“Fit” for service: contrasting physician profiles and motivations for short-term medical missions and Médecins Sans Frontières

Defining the profiles and motivational characteristics of participants in humanitarian medical care may influence recruitment and investment strategies of policy makers. In addition, having reference models may assist current or potential participants in reconciling their own compassionate yearnings and may be valuable in supporting their decision to act. The diverse array of actors and dimensions compels that the study of humanitarian care be parsed into segments that ultimately reconnect to form a body of relevant knowledge. Such a composite, though ever evolving, may inform effective implementation strategies and utilization of resources. Among the myriad of skilled personnel required in effective and sustained direct medical interventions, physicians remain essential, so the features of physician participation are a good starting point. This review approaches characterization of physician participation in humanitarian medical care by comparison of paid and unpaid private sector participation that tends to align with short-term and long-term deployments. Some important variations and commonalities in profiles and motivations emerge that are relevant to both policy makers and participants.

Participation of physicians from high-income countries in direct overseas humanitarian healthcare in low- and middle-income countries varies with respect to duration of commitment [1]. Long term commitments are exemplified by Medicines Sans Frontières (MSF; Doctors Without Borders), widely recognized through its work in slow disasters of conflict, epidemiologic crises, and famine. The less visible dimension of humanitarian medical care is short-term medical missions (STMMs). These commitments for few days to a few weeks are performed by physicians who are gainfully engaged in their own practices at home. In this paradigm, physicians go, sometimes alone and more often accompanied by ancillary staff, to poorer countries, where they provide direct medical or surgical care without compensation to those who have little access to medical care related to their poverty. Survey and narrative data have accumulated in recent years that allow an initial comparison of profiles and motivations of physician participants in STMMs from the US and long-term medical missions (LTMMs), specifically from MSF. The aim of this review is to coalesce information from multiple sources that may provide for a comparative description of physician profiles and motivations for STMMs and LTMMs. The utility of this comparison is to provide an insight into the pathways physicians may choose in overseas direct caregiving.

Considerable overlap and confluence exists between STMMs and LTMMs from the perspective of time, mission objectives, and mission execution. The distinction in this analysis emanates from the financial perspective of the physician participant rather than specific time parameters, the mission, or mission organization. STMMs allow for the maintenance of a continuous domestic practice and LTMMs do not. Concordantly, STMMs are uncompensated, whereas LTMMs generally require a stipend of some sort for the physician to participate. Because the most discoverable information to date regarding physician profiles and motivations for LTMMs is from MSF, the contrast will be developed upon data on STMMs from the US and from MSF LTMM physicians. The Nobel Peace Prize-winning organization MSF is perhaps the most recognizable long-term option for which information is accessible and current [2].

Several dimensions of humanitarian healthcare are excluded from this comparison. The acute medical component of international response to geophysical disasters generally takes the form of civil military action financed and coordinated through and among governmental agencies, and is not included in this comparative discussion of physician volunteering. MSF and STMMs are purely private sector initiatives, wholly disconnected from government. Along with US military humanitarian medical relief, this comparison excludes long-term expatriate medical efforts directly supported by the US government such as USAID President’s Emergency Plan for Aids Relief (PEPFAR) and the Peace Corps Global Health Service Partnership wherein physicians receive stipend support for capacity building programs. Whereas those civilian federal programs show promise in their early years towards narrowing disparities in global health, information on demographics and motivations of physicians does not yet appear to have been systematically evaluated. Further, this essay compares motivational characteristics of physicians engaged in direct surgical or medical care of the injured or sick, and does not address these aspects of physicians that focus on public health measures. Unquestionably, nursing and ancillary medical personnel make enormous contributions to humanitarian and global health; for the sake of manageability, this review only examines and compares information on physicians licensed to practice the full scope of medicine (MD and DO degrees, or US equivalent).

This topical review is not an original systematic literature review nor does it represent new primary research data. Rather, the evidence, as referenced throughout the review, is drawn from several sources. These include the author’s prior published systematic literature review, numerical data from a primary demographic and economic survey of physicians, and narrative data on physician participation in STMMs. Comparative information is coalesced from available online sources regarding MSF and from the MSF Foundation Centre de réflexion sur l’action et les saviors Humanitaires (CRASH), including personal communications. Organizational perspectives that may influence actors in humanitarian medicine are supported by key referenced publications of the current decade.

Broadly speaking, personal risk may be higher in LTMMs, whether by exposure to open conflict, civil unrest, uncontrolled epidemic, or an unsafe geophysical environment. MSF, as the operational comparator, purposely goes to areas where populations are at risk from conflict, whereas STMM volunteers typically do not, and may be restricted from travel to conflict areas by the US State Department.

Doctors and journalists were the founders of MSF in 1971 with the intention to treat people subjected to conflict, famine and natural disasters, and simultaneously call attention to their suffering and its geopolitical causes. In her seminal article on the characteristics of those who are attracted to and remain with MSF, Siméant described the socio-cultural milieu that witnessed the ascent of MSF during a time of political and religious crisis in France in the 1970s that created a vacuum for people longing for social reform [13]. Siméant’s French language narratives are enhanced and supported by her references to the zeitgeist of the epoch. Left-leaning parties were beginning to lose power. By the early 1980s, humanitarian vocations were viewed as honorable, and the humanitarian posture was considered both moral and politically neutral or centrist. Media increasingly extolled the humanitarian activity of organizations like the Red Cross. Pro-humanitarian youth literature proliferated as did the influx of funding from public and private sources for humanitarian groups. Humanitarian zeal, along with environmental activism, became the prevailing inclination, and seemed to substitute for political activism.

MSF has grown and been sustained by effective marketing, the impact of which has resulted in a faithful five million individual and organizational donors worldwide who provide 90% of revenues [14]. According to online annual reports, global expenditures by MSF in 2015 reached $1.3B, underwritten with a US component contribution of $0.38B [14].

Skilled health care personnel make up about 65% of the roughly 30,000 deployed MSF staff at any given time [15]. Approximately 26% of skilled healthcare staff is physicians of which an estimated 7% is from international sources and the remainder is locally sourced. In 2014, an estimated 115 US physicians were deployed [16].

Physicians with MSF are generally required to commit to a 9–12-month period of service at a time. Exceptions include surgeons, anesthesiologists and obstetrician-gynecologists who sometimes are accepted for period commitments of 6–12 weeks [16].

Physicians’ billeting and meals are provided communally or by per diem allowance. Starting pay, according to the MSF website, comes in the form of a $1731 monthly stipend that may increase with accumulated service time and level of responsibility [16]. Although incomes are relatively low in MSF compared to fulltime domestic practice, one can make a living and accumulate savings. Full health insurance is provided along with other benefits.

Though a structured qualitative analysis of motivation of comparative cohorts has not been performed, several parallel themes emerge from what has been heretofore published in various media. Demographic profiles hold the most distinction: whereas STMM physicians tend to be older, male, and married, MSF physicians are younger, more gender-balanced, more risk-tolerant, and less woven into the traditional domestic medical system. The most obvious driver that joins physicians of MSF and STMMs on the same platform is the underlying element of altruism, used herein as interchangeable with idealism. This altruism must endure, or else the hardships of both STMMs and MSF field deployment are too discouraging for one to continue. Flexibility, as an intrinsic source of resilience and effectiveness, is also essential. Until global health inequities converge sufficiently, strategies to identify and sustain that altruism and flexibility should be elucidated and leveraged.

The economic comparisons of MSF and STMM participation relevant to personal motivation are moot since the former endeavor is compensated while the latter is pro-bono, notwithstanding that STMM participation preserves the opportunity for a more lucrative medical career. At a composite level, though fragmented, the economic inputs to STMMs from the US alone are more than double the resources expended annually by MSF. The number of physicians participating in STMM sorties dwarfs the cohort inclined to undertake the total commitment and risk in MSF. Though less recognized, the relative magnitude of the STMM inputs cannot be overlooked. One can only speculate about the uncounted lives saved and disability adjusted life years saved in STMMs in relative proportion to the relief efforts of MSF as such impact data is heretofore unavailable.

Physicians involved in both long-term and short-term humanitarian care endeavors go beyond epidemiological remedies to one-on-one actions, and in doing so, occupy the same space at the effector end of the implementation process. Each of these humanitarian medical pathways presents its own sources of friction to the professional: cost and practice stress on the STMM road, and perhaps some professional stagnation on the MSF road. The acuity of the MSF LTMM response demands continuous activation and forward planning. It succeeds on the rails of tapping into a world of donors who care, and physician participants who are less encumbered by the circumstances of lives that hold them to other commitments. In contrast, STMM physicians fit their resolve for altruism into lives fully integrated into the domestic social fabric and its continuous demands. The two dynamics are not competitive for the hearts and minds of physicians, but rather complementary. As Siméant insinuates, humanitarian medical work is a matter of coupling of the individual physician life circumstances to differing venues for the same purpose [13]. As in narratives indicating that direct interactions with patients in STMMs evoke the desire to repeat, Dr. Mutwali Adam of MSF notes the reinforcing effect of saving a life during conflict. He finds resonance with a passage from the Quran: “If anyone saved a life, it would be as if he saved the life of the whole people” [27].

This review has focused on backgrounds of STMM and LTMM dimensions and the profiles and motivations of physician participants and provides insights for policy and research communities on physician humanitarian work. Future research on the profiles and motivations of physicians, as well as other health professionals, could be enhanced through national or international registries of participants, capturing demographics and records of humanitarian service deployments. Through research fostered by groups such as Partners in Health and the Consortium of Universities for Global Health, the future holds promise for the development and implementation of measures of impact and improved effectiveness of these dimensions [28, 29]. As the knowledge base on effectiveness builds, new insights are likely to evolve on the physician subset destined to be involved in these efforts.