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International health volunteers 'can harm' local relationships in Africa

Every year, thousands of international health volunteers travel to Africa with the intention of “improving health outcomes” and learning about “global health”. However, from his experience in Zambia, researcher James Wintrup argues in The Conversation that their presence may in fact damage relationships between health professionals and patients.

Wintrup writes:

In my research I have studied the impact of these volunteers – from diverse backgrounds, with varying levels of experience, and include surgeons, anaesthesiologists, nurses and medical students – in Zambia. Between 2014 and 2016, I conducted research at a rural hospital where medical volunteers from the US provided various forms of medical care, including eye surgeries, Caesarean sections, and treatments for malaria, TB and HIV.

In my latest research paper I examine how the presence of these volunteers affected the lives and relationships of people in Zambia.

My key finding is that the presence of medical volunteers caused what I call “relational harm”.

These findings are important because relationships are central to the delivery of effective healthcare. Clinical care requires material infrastructure: power, water, hospital beds, medical gloves and technical devices.

But it also requires strong relationships of cooperation, trust and mutual recognition, and my conclusion is that academics, volunteers, and global health organisations should pay more attention to the “relational harm” volunteering can cause in under-resourced settings where privileged volunteers work amid extreme inequality.

The impact

Drawing on long-term ethnographic research and interviews with Zambian health workers and patients, I found that local opinions about global health volunteers were divided.

At the hospital where I conducted my research, patients were often enthusiastic about their presence while many Zambian health professionals were critical.

Patients regularly praised volunteers and described positive encounters with them.

One Zambian patient described a medical volunteer as having “a heart for patients … he doesn’t look at who he is dealing with … he can be there for anyone”.

To many patients, it seemed that volunteers often provided a higher quality of care than Zambian staff.

But this was, in part, due to differences in wealth, status and privilege between American volunteers and Zambian health workers.

While American volunteers could focus entirely on their hospital work, Zambian staff had families to support, social events to attend, and school bills to pay. This meant they could not spend as much time at the hospital or offer patients gifts, including small payments (known as “transport money”), that volunteers often offered to patients.

This was noted by Zambian health workers, like Matthew, who told me: “Most patients will say that the volunteers will help with transport money and (the patients) get back home and then they share with their friends that they got transport money. But sometimes this is at the expense of local staff, who then get called bad.”

In addition, Zambian health workers felt that their hard work and expertise were being overlooked. As another employee explained:“These international (volunteers) … they really look as if they are better, and even patients start to see a big gap. But it is not that Zambians are worse.”

This employee was pointing out that volunteers were often able to provide care that appeared to be “better” because they could work longer hours, offer transport money, or even use newer technologies and medical devices.

In this context, staff felt that they were judged negatively by patients because of the presence of volunteers.

When patients expressed a preference for white volunteers – particularly those with less expertise – it often negatively affected Zambian health workers. As an experienced Zambian health professional told me: “When somebody comes in and says they want to be treated by a white student, then you feel like a stranger in your own country.”

The presence of volunteers therefore strained the relationships between staff and patients, creating new forms of anxiety, resentment, and division.

Staff and patients were concerned that these tensions would continue to affect their relationships in the future – even in the absence of volunteers.

What can be done

These findings can contribute to growing debates about the benefits and risks of global health volunteering.

Critics have argued that medical volunteering reinforces inequality and paternalism, and caused direct harm through medical negligence. Supporters of medical volunteering argue that these risks can be overcome when medical volunteers are responsible and informed.

Focusing on the impact of medical volunteering on local relationships offers a new perspective.

In the future, global health volunteers and the organisations that promote volunteering should reflect on whether their work is damaging relationships in healthcare settings. In under-resourced contexts, these relationships are often particularly fragile, as researchers working in Sierra Leone in the aftermath of Ebola have shown.

Those who decide to volunteer should consider whether they are leaving these relationships in a better or a worse condition than they found them. If their aim is to improve health outcomes, they should ask how they might use their resources to strengthen these relationships instead of undermining them.

Study details

Relational Harm: On the Divisive Effects of Global Health Volunteering at a Hospital in Rural Zambia

James Wintrup

Published in Medical Anthropology on 4 March 2024


Drawing on ethnographic research at a hospital in rural Zambia, I show how the presence of white Christian medical volunteers from the United States damaged relations between local health workers and patients. Working from a position of economic and racial privilege, medical volunteers received praise from many patients and residents. However, these positive attitudes incited resentment among many Zambian health workers who felt that their own efforts and expertise were being undervalued or ignored. Focusing on these disrupted relationships, I argue that it is crucial to understand how global health volunteering can produce enduring forms of “relational harm”.

James Wintrup – Senior Researcher, Chr. Michelsen Institute, Bergen, Norway.


Medical Anthropology article – Relational Harm: On the Divisive Effects of Global Health Volunteering at a Hospital in Rural Zambia (Open access)


The Conversation article – Foreign healthcare volunteers in Africa can harm local relationships – Zambian study (Creative Commons Licence)


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Medical ‘voluntourism’ in Tanzania: Some help does cause harm

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