• Feature

    Making the Most of International Volunteer and Learning Opportunities

    A growing number of PTs, PTAs, and physical therapy students travel outside the United States to volunteer their services and to learn more about health care worldwide. How can these experiences help ensure a successful experience for everyone?


    Before he or his students become involved in any international volunteer activity, Michael Landry, PT, PhD, presumes the worst. "I go in with the assumption that I'm going to do more harm than good. Then I must prove myself wrong. Because," in his opinion, "in the aggregate over the centuries, [volunteers] have done more harm than good."

    Landry is chief of the Doctor of Physical Therapy Division in the Department of Community and Family Medicine at Duke University Medical Center in Durham, North Carolina.

    If his stance seems harsh, it reflects a fear shared by many physical therapists (PTs) and other health care professionals. They note that poorly constructed volunteer programs can harm that nation's patients and its health systems. Although it sounds obvious, programs that send professionals or students to other countries to "help" ought to benefit patients, the host country, the professionals or students, and the educational institution.

    Different Programs, Different Goals

    PTs and students can choose among several "flavors" of international experiences, each with potentially different approaches and goals. [See "Experiences at a Glance" on page 19.]

    One type of experience is what's termed "voluntourism"—typically a combination of tourism and volunteering, often in developing nations, in which the volunteer pays a fee to a sponsoring company. It's estimated to be a $173 billion industry.

    A potential downside, as expressed by a critic of voluntourism, is, "Travel is designed to benefit the sponsoring companies rather than disadvantaged communities. It is done by selling international service experiences to young people, mostly students, and is branded as a way to enhance their resumes. While host communities benefit from the rise in tourism and labor, nongovernmental organizations (NGOs, which often partner with lucrative-seeking volunteer organizations) benefit from their projects gaining international exposure in fields such as science, medicine, and infrastructure."1

    On the other hand, well-run volunteer programs—with the emphasis on volunteer, not tourism—can result in great benefits for both patients and health care professionals. Posting on LinkedIn, Renee Cordrey, PT, MSPT, wrote, "I am very involved with Health Volunteers Overseas (HVO), which partners with APTA … The focus of HVO is education. We don't work with patients directly, but teach local clinicians. That might be via rounding, classroom sessions, and whatever else is appropriate for that setting … .

    "I'm not a fan of many of these programs that just send a group into a village, try to round up people for surgeries or other care, then leave," Cordrey continues. "There is no follow-up on who got treatment, and the person who has a need the day after the plane leaves has no potential to receive care. By training local people, on the other hand, the knowledge stays, and those clinicians teach more students and their peers in the community. The footprint you leave can be huge." Cordrey is a wound care specialist at Genesis Rehabilitation Services and MedStar Georgetown University Hospital.

    Some international programs are extensions of the service learning concept. Service learning has been defined as "a structured learning experience that combines community service with explicit learning objectives, preparation, and reflection."2  

    The experiences usually are short—often 3-12 weeks—and occur in developing countries.

    Similar but less structured than service learning are what Jennifer Audette, PT, PhD, an assistant professor at the University of Rhode Island, terms "broadening experiences." The goal is to offer students opportunities to learn how PTs are trained in other countries. Audette's programs send DPT students to developing and developed countries for 2 or 3 weeks. In developed countries, they sit in on university classes, interact with other students and faculty, and, if the opportunity is there, observe in a local clinic. In developing countries, they may perform hands-on interventions under the supervision of a local PT.

    Another type of global experience is international clinical education—an opportunity outside the country where the physical therapist education program is situated, for which students earn clinical education credit. As such, these experiences are likely to be longer than service learning experiences, and occur in both developing and developed countries.3

    Who Benefits?

    Regardless of the nature of the program, the goals often aren't well-defined in terms of who or what is to benefit.

    "How are we going to look at the outcomes we're achieving, and how do we get better at describing the outcomes we want?" Audette asks, regarding educational experiences in particular. "That's been a soft spot in the past. We know there are benefits to taking students abroad. I think it changes their ability to relate to different kinds of people, and to use their resources and knowledge."

    She is developing objectives for her school's programs, and in doing so conducted a survey. "Most people who responded said the most important element was giving students opportunities to encounter situations and people different from those they know," she says. "Less commonly cited objectives were development of clinical skills and knowledge."

    Although the goals of these education programs—and the way goals are measured—still need strengthening, they've come a long way in the opinion of Celia Pechak, PT, PhD, MPH. "When I got into global health work, it usually was, 'What I did last summer,'" she says. "But we've since made real changes, molding these experiences into scholarship in global engagement. What are best practices? How can we use data to drive programs?" Pechak points to presentations on global engagement at APTA's Combined Sections Meeting (CSM) over the past 15 years as a demonstration of the inroads made. "Their quality is the difference between black and white."

    Pechak is interim associate program director and an associate professor in the College of Health Sciences at the University of Texas at El Paso. She also is chair of the executive committee of the Global Health Special Interest Group of HPA the Catalyst, APTA's health policy and administration section.

    One of Pechak's section colleagues, Ira Gorman, PT, PhD, MSPH, is assistant dean and associate professor at Regis University and president of HPA the Catalyst. Regis offers 3-week international clinical education experiences in Nicaragua, Peru, and Ethiopia as part of students' 12-week clinicals. In Ethiopia, students are placed with local physiotherapists. "The relationship is between our students and those physios. Their physios are licensed to teach our students," Gorman explains.

    Gorman adds that the Ethiopian program, based at Black Lion Hospital in Addis Ababa, is interdisciplinary, involving nursing and pharmacy students. It also includes primary care. Regis's Peru and Nicaragua programs, meanwhile, involve work in the community—including homes and schools.

    Gorman outlines the goals of the school's international experiences: "Students gain clinical skills, and they get to teach. They also see things they may not see in the United States—certain modalities or techniques. Most important, they gain an understanding that the rest of the world is not like our country," he says. "The experience opens their eyes to very different people, cultures, and health systems. It makes them better able to appreciate things when they get back here."

    Like those of education programs overall, the Regis program's goals are geared toward the students. Gorman says, "Students come to appreciate that there are low-income countries with limited resources. They get creative. They experience cultural exchange. They work with patients with different beliefs and desires. The key is to make them a different kind of PT when they return."

    Landry concurs. "In academia, we have a responsibility to respond to students' needs—they're our customers," he says. "This is something they want, and, so, the responsibility we have at Duke is to create a structure within which students can get a meaningful experience and figure out where they fit in the global continuum." He continues: "Students come into these programs with an amazing spirit of service. They have a huge, passionate interest in giving back to the community. I wouldn't want to discourage that in any way. We've even hired a new faculty member as director of community and global services to help fill this student need."

    Gorman is blunt, though, about secondary goals and benefits. "We think we're going over there to do service' in these countries. But if we really want to help them, we'd just give them money. It would be better than spending money for travel, housing, and so on." Students do provide service, he adds, but what they themselves get out of the experience is at least as important as what they give in return.

    Do These Programs Help Patients?

    Most of the PTs interviewed for this article said programs can help patients provided they are run properly. The University of Minnesota offers clinical education programs in Niger, Tanzania, Ecuador, and Italy. The school's James Carey, PT, PhD, gives this example: "We learn about other things—not just clinical conditions, but also cultural issues, such as female genital mutilation," he says. "It's supposedly been outlawed, but it's still practiced by some tribes. It leads to problems—including pain—with which PTs can help." Sadly, he adds, the experience gained is useful back home. "We sometimes encounter these patients here in Minneapolis."

    On the other hand, patients can be adversely affected by poorly designed programs and volunteer efforts.

    Take, for example, a dilemma that may arise after a natural disaster. An April 2015 earthquake in Nepal killed more than 8,000 people and injured another 21,000-plus. "A decade ago, people with spinal cord injuries would die or would be triaged very low," Landry says. "Now we can preserve life. But then we leave. Having a spinal cord injury is very serious, very complex. Are we prepared for long-term involvement with these patients? These stories can be inflammatory to a PT who may ask: Isn't something better than nothing?' I invite them overseas to show them a few things."

    Harking back to Ira Gorman's insight, a follow-up question is: Even if programs help patients, are they efficient? In other words, are there better ways to provide aid? Here, there's fairly widespread agreement: There's much room for improvement.

    Karen Coker, PT, DPT, an assistant professor of physical therapy at Tennessee State University, comments on whether using foreign-based volunteers in Kenya is efficient.

    "Definitely not," she says, conceding that for immediate needs, though, "it's a balancing act. We must train health care workers from these countries. We must set up schools and teach people how to give care in their own communities. That is the only long-term solution. But currently nothing is there. There's no real medical care. You have to double your time because you are reliant on interpreters. You don't know the people, their living situations, or the diseases. Can you even recognize the diseases you see in the patient population?"

    A staff member of a US-based medical volunteer organization who we'll call Robin—she asked not to be identified—said this when asked which aspects of aid from US-based PTs are most beneficial: "Honestly, financial aid is typically most beneficial. It's great when PTs bring supplies with them to eliminate the cost and hassle of shipping those items, but often PTs from the United States have a poor grasp of what supplies are actually needed. This is especially true of first-time volunteers," Robin adds. "For example, we had 1 very well-intentioned but uninformed PT who brought an entire suitcase of eStim products: machines, pads, and so on. But we don't have reliable electricity in this locality, and batteries are far too expensive to make appropriate use of eStim. I know the PT meant well, but I wish she had stuck to the list of supplies we actually need."

    Reflecting or Imposing US Values?

    Many of those interviewed for this article mentioned the role of the PT as an ambassador and discussed the delicate balance between reflecting US values and imposing them on citizens of other nations.

    "The idea of ambassadorship is important when we go into developing countries," Carey says. "Niger, for example, frequently ranks last in international measures of health and infant death. We go there and learn. Niger is 99% Muslim, and it's a patriarchal society. Traditionally, women haven't been educated. When we bring in women as students and faculty, we're sending a message that women can achieve. When we bring in Christians, we're showing that Christians and Muslims can get along."

    On the other hand, Carey continues, "Our students have to honor the rights and privileges of the culture. For example, wearing headscarves, shaking hands, or understanding that men enter a room first at formal events. Some of these things may be uncomfortable for some students, but forcing our cultural practices onto local populations could be damaging."

    Audette says, "We sometimes go in with the idea that we're going to teach them everything we know. But frankly, most of our partner organizations largely don't want to know what we know. They want to know that they're doing a good job with what they have. And, for the most part, they are. A large part of our job is to be good ambassadors, because people have preconceived notions about what Americans are."

    Robin, from the US-based medical volunteer organization, says, "It is really frustrating, especially for our in-country health care staff, when US volunteers insist on doing things the way they do them in the States. I understand that's how they were trained, but a great degree of flexibility is needed if you are working in another country. It's a matter of respect for the culture and the local medical workers, as well as a safety concern. Patients are best cared for when cultural and environmental factors, plus notions of access, are taken into account—all of which may require drastic changes from the US standard of care. The quicker volunteers come to realize this, the better."

    There's also the threat of what Landry calls "inadvertent harm." He explains: "You have many students who want to treat patients. They enter a community with a local NGO, and the people see these Americans coming. Somehow they think they have this [special] expertise. It usurps the power of local providers. If we're not careful, we perpetuate the myth that if you're from the US you're better than, say, a Malawian physiotherapist. We must be acutely aware of our capacity for doing harm. Our role primarily should be to support the local infrastructure, not recreate it."


    A term that's often used in describing the goals of learning and service programs is "sustainability." One aspect is sustaining a long-term partnership between the university and the local health organization, so students continue to have the international opportunities. Pechak says, "It used to be that you'd take students to one place one year, another place another year. We collectively have made progress in developing long-term sustainable partnerships."

    Audette adds that is must be a 2-way street. "You also must ask if [the partner group] is a sustainable organization. Has it been there a while? Will it last a while? Our relationship with that organization should last for some time. There must be the potential for initial and ongoing communication, and a mission that aligns with the opportunity."

    Trickier is the aspect of sustainable outcomes. "Are we doing something that is changing the clients or agency?" Pechak asks. "The question now is developing sustainable change [in the host country], for which there's no easy answer."

    Michael Landry identifies 3 keys to sustainability. The first, he says, is "a much stronger onboarding process for students going overseas." In other words, students need to be well prepared for the experience. Most recently, Landry notes, this has been complicated by recent terrorist attacks in locations previously considered safe, such as France and Belgium.

    The second key, Landry says, is developing a relationship with the host community that extends beyond an individual or project.

    And third, he says, the program must reflect the wishes of the host community. Landry explains, "Someone will go to a developing country and ask: Would you like us to build something?' They say yes' because huge power differentials [between the foreign volunteers and the onsite health care workers] are involved. But the host community should have skin in the game."

    Robin, the volunteer, says, "Our goal is to have a fully sustainable health care system that functions independent of volunteers. Ideally, staff would all be locally trained and would be paid living wages. We would have our own education system to support our own health care system. Volunteers from the US truly are a valuable resource, and at present we could not function without them. But to best serve these communities and create incentives for locals to enter the field of health care, we need an exit strategy for volunteerism."

    Coker expresses a similar desire for Kenya. "Long term, we need Kenyan health care. US health care does not translate well in other countries. How that process can unfold will be tricky."

    A clinic manager in Haiti who plans on becoming a PT—like Robin, she asked not to be named—explains how prolonged volunteer efforts can erode a country's health care system. "American help has been very good. This clinic is great for this area and the people here," she says. "I would not be going to study physical therapy if I had not met the PTs from America. But it is dangerous when patients do not have to pay for their care, even if only a little." Most patients would pay what they can if they were required to, she adds.

    "After the earthquake, we needed free care, but if we do not start having patients pay now, then therapists from Haiti cannot make enough money to live and care for their families," the clinic manager says. "They either will not go to therapy school at all or they'll leave for another place where they can get jobs for a living wage. If countries want to have their own therapists, they need to ensure therapy can be a good job there."

    Carey describes how the University of Minnesota is working toward that goal in Niger. "We've been going there for 8 years," he says. "For the past 6 years, we've tried to get a physical therapy school started. We've had to be careful not to look arrogant, as if we know it all. We could be asked to leave, as has happened to other groups. After 8 years, we've earned respect from the community. The local university welcomes us. That's another piece of what we do—interact with the local university beyond the internship. But it will take time. Right now, the country is diverting money to the military to fight Boko Haram [an Islamic extremist group]. So, there's not enough money to start a physical therapy school."

    The picture is brighter in Ethiopia. Addis Ababa University is scheduled to graduate its first class of DPTs in 2018. Ira Gorman recalls, "A number of years ago, Richard Jackson of The Jackson Clinics was trying to start an orthopedic residency. We asked, How can we make this more than a residency?' The university was intrigued that physios could become doctors of physical therapy. They embraced it. They identified 20 practicing physios, then transitioned them to DPTs. We're in the third year of a 4-year program. Once they graduate, those DPTs will teach the DPT courses."

    Donald Tepper is editor of PT in Motion. Some interviews were conducted by Kaitlyn Bachman, a physical therapist student at Tennessee State University.


    1. Wesby M. The help and harm of the $173 billion "voluntourism" industry. The Wilson Quarterly. July 23, 2015. http://wilsonquarterly.com/stories/the-help-and-harm-of-the-173-billion-voluntourism-industry/. Accessed August 29, 2016.
    2. Lattanzi JB, Pechak CM. Educating Globally Minded Physical Therapist Students: Curriculum Strategies to Equip the Next Generation. Journal of Physical Therapy Education. Winter 2012. 26(1):55-60.
    3. Loh LC, Cherniak W, Dreifuss BA, et al. Short term global health experiences and local partnership models: a framework. Globalization and Health. 2015. DOI 10.1186/s12992-015-0135-7.
    4. Pechak C, Thompson M. International Service-Learning and Other International Volunteer Service in Physical Therapist Education Programs in the United States and Canada: An Exploratory Study. Journal of Physical Therapy Education. Spring 2009. 23(1):71-79.
    5. Pechak CM. Survey of International Clinical Education in Physical Therapist Education. Journal of Physical Therapy Education. Winter 2012. 26(1):69-77.

    Experiences at a Glance

    International experiences and programs cover a wide range of activities. Here's a quick summary:

    Global Health Experience

    Sometimes referred to as "short-term experiences in global health," it's an umbrella term often describing programs originating in higher-income countries that may vary in length, from weeks to months, and in purpose—educational, research, or community service.


    A combination of tourism and volunteering, often in developing nations, in which the volunteer pays a fee to a sponsoring company.


    Programs that emphasize volunteer service, not tourism.

    International Volunteer Service

    Informal volunteer service opportunities outside the country where the physical therapist education program is located that faculty offer to, or organize with, students, and which do not meet the criteria for service learning.4

    Broadening Experiences

    These offer students opportunities to learn how PTs are trained in other countries. Due to their short-term nature and the difficulty in awarding credits, they lack the requirements to be considered service learning.

    Service Learning

    A structured learning experience that combines community service with explicit learning objectives, preparation, and reflection. Unlike practica and internships, experiential activity in a service-learning course is not necessarily skill-based within the context of professional education.2  

    International Service Learning

    A service-learning opportunity that occurs outside the country where the education program is located.2 The reflective component cultivates student learning about the greater social issues that create the need the service seeks to alleviate. A survey of PT education program directors found that the greatest benefits were facilitation of students' development of cross-cultural competency and a positive effect on student personal development.

    International Clinical Education

    An opportunity outside the country where the physical therapist education program is situated for which students earn clinical education credit.2 One study found that most programs lasted 6-8 weeks and were located in high-, upper-, or middle-income countries. The majority were in outpatient and hospital settings. Most clinical instructors were non-US citizens whose education was commensurate with US-level training. Some educational institutions refer to these programs as internships.

    Educational Partnership Exchanges

    Some international clinical education models include education exchange components in which clinical faculty from the international site travel to the United States for continuing education, or US faculty provide education at the clinical site, creating an educational exchange between a university and a clinical site. Educational partnership exchange programs also exist between universities internationally.2

    The United States as Part of Global Health

    In a nation as expansive and diverse as the United States, volunteer and educational opportunities within a culture different from one's own may not require overseas travel or a passport.

    Michael Landry, PT, PhD, urges educators to look at community, population, and public health in the US. "In Appalachia, we have health outcomes that are as poor as those in northern Africa," he notes. "It sounds more exotic to say we're going to Niger than into parts of Arizona or Appalachia that are equally in need." But he believes American PT students may be more successful in the US than in other nations. "Overseas, students often are overwhelmed," he says.

    Celia Pechak, PT, PhD, MPH, agrees. "International work is sexy. It's exciting. There's a thrill to it. It's not as sexy or thrilling when it's in your own neighborhood. I work and live right on the US/Mexico border. It's very rewarding to get our students out into the community and engage that way."

    Jill Black, PT, DPT, EdD, an associate professor and the pro bono services coordinator at Widener University, manages a student-run pro bono clinic in Chester, Pennsylvania. She compares international service to community service. "So much is directly parallel to looking in your backyard. The important thing to consider is the client, the community, and the impact—positive or negative. When you leave an overseas site, you don't see the fallout. But when you practice in your community, it's your backyard. They're your neighbors. You have to be aware of long-term relationships."

    Pechak sees the similarities and says she hopes international service will lead to community service: "Our core pillar as PTs is social responsibility. Hopefully, a student who goes overseas will later serve his or her local community with the same passion. It is transformative for students to be immersed in another culture. But I think it would be great for us to have similar immersion programs in the local community."

    Elsewhere in this article, a clinic manager in Haiti describes the importance of collecting payments from patients and clients. The same applies to the Chester clinic. Black explains, "What we're doing with pro bono service is not charity. It's not just a free giveaway program. We always want to establish a professional relationship with the client in which someone without coverage can come for professional, legal, ethical physical therapy care. One thing we do is request a fee for service. We've chosen $5. If the client can't pay, we'll waive it. But we ask for it to establish a professional relationship."

    In fact, the clinic takes payment and professionalism a step further. "Sometimes a professor—for instance, a neurology professor—wants to interview clients with a specific type of condition. We'll go out to our clients and look for those who may have that neurological impairment. And we offer to pay them. They get to come back in, meet familiar people, and share their experiences. They chose to do it, and they're getting paid by the hour. That is much more dignified than having them come in and get free care' while they're part of the lab experience."


    HPA the Catalyst

    HPA Global Health SIG

    Health Volunteers Overseas


    Interesting that you do not mention Peace Corps. Served in the 70's. Trained people to do basic rehab after a major earthquake with spinal cord injuries, amputees, head injuries. Electricity was so intermittent that we did not bother with modalities. After we left, the project continued!
    Posted by Kathleen Clarke -> AMQc< on 10/31/2016 10:43:53 PM

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