I have been going back and forth between addressing issues related to short-term and long-term medical missions, in this post I want to talk about this something I believe all short-term medical mission programs are concerned about to some degree, that being medication safety and adverse drug reactions. The idea of adverse drug events is a concern for healthcare professionals serving everywhere and in all contexts. However, they represent a much greater challenge for short-term medical work overseas.
Adverse drug reactions are now among the leading causes of death in many countries. Adverse drug events alone are estimated to account for 140,000 deaths in the US annually. One study of ambulatory care in the US showed that 1.4% of hospital admissions were for adverse drug events. A second study described how 25% of patients who received a prescription from a primary care provider experienced an adverse drug event. A third study revealed that 5% of elderly patients who were seen in the ambulatory care setting suffered an adverse drug event.
Based on what is known about short-term medical mission and global health programs, it is clear there is a much higher risk from healthcare interventions and treatment in such initiatives than in long-term medical programs. This is especially true when those interventions and treatments occur outside functional healthcare systems.
In order to improve patient safety in global health initiatives, we must be able to identify barriers that impede patient safety. The greatest barrier to achieving better levels of patient safety in such programs is that they often lack a physical infrastructure through which to provide care. Many global initiatives attempt to provide patient care and dispense medications in churches, schools, or community centers disconnected from any existing health services.
In “The Perils and Promise of Short-Term Healthcare Missions,” (an article I wrote some years ago with my wife Candi Seager and Grace Tazellar of Nurse Christian Fellowship), we describe how this often leads to situations not conducive to safety. One reason that this can be problematic is that non-medical church volunteers often help fill prescriptions. Because they are inexperienced and are not medical professionals, this can lead to errors in filling the prescriptions. Another challenge is that a nurse or paramedic typically gives instructions through a translator. This makes the communication less direct and can lead to misunderstandings. If there is very limited time to serve each patient, confusion and mistakes are significantly more likely to occur.
Gorske addresses this issue in his article, “Why Patients are at Much Greater Risk of Serious Harm from Drugs
in the Short-term Missions (STM) Setting—33 Systems Problems.” He outlines common reasons dispensing drugs in communities as part of short-term projects (as opposed to the hospital or clinic setting) places patients at much greater risk of serious harm.
Why patients are at a greater risk of harm from drugs in the short-term mission setting:
Why Patients are at Much Greater Risk of Serious Harm from Drugs
in the Short-term Missions (STM) Setting—33 Systems Problems
Please see Harm from Drugs in Short-Term Missions–A Review of the Medical Literature for the
corresponding international standards and guidelines and references.
- Lack of understanding of the critical importance of the STM setting itself on the increased
risk of serious patient harm.
- Lack of knowledge of the patient (Every patient is a new patient).
- Lack of adequate medical record, medication list, allergy record, list of diagnoses, etc. to
determine whether a drug may be contraindicated.
- Lack of adequate time for obtaining accurate and complete history.
- Lack of adequate time/facilities for obtaining accurate and complete physical exam.
- Lack of availability of reliable laboratory testing.
- Misdiagnosis and inappropriate treatment of psychosomatic symptoms.
- Lack of adequate provider training and knowledge of WHO evidence-based international
standards and practice guidelines for patients of developing countries.
- Confusion due to language and cultural differences.
- Increased mortality due to lack of emergency medical systems and intensive care units
for timely and appropriate treatment of adverse effects.
- Lack of patient awareness of medicine’s adverse effects.
- Lack of package inserts, patient medication guides, black box warnings or other informed
consent information legally required in the US.
- Lack of adequate time for counseling concerning adverse effects by either the physician
or the pharmacist.
- Increased risk of drug interactions and drug overdose.
- Disrupts the patient/physician relationship and continuity of care for chronic conditions
such as hypertension.
- Significant increased risk of accidental poisoning by STM children.
- Increased mortality due to lack of poison control centers, emergency medical systems and
intensive care units for timely and appropriate treatment of accidental poisoning or overdose.
- Failure to comply with International Standards and Guidelines that require “There should
be no double standards in quality,” regardless of culture or economic status.
- Neither the prescribing provider nor the dispensing pharmacist will be available when
there are adverse effects from the treatment.
- Local in-country health care providers and pharmacy personnel usually have little
knowledge of our drugs and their adverse effects, and/or lack the resources to treat our patient’s
drug related complications.
- Medications used by STMs are often donated and lack compliance with WHO
international standards and practice guidelines for donated medicines.
- Increased patient harm due to STM use of drugs which the CDC, AAP, WHO and other
evidence-based guidelines report are of no therapeutic value and increase morbidity and
mortality, especially in children.
- STM use of drugs leads our patients to over-value them, resulting in additional increased
patient morbidity and mortality, especially for children, long after we are gone.
- Lack of compliance with International Standards and Practice Guidelines for the 70% of
our patient’s problems requiring health education and other preventative care.
- STM use of drugs impairs and often delays local community health worker’s efforts to
resolve true causes of illness, resulting in increased morbidity and mortality.
- STM use of drugs impairs local health worker’s efforts to promote self-reliance,
independence and personal dignity.
- Because our patients are poor and drugs are expensive, medicines are often sold on the
“black market” in developing countries.
- STM use of drugs supports and increases the effectiveness of pervasive worldwide drug
- In spite of our best intentions, the previously listed problems inherent in the typical STM
setting magnify our drug-based system’s harmful effects.
- For the above reasons, the typical STM primary care setting provides a very poor
teaching example for medical students and local health care providers and results in perpetuation
of irrational use of medicines and resulting poor quality care
- STM use of drugs inappropriately utilizes the placebo (belief or self-healing) effect,
resulting in drug dependency.
- Drugs as used in the typical STM setting do not support Jesus’ teaching and holistic
(Mind, Body, Spirit) approach to healing, but rather support a belief in drugs and magic.
- Drugs as used in the typical STM setting also impairs the efforts of the WHO and our Christian physician missionary mentors to promote an evidence-based holistic (mind, body, spirit or Christ-centered) approach to healing.
(Last updated: November 2016. Originally published in BPGHM August 2009: Why Patients are
at Much Greater Risk of Serious Harm from Drugs in the Short-Term Missions Setting
Arnold Gorske MD, FAAP for BPGHM Working Group. http://www.bpghm.org/wp-content/uploads/2017/07/WhyPatientsAreAtMuchGreaterRiskofSeriousHarmFromDrugs.pdf)
Utilizing Medications Well
The appropriate use of medications can alleviate suffering and improve the well-being of patients in resource-poor settings. Therefore, when patient safety is our highest priority, we can greatly reduce the number of adverse drug events that our patients will experience. Being aware of the challenges involved in cross-cultural prescription distribution will help us structure our programs more effectively.
Gandhi, T. K., Weingart, S. N., Borus, J., Seger, A. C., Peterson, J., & Burdick, E. (2003). Adverse drug events in ambulatory care. New England Journal of Medicine, 1556-1564.
Gurwitz, J. H., Field, T. S., Harold, L. R., Rothschild, J., Debellis, K., & Seger, A. C. (2003). Incidence and preventability of adverse drug events among older person in the ambulatory care setting. Journal of the American Medical Association, 1107-1116.
Jha, A. K., Kuperman, G. J., Rittenberg, E., Teich, J. M., & Bates, D. W. (2001). Identifying hospital admissions due to adverse drug events using a computer based monitor. Journal of Pharmacoepidemiology, 113-119.
Seager, G. D., Tazellar, G., & Seager, C. D. (2010). The perils and promise of short-term healthcare missions. Journal of Christian Nursing, 262-266.
Blog editor – Lynley Hatcher