to prepare for their roles.

“For ophthalmologists, a subspecialty focus in pediatrics, cataract and glaucoma is particularly welcomed. Your role will involve providing direct patient care, performing surgeries and mentoring local health care providers. You’ll participate in hands-on training and workshops, both in-person and through Cybersight,” Kahook said.

He recommended being prepared for diverse cultural settings and possibly challenging travel conditions in remote or underserved areas. Orbis usually covers health insurance, handles travel logistics and provides accommodation, but flexibility and adaptability are crucial.

The results of a long-term project

As a founding board member, John A. Hovanesian, MD, FACS, has been regularly volunteering with the Armenian EyeCare Project (AECP) almost since its inception in 1992. At the time, Armenia had suffered the devastating effects of an earthquake that killed more than 50,000 people and a war with Azerbaijan that lasted for 6 years. Armenia’s Minister of Health launched a call to help fight the growing wave of blindness due to eye disease and the consequences of war-related trauma that the country was not equipped to manage.

“We’ve been working there for 30 years, and there are now well-trained doctors who did part of their training here in the U.S. There’s modern equipment, and there is an infrastructure for teaching new doctors, including wet lab facilities. The main thing we do there now is teaching new techniques, helping with challenging cases and building eye care capacity in underserved areas,” Hovanesian said.

The population of Armenia has its own genetic profile, and there are diseases that are frequent, such as Behçet’s disease and pseudoexfoliation. Retinopathy of prematurity-related blindness was a widespread problem, but AECP contributed to prevention through education on judicious use of oxygen in preterm infants, screening and laser treatment.

The less served populations in rural areas are reached by a mobile eye hospital with full surgical capabilities that travels throughout the country, and 10 clinics have been set up in various regions.

Being a place that is easy to travel to, where there is equipment and an infrastructure for teaching new doctors, Armenia can be a pleasing first location for those who wish to volunteer abroad, Hovanesian said.

“U.S. doctors are always very welcome, and working alongside Armenian colleagues is easy because most of them speak English,” he said.

Be prepared for unplanned challenges

Cynthia Matossian, MD, FACS, stepped into international volunteering programs later in her career, with her first trip to Saint Vincent and the Grenadines in 2023, joining Sight for Life.

“I always said to myself I want to go on an outreach trip. It is a way of giving back to the overall community of ophthalmology and eye care from which I received so much. I will be joining other programs later this year, including AECP with John Hovanesian,” she said.

Her advice to first-time volunteers is to be prepared for unplanned challenges. It happened to her in the middle of surgery when a massive power outage occurred.

“We had to open windows to get air circulating, and we had to use flashlights to complete the surgery. You need to jump right to alternative solutions, think on the spot, be nimble and adaptable. This will teach you that there are multiple approaches to solve the same problem and eventually will make you a better surgeon all around,” Matossian said.

She also encouraged volunteers to bring their families. Even if they have no skills in ophthalmology, they will be able to contribute.

“We’ll find tasks for them to do. It could be patient registration or walking the patient to the operating area,” she said.

Lessons learned

When embarking on an outreach trip, it is important to plan for all possible risks. Safety and security information is provided by the U.S. Department of State.

“I suggest that you register with the embassy. They will notify you if there is an emergency, and if you have an emergency, your family can notify them. I always have a copy of my passport on my phone, in the cloud and on me as well and the name of the hospital where I would want to be treated in case something happens,” MacDonald said.

She recommended carrying a medical kit that includes HIV testing and a dose of antiviral medication and being up to date on the vaccines that are needed, including malaria chemoprophylaxis.

“If there is dengue fever in the area, make sure you have mosquito repellent, and if there’s Zika virus and you are of reproductive age, make sure you’re using birth control,” she said.

Overall, it is important for those who want to join a medical volunteer project to have clear goals and reflect on what they want to leave behind.

“Have a realistic idea of what will happen after you leave. It does no good if you come, do a bunch of surgery, and don’t teach it and provide equipment so that others can replicate it. You’ll make a difference in the lives of a few patients, but it’s limited,” Hovanesian said.

MacDonald said that the biggest mistake she made when she started volunteering was to bring a phaco machine for phacoemulsification surgery.

“My bias was that phaco was the best technique in my hands. But phaco is expensive, and there is no one in [Tanzania] to repair a phaco machine. It is also not the best technique to teach and to perform for the hard cataract cases we encounter there,” she said.

In addition, she realized that she created a bias that phaco was better than MSICS and that MSICS was a fallback option.

Both MacDonald and Hovanesian agreed that choosing one place to return to and stay connected with is more impactful and more rewarding than scattering efforts between multiple places.

“I am very much about not going all over the world. If you really want to change the world, you need to decide where you’re going to work and keep going back to that same place,” MacDonald said.

“Find a place where you like working and continue to go there. You’ll see that you are building something that lasts,” Hovanesian said.

Another call for concentrating rather than dispersing efforts came from Swai, who said that donating one new slit lamp that will last for 20 years is better than donating 20 used slit lamps that will last for 1 or 2 years.

“In the same way, if you are donating 20 trucks that have been used to Africa, where the roads are harsh, the drivers are not skilled enough to handle them and maintenance service is not well established, those trucks will die in a very short period of time. Equipment is expensive, but considering the associated shipping costs, one new truck that lasts for 20 years makes more sense,” he said.

• References:
• Armenian EyeCare Project. https://eyecareproject.com/. Accessed May 29, 2024.
• ASCRS Foundation international humanitarian eyecare collaboration. https://ascrs.org/foundation/international. Accessed May 30, 2024.
• Cybersight. https://cybersight.org/. Accessed May 30, 2024.
• Eye Corps. https://www.eyecorps.org/. Accessed May 29, 2024.
• HCP Cureblindness. https://cureblindness.org/. Accessed May 30, 2024.
• Orbis. https://www.orbis.org/en. Accessed May 30, 2024.
• Sight for Life. https://sightforlife.org/. Accessed May 30, 2024.

• For more information:
• John A. Hovanesian, MD, FACS, of Harvard Eye Associates in Laguna Hills, California, can be reached at drhovanesian@harvardeye.com.
• Malik Y. Kahook, MD, of UCHealth Sue Anschutz-Rodgers Eye Center in Aurora, Colorado, can be reached at malik.kahook@cuanschutz.edu.
• Susan MacDonald, MD, of Tufts University School of Medicine in Massachusetts, can be reached at susanmacdonaldeyecorps@gmail.com.
• Cynthia Matossian, MD, FACS, founder of Matossian Eye Associates, can be reached at cmatossianmd@icloud.com.
• Nelson Swai, MD, of Muhimbili University in Dar es Salaam, Tanzania, can be reached at nelsonswai@live.com.

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