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Feb. 13, 2019

Kevin Johnston: Ethical service learning

Feb. 13, 2019

Kevin Johnston is a fourth-year student in the College of Human Medicine, currently studying and working in a village hospital in Bududa, Uganda as a part of the Leadership in Medicine for the Underserved program. 

With two peers, I have spent the past four weeks in Bududa, Uganda as part of a partnership between Leadership in Medicine for the Underserved at Michigan State University College of Human Medicine and Foundation for the International Medical Relief of Children. Bududa is a village in Eastern Uganda located at the base of Mount Elgon, a 10,000-foot tall, 50-mile-wide extinct volcano. Most of the people here speak Lugisu.

Every day, we walk more than two miles each way to and from the clinic along a rocky, bumpy, hilly dirt road in the hot sun. As we hike to a backdrop of the gorgeous peaks of Mount Elgon, we are greeted by villagers as we walk past homes and schools (“mzungu!", "how are you?!” the children shout). The walk is tiring, the fast bodas (motorcycles) sometimes force us off the road and great clouds of dust sting our eyes, but it gives us time to reflect on our experiences.

One of the most important topics we have continued to consider are the concepts of ethical service learning versus the White Savior Complex, so we thought we would share with you some of our insights.

There is no single definition of “White Savior Complex” that would satisfy everyone, but it is essentially a desire among people from affluent nations to save poor people in developing countries, without consideration for how to do so ethically. Plenty of good people want to help people, especially people they believe are in the most need. Surely, service-learning is always good: affluent people have an exciting experience, and the population they’re serving is helped.

However, service learning can be unethical, such as when people from developed nations benefit from policies that harm the communities they are serving or when a person paying to work takes a job from a local who needs to work for pay. Volunteers don’t simply arrive with donations — everyone arrives in foreign lands, a product of one's own culture, with prejudices in tow.

For a service learning trip to be ethical, it must be sustainable. Volunteers should be present merely to enhance the work of a project that exists with or without them. The project should be locally-driven and led by the communities they’re serving.

How does our work measure up?

One of our jobs is to help with consultations. We have two consultation rooms, each staffed by a nurse who assesses patients (sometimes more than 150 patients in a single day!) and decides on a management plan. The two nurses we work with live with their families near the clinic. Our junior nurse lives a few miles up on the journey to Mount Nwsu (a several-thousand-feet peak). She arrives most days by boda, although plenty of the workers traverse the hills and miles to get to work.

The senior nurse is known for being blunt. On my first day working with her, she had me typing up her notes. I’m used to seeing no more than 20 patients a day. On that day, we saw 150, each appointment lasting no more than 2-3 minutes. As I typed frantically on a laptop that doesn’t scroll well and has a broken “c” (turns out “c” is a commonly used letter in the English language), our senior nurse said to me, “Can you add more speed?” I asked for clarification. She said, “We have many patients; add more speed.”

Since then, I have come to understand her sense of humor much better. When my colleague, Lorena, taught the senior nurse about a disease that shared a name with one of the nurse’s colleagues, our senior nurse frantically called that colleague over and informed him, “You are a disease.”

Our clinic is managed and staffed entirely by locals, functioning and seeing the same number of patients regardless of the number of volunteers. Monday through Friday each week, we have the honor of working with a group of people who grew up in Bududa or surrounding areas and are passionate about helping their community.

One day, I rode a boda up the mountainside with a staff member who teaches on sexual health. He travelled to an area where a lot of men gather to drink a homemade alcoholic beverage consisting of fermented yeast and boiled water. Men and boys continued to gather as he spoke about condoms and safe sex, listening, asking questions and laughing away their discomfort as they asked embarrassing questions. An outreach that was scheduled to last 20 minutes went on for two hours thanks to an educator who knew how to keep his audience engaged.

So, if all is well in Bududa, then what are we doing here? In the first few days, my peers and I identified areas for quality improvement. Right away, we set to work to design a triage system.

To understand the importance of this, you need understand something about waiting rooms in Uganda. Unlike in the United States where patients schedule appointments and hope to wait no more than 15 minutes prior to seeing a physician, the patients at our clinic travel many miles by foot or by boda to get to the clinic as early as possible in the morning and are seen in the order they arrived. Some patients even camp out on Sunday nights to try to be the first patients seen on Monday, the busiest day of the week.

We quickly realized that patients were being seen on a first-come, first-serve basis with little or no consideration given to the acuity of their condition. This sometimes meant that very sick patients had to wait several hours to be seen.

We educated the intake staff about danger signs, including vital signs that could suggest shock in dehydrated children — something we see too often. We made posters to reinforce the lesson and regularly staff that area to ensure adherence to the new triage system. We have addressed other areas of improvement through continuing education meetings with the staff, using Ugandan clinical guidelines to set the standard of care.

We are thoughtful about the sustainability of our work. We cannot simply transpose American solutions here. And that has made our work much harder. We are up against training standards that differ from our expectations, language barriers, differing values and limited resources.

Climbing the slopes of Mount Elgon in the 90-degree heat feels easy by comparison. Rafia Zakari writes in Aljazeera America that “other people’s problems seem simpler, uncomplicated and easier to solve than those of one’s own society." Whether or not we arrived with such notions, our experience has taught us that nothing could be further from the truth.