Medical Brigades to El Salvador and Honduras: Travel imaginaries and volunteer tourist recruitment

Abstract

In this paper, I explore travel imaginaries in the recruitment of participants to short-term medical brigades in El Salvador and Honduras. I look in particular at how trip leaders and organization website frame the volunteer tourist experience, drawing on familiar, shared imaginaries of poor, backward international settings, and related performative interventions that echo white colonial relationships. Recruitment messaging offers little specific or informed sense of place, ignoring the national histories and socio-economic circumstances of the receiving countries. As a consequence, the health profiles and capacities of El Salvador and Honduras are finally obscured in favor of the valorized performance of visitors and externally-driven protocols and care. The efforts of some brigade sponsors and related organizations to improve health-care delivery to local communities, in particular fundraising among brigade participants and other donors, would seem to separate the link between travel and volunteerism. They continue, however, to reinforce broadly-held imaginaries of international poverty and economic backwardness and related rescue by the Global North. A more realistic understanding of Honduran and Salvadoran economies and politics remains elusive and requires a reorientation of voluntary engagement.

Keywords

El Salvador Honduras medical brigades travel imaginaries volunteer tourism

Introduction

Travel imaginaries are the deeply-held and broadly-shared understandings of other settings (Salazar and Graburn, 2014). Scholars have considered such understandings to better grasp how travelers and sojourners conceive of their destinations and how these conceptions influence visitors’ experiences. The draw of sunny “coastal paradises” has been explored for short-and longer-term travelers, who often have only a vague but positive sense of lived experience in these locations (Spalding, 2013). Those attracted to ideal and idealized locations generally recall visual images from movies and television programs and may well have traveled to similar locations for vacations. The performative ways in which longer-term travelers, for example, expatriates, spend their time are similarly unclear beyond recreational activities, but are linked to a sense of freedom, happiness, and the broadly-held belief that travel is transformative (Morrissey, 2018; see, also, Benson and Osbaldiston, 2016; Hayes, 2014; Lean, 2012).

Volunteer tourism has become increasingly popular in the last three decades. Private companies, along with educational and other non-governmental organizations (NGOs), have structured opportunities for travelers from wealthier countries to do “good,” generally in the form of short-term humanitarian assistance, in lower-income international settings (Skinner and Lester, 2012; United Nations Office of the Coordination of Humanitarian Affairs [UNOCHA], 2021). Educational institutions promote the value of “cosmopolitan” awareness in students in preparation for work and further study in a “multicultural” world (Vastri, 2013: 79); course credit and the cultural capital accrued from volunteer work generally in an international location are benefits to travelers. Also termed voluntourism, charity, and pro-poor tourism, volunteer tourism has drawn individuals of all ages and skill levels, traveling in groups or alone (Wearing and McGehee, 2013).

Like other kinds of travelers, volunteer tourists respond to imaginaries, but in ways that differ from those drawn to locations considered highly attractive. These travelers also conceive of their destinations in indistinct terms (Mostafanezhad, 2013), but draw on media images of international poverty that depict catastrophic levels of need as well as cultural exoticism (Schneider, 2018). The performative role of the volunteer is quite clear and inseparable from a romanticized understanding of external interventions in under-resourced and seemingly helpless international communities (Schneider, 2018; Vastri, 2013; Watkins, 2015). Thus, like other humanitarian projects, volunteer tourism valorizes the role of the volunteer (Skinner and Lester, 2012) as it defines host populations in terms of need. Further, whatever their intentions, volunteers commonly define and address local problems in terms that reinforce Western, white dominance and objectification of receiving locations (Baillie Smith et al., 2013; Bandyopadhyay, 2019; Guttentag, 2011; Laurie and Baillie Smith, 2018; McLennan, 2014a; Schech et al., 2015; Schneider, 2018; Sin, 2010; Smith, 2015; Welling et al., 2010). Moreover, aspirations of worldly knowledge and sophistication, promoted in particular by educational institutions, ignore the meaning of cosmopolitanism in the postcolonial context (Go, 2013).

Critics argue as well that volunteer tourism mimics colonial relationships and later neocolonial programs of development aid and assistance that have worsened inequality and poverty in the Global South (McLennan, 2014b; Schneider, 2018). Political incursions and international economic investment and lending have impeded economic development and inequality reduction (Cardoso and Faletto, 1979; Deaton, 2013; Muñoz, 1981). Western dominance has muted national political and cultural autonomy (Said, 1978; Spivak, 1988). Vastri (2013) takes the discussion further, asking how the current global political economy shapes international humanitarianism. Basing her argument on the work of Foucault (2008, in particular) and other critical theorists, she argues that the neoliberal withdrawal of state market regulation has encouraged social reproduction through the development of individual subjectivities—for some classes, for example, well-resourced volunteer tourists—while further impoverishing host countries.

Large-scale international organizations, for example, United Nations agencies, have responded in part by funding more self-sustaining development programs and projects. The goals include a reduction in the need for short-term humanitarian assistance and strengthening of local organizational capacity and control. It has been argued, further, that long-term volunteer participation can engage local communities in beneficial ways (see, e.g. Zahra and McGehee, 2013). However, the growing presence of NGOs in Central America, reflecting a “privatization” and “commodification” of humanitarian and development assistance (Mostafanezhad, 2013), and related intensified international competition for support from smaller-scale donors and volunteers, both reproduces colonial patterns of cultural and social dominance and engages volunteers in subjectively-valuable experiences (Banks et al., 2015; Vastri, 2013).

In this paper, I examine the ways in which organizers of a form of volunteer tourism, short-term medical brigades, recruit volunteers for travel to El Salvador and Honduras. Through interviews with organizers and participants, reviews of pertinent printed materials and reviews of organization websites, I explore the ways in which the presentation of local communities reinforces travel imaginaries and the performative roles of volunteers, while eclipsing the complex histories and present-day social structures of El Salvador and Honduras. I consider as well the terms in which brigades assess their successes and failures, arguing that their problem-solving strategies remain grounded in broadly-held understandings of poor countries and health care models from the Global North.

Medical brigades

Medical brigades or medical missions are a form of volunteer tourism that originated in European colonies and often accompanied evangelical missions (Hardiman, 2008; Skinner and Lester, 2012; Vaughan, 1991). Wars, natural disasters, and other physical hardships have also drawn medical teams (Caldron, 2017) to provide relief and other forms of humanitarian assistance. Today’s short-term medical brigades are commonly sponsored by religious and other non-profit organizations in high-income countries with ties to NGOs in recipient low-income nations. A week or two in duration, medical brigades or missions bring groups of health care professionals and others providing direct services to patients in remote locations (Nouvet et al., 2018).

Not surprisingly, much research on short-term medical brigades emphasizes the volunteer experience, focusing on three themes: participant motivation, brigade organization and objectives, and brigade interaction with local community members. Considering volunteer motivation, Caldron’s (2017) meta-analysis of physicians’ reasons for joining brigades suggests that “altruism and idealism” motivate participation. Caldron (2017) adds that the altruism of physicians participating in medical brigades must be great to overcome the rigors and risks of the travel and settings involved. Lasker’s (2016) interviews with 119 individuals associated with medical brigades, including 15 volunteers, and survey results from respondents representing 177 organizations also address motivation. She found that medical brigade volunteers generally display the mix of “self-interest and altruism” found commonly among volunteers, while religious belief may play a part as well.

Looking at brigade organization and links to local actors, research by Lasker (2016) and the Catholic Hospital Association’s (2015) survey of 205 participants in and 152 organizers of medical brigades suggest that sponsoring organizations and in-country NGOs’ goals for visiting medical teams are narrowly focused on the delivery of medical services, often without consultation with local organizational or medical personnel. Studies of particular brigade operations in Guatemala (Berry, 2014; Green et al., 2009), Nicaragua (Nouvet et al., 2018) and Honduras (McLennan, 2014b) also report the dominance of visiting health-care workers and brigade leaders in determining the structure, operation, and evaluation of the mission.

Taken together, these and related studies (Bonner et al., 2013; Bradke, 2009; Caldron, 2017; Martiniuk et al., 2012; Sykes, 2014; Welling et al., 2010), agree that medical brigades are deeply performative, reflecting immediacy in addressing medical issues and the participation of highly-trained and focused personnel. Care-giving supersedes the desired sense of worldliness or cosmopolitan sophistication associated with some forms of volunteer tourism. Indeed, participating health care personnel may have volunteered in other poor and under-resourced international settings and while these locations may differ in fundamental ways, the medical service model remains the same. Second, a commitment to global citizenship found in much volunteer tourism is often redefined in terms of religious, spiritual or humanitarian sensibilities. Again, many participants have long-standing commitments to related volunteering. Third, and most significant, is that imaginaries of poor, under-resourced, and backward locations apparently requiring external intercession are understood NOT in terms of country-specific knowledge, but rather broad notions of international economic backwardness. The war-like terminology itself—“brigade,” “mission”—suggests a heroic rescue of a community from threat or attack.

Methods

We know relatively little about how travel imaginaries have been tapped in recruitment messaging for medical brigades. But messaging to prospective participants in other forms of volunteer tourism are suggestive. Caton and Santos (2009) consider the goal of cross-cultural awareness and more indirect messages for an educational program, Semester at Sea, which conveyed through visual and print media the “otherness” of people in the receiving nation. Photos of poor, darker-skinned individuals, often children, especially reinforced the seeming need for visitors to manage improvements in local circumstances. Kascak and DasGupta (2014) makes many of the same points about volunteers’ accounts on social media of their voluntourism in Africa; messaging and photos of these “self-directed Samaritans” present “the suffering other.” The satiric Instagram series on white “savior Barbie” in Africa (Zane, 2016) recalls the earlier, more serious discussion of the “white savior industrial complex” by Cole (2012) and others (see, e.g. Bandyopadhyay, 2019). Kadomskaia et al. (2018: 636) analyzed actual Instagram accounts of volunteer tourism experiences, noting the “dominant positioning of volunteer tourists as rescuers” in shared photos. However, none of these cases focus on medical brigades in particular.

In 2016, I served as an unpaid English-Spanish interpreter for a short-term medical brigade to Honduras. I noted the seeming dedication of the health care volunteers to their patients. I was at the same time perplexed by the disconnect between the shared perception of extraordinary need and lack of interest—even among repeat volunteers—in Honduras; neither the historical origins of the extreme poverty and inequality surrounding us nor the question of where the brigades fit into the overall medical infrastructure were addressed by organizers or in conversations that I observed.

The literature on travel imaginaries was informative for me in establishing the frequent gap between broadly-shared images of international settings and behavior in those locations. I wanted to understand more fully how the Honduras brigade organizers validated and reinforced the divide between participants’ vague understandings of the place and their purposeful, focused medical activity. Using a grounded theory approach to qualitative data gathering (Glaser and Strauss, 1967; Hallberg, 2006), I conducted in-person and telephone interviews of average 1-hour length in 2017 and 2018 with 14 people who had worked with non-profit agencies in the United States and in El Salvador and/or Honduras, organizing, implementing, and participating in medical brigade. The interview instrument, approved by my university’s Institutional Review Board, included 17 open-ended questions designed to guide informants in presenting their experiences. Questions focused on the organization of brigades, strengths, and weaknesses of healthcare delivery in the brigade context, relationships between brigades and both NGO and sponsoring organizations, and more specifically, the recruitment of volunteers. I also reviewed relevant organization websites and print materials, where available. Informants were identified in snow-ball fashion, through recommendations by other respondents; all informants were anonymized in later reporting. I analyzed personally-recorded transcripts, web, and print information for common concepts and categories that addressed my research questions about volunteer recruitment strategies and messaging in relation to travel imaginaries and performative volunteer roles.

My informants were highly consistent in describing the organization and goals of brigades to El Salvador and Honduras, including the recruitment of volunteers. In order to explore further messaging employed in drawing brigade participants, I reviewed an additional 28 websites of organizations sending or receiving medical brigades in El Salvador and Honduras and not represented in my interviews. The websites were identified in 2018 and 2019 through these search terms for Honduras and El Salvador: medical brigades, medical missions, health care, volunteering. I reviewed the websites for changes in 2020 and 2021. I was particularly interested in the ways in which organizations described the volunteer experience, the Salvadoran and Honduran settings, and the value of the volunteers’ tasks in relation to conditions in local communities, as well as reports of volunteer satisfaction and effectiveness. In addition, I reviewed photos of volunteers interacting with local community members. Only one organization, a study abroad program that includes medical brigades, was explicitly for profit; all others claim to be non-profit-making entities. Nevertheless, web presentation has a marketing function, generally expressed in terms of requests for volunteer recruitment and/or donations.

The selection of El Salvador and Honduras, neighboring Central American countries, as hosts to medical brigades was based on two factors. First, they have been frequent sites of brigade visits. Indeed, Honduras was the second most-visited site by 162 organizations sponsoring medical brigades studied by Lasker (2016: 54).¹ Their short distance from the United States and easy air connections have fostered ties between in-country NGOs and churches, hospitals and other organizations in the United States. The devastating effects of Hurricane Mitch in Honduras (1998) and the lengthy Salvadoran Civil War (c.1978–1992) brought donors and volunteers who established continuing relationships with local groups and communities (Smith, 1996, 2013; Todd, 2021). These same events contributed to extremely uneven medical access, with a continuing lack of resources and trained medical personnel limiting the reach of public health services. Remote rural areas are especially poorly served.²

Second, El Salvador and Honduras are both characterized by political violence, instability, and corruption (Chayes, 2017; Miguel Cruz, 2019; Moodie, 2010), in part resulting from long histories of Western economic, cultural, and political influence. The deportation of gang members from the United States to Central America in the 1990s through early 2000s contributed to the regional growth of organized crime and its control of considerable territory (Ambrosius, 2018). These conditions challenge public health infrastructures and local medical capacity and significantly complicate explanations of poverty and need. The discussion of these circumstances in recruitment messaging—or its absence – tells us much about the imaginaries projected to prospective medical volunteers in these settings.

A weakness of this research, like the brigades themselves, is the focus on volunteers rather than those receiving care. We know little about how Salvadorans and Hondurans experience interaction with international volunteers and donors, in this case health care professionals. The dependence of these communities on external assistance complicates the evaluation by clients of medical brigades and indicates again the hierarchical relationships that have long defined the Western presence in low-income countries (Berry, 2014; Spivak, 1988).

Delivering short-term medical care to El Salvador and Honduras

Medical brigades that visit El Salvador and Honduras vary in the kind of treatment that they provide, but all give direct, humanitarian assistance. Many teams have offered wellness checks and distributed commonly prescribed medicines. In the process they may identify a few more serious cases that can be followed-up on with urban medical specialists or, under unusual circumstances, hospitals in the United States. Others provide more focused services, including eye tests, dental treatment, and various kinds of surgery. For example, vision testing and surgery and eyeglass distribution is delivered to poor areas by Servants for Sights (servantsforsight.org, 2020) in both Honduras and El Salvador. Helping Hands for Honduran Children (Handsforhonduras.org, 2020) brings “cardiovascular medical teams” to Honduras in partnership with a local hospital to treat congenital and other heart problems in children.

Building a team of volunteers to fulfill brigade medical missions depends in large part on the financial ability of health care professionals to participate. Between the costs of airfare from most U.S. cities to major cities like Tegucigalpa and San Salvador and local travel support, security, translation services, food, and lodgings, the total cost is generally close to USD $2000. Caldron (2017) notes additional opportunity costs in the form of lost income to physicians participating in medical brigades that can be extended to other participants as well. One organizer described for me the effort to reduce costs against the backdrop of extreme community need: hosting a brigade brings money to local providers of a range of services. Sponsoring organizations in the United States may have access to resources or the capacity to raise money for a brigade, mitigating individual costs.

Physicians and other health professionals are in greatest demand by brigade organizers. Some will accept non-medical volunteers to do ancillary medically-related tasks, for example, registering patients, or to provide non-medical services to the community. These may include distributing water filters to local families, distributing health education materials, and making improvements in clinic buildings. Non-professional volunteers are especially welcome in clinical and related settings that have U.S. campus partnerships (e.g. Foundation for International Medical Relief of Children (FIMRC.org, 2020)), whereby students in health-care and other professional training areas can both fundraise for a worthy cause and get experience volunteering abroad.³

NGO organizational characteristics vary greatly, with some groups reporting large full-time staffs, others carrying on with a paid staff of only a member or two. Central American Medical Outreach (CAMO.org, 2020) has 38 employees in Honduras providing medical services, education, and training as well as supporting community development projects; Familias Saludables (Familiassaludables.org, 2020) addresses the transmission of HIV/AIDS from mothers to newborns operates in Honduras with volunteers alone. Smaller Salvadoran and Honduran health-focused NGOs often operate on a shoe-string, making help of almost any kind desirable.

Recruiting volunteers

Many medical brigades from the United States are organized by individual churches and other small non-profit institutions that regularly visit one or more communities (Lasker, 2016). Few are represented on the internet; of the 28 websites I reviewed, only seven represented small religious or other small non-profit organizations. Among the 14 individuals interviewed, however, 12 informants had participated in brigades sponsored by churches or small non-profit organizations or worked for such groups in El Salvador or Honduras. In these cases, recruitment occurred through membership networks. Organizers and past participants tell friends and relatives who in turn pass on information about the brigade. Newsletters, church bulletins, e-mails, and less frequently, websites share information about upcoming brigade trips. Consistent with Lasker’s (2016) and the Catholic Health Association (2015) findings, my informants reported little selectivity in building teams; rather the goal was to have an adequate number of practitioners and support staff to both attend to the patient population and contribute to over-all trip costs.

Participation in brigades to El Salvador and Honduras may yield continued commitments to both future brigades and sponsoring in-country NGOs. My interviews revealed frequent continued participation: a church staff member who organizes twice-yearly brigades to El Salvador reported to me that “ninety percent of participating physicians” had joined in earlier brigades. Another estimated that about half of the 13–14 brigade members have generally participated in the past. As noted, each trip brings funds to the in-country NGO and surrounding community. Once engaged in a brigade, sponsoring NGOs may seek funds through direct mail and other forms of solicitation. The purpose of monetary donations can be broad: Honduras Good Works (hondurasgoodworks.org, 2020) invites donations for the purchase of vitamins, water filters, and supporting a child’s education for a year. In addition, non-profits and churches in the United States may make a continuing institutional commitment to church and NGO-run medical services in the receiving country. I interviewed an outreach coordinator of a midwestern urban Catholic parish that in partnership with an El Salvadoran parish supports a variety of local projects, including a health clinic. The U.S. parish pays the salaries of continuing clinical staff along with funding for some medical supplies.

Larger NGOs, many religious, have an active web presence. They generally work with NGOs and hospitals in more than one country, ranging from three locations (Austin Smiles (austinsmiles.org, 2021)) to 110 (Operation Mobilization—USA (omusa.org, 2020)). Twenty-one of the 28 websites I reviewed and one interview informant’s organization fit this description. Larger organizations can assist potential volunteers in choosing appropriate time and circumstances for travel abroad. Samaritan’s Purse (Samaritanspurse.org 2020), for example, recruits Christian medical professionals to hospitals throughout the developing world and including Honduras and El Salvador. Directed by a board chaired by noted American evangelical leader Franklin Graham, Samaritan’s Purse began in 1970 and now has partnership relationships with 40 hospitals in Africa, Asia, and Latin America and a variety of other non-medical projects in the United States and abroad.

Large organizations seek both volunteers and donations through various means, including websites. Many of these organizations, too, post their need for medical equipment and pharmaceuticals; Central American Medical Outreach (camo.org, 2020), for example, solicits medical equipment and supplies as well as used glasses and hearing aids for health providers in Honduras and other Central American locations. Some organizations offering medical trips to El Salvador and/or Honduras also offer opportunities for Spanish classes (e.g. A Broader View Volunteers (abroaderview.org, 2021)). Others invite families as well as individuals to participate (see, e.g. Global Health OutreachChristian Medical and Dental Associations (cmda.org, 2020)). Many in-country clinics and health providers welcome longer-term volunteers as well as short-term brigades (see, e.g. Love Volunteers (lovevolunteers, 2020) in Honduras).

Travel imaginaries and recruitment messaging

Recruitment to medical brigades generally stresses the performative satisfaction of helping people who are in another country, defined not by its history or specific circumstances, but by perceived need. In this sense, the recruitment message reflects an earlier advocacy stage of research on the value of volunteer tourism rather than the later more critical literature (Wearing and McGehee, 2013). Also described may be the pleasures of working with fellow-practitioners and others. An informant told me that the brigades that he arranges might be “the only times” that doctors and other medical personnel from the same and neighboring communities “get to see each other.” That the setting is generally unfamiliar may suggest an exotic shared adventure for the generally well-resourced brigade participants. In the case of student groups, particularly those in health-related areas, such messages may complement those from their institutions encouraging participation in hands-on experiences like short-term brigades (Green et al., 2009; Martiniuk et al., 2012; Vastri, 2013).

For many prospective volunteers, the wish to provide care to the needy is grounded in spiritual beliefs and practices, recalling both travel imaginaries associated with tales of religious missions in poor, backward countries and the widely-held position that travel is transformative (Lean, 2012; Vastri, 2013). Of the 28 websites I visited, 14 represented religious institutions; of 14 interview subjects, 10 had volunteered or helped organized religiously-based medical brigades.⁴ Messaging frequently includes evangelical or scriptural language. For example, E3Partners invites participants to “Come spread the love of Christ across the world!” while offering medical services in various settings, including areas of Honduras (e3partners.org, 2021). Christian Medical Missions, Inc.’s website (christianmedical.org, 2021, “Who are We?” tab) notes that the brigade participants “received gifts we couldn’t begin to imagine, from fellow teammates, from those we serve and those who serve us, and ultimately from God, our father.” Participant testimonials, blogs, and program goals found on religious organization websites often describe the experience delivering health services to Honduras’ poor as “life changing” (see, e.g. The Isaiah Connection (isaiahconnection.org, 2021)). I interviewed a brigade organizer from a Catholic church, whose letter to volunteers for an upcoming medical mission to El Salvador stated, “You are about to embark on a life-changing and life-giving experience.”

The notion of transformative travel through the brigade experience is not limited to religiously-based organizations sending groups to El Salvador and Honduras. Other organizations refer to the personal, life-changing value of the volunteer experience in direct messaging or participant statements. Some research has confirmed this effect as well (see, e.g. Alexander, 2012; Zahra and McIntosh, 2007). The mission statement of A Broader View Volunteers (abroaderview.org, 2021) states: “Returnees usually state that their lives have been changed forever.” Austin Smiles (austinsmiles.org, 2021) describes the experience of working in a team that corrects cleft palates and cleft lips as “powerful” and “gratifying enjoyment.” International Medical Relief calls their medical mission experience one that “you won’t forget” (internationalmedicalrelief.org, 2020).

Some organizations convey the intensity and task focus of the brigade experience, emphasizing the amount of work accomplished in a short period of time and in a challenging setting. Brigade activity may be presented in numerical terms; 5 of 28 websites shared metrics of patients seen, supplies shipped, volunteer hours contributed or money raised (see, e.g. Medwish (medwish.org, 2020); Central American Medical Outreach (CAMO.org, 2020)). Bridge of Hope International (bridgeofhopeinternational.org, 2021) suggests the same idea in another way, describing “impact” trips, implying the exceptional success of visiting medical personnel given the circumstances. Indeed, such a selective and narrow definition of success would not be acceptable in large-scale medical institutions in the United States, where governing boards or funders require formal, multi-dimensional, and contextualized evaluations; it is, however, consistent with my interview findings that only limited, informal assessments take place (see, also, Berry, 2014; Lasker, 2016).

A web presence allows for visual presentations that can convey subtle messages to potential volunteers. For example, photos can establish the otherness of patients in an international location and the dominance of visitors’ knowledge, technology, and organization. In their study of Semester at Sea visual and textual messaging, Caton and Santos (2009: 198) note “essentialization of host and host cultures as fundamentally different.” Visual images on websites recruiting participation and support for medical brigades to El Salvador and Honduras routinely present health care professionals treating patients; others show brigade members interacting with smiling clients in informal settings. Every website reviewed included photos of dark-skinned children, while only four brigades specifically geared care to children. The seemingly benign and engaging imagery depicts an inviting setting, consistent with recruitment goals. But it also suggests that the superior knowledge and authority of U.S. medical personnel and other brigade members has come to the rescue of a needy and helpless community (Welling et al., 2010).

Keeping it vague, reframing reality

As noted above, many organizations considered here direct recruiting messages based on religious or ethical principles, but within a context of international poverty and backwardness. Smith (2013) found that among “young UK Christians volunteering in Latin America,” a tendency to “smooth over inequalities” in the pursuit of caring activities can be seen. Interviews and reviews of on-line descriptions of brigade trips to El Salvador and Honduras that I conducted indicate that the socio-political circumstances contributing to living conditions were seldom mentioned. Considerations of inequality were generally beyond the scope of volunteer recruitment messaging. Two brigade organizations, one on-line and the other represented in an interview, noted their origins during the Salvadoran Civil War. Another, The Isaiah Connection (isaiahconnection.org, 2021), describes the lack of amenities for volunteers in rural Honduras. But only one website and one informant mentioned the extreme violence, instability, and corruption in El Salvador and Honduras. Yet the larger economic and political circumstances experienced by the majority of people in these settings are central to the needs of local communities and an understanding of why national health programs are not adequate.

As the local representative of a religious-based institution receiving brigades in El Salvador noted, a critically important part of those NGO arrangements for visiting brigades is likely to be negotiating with gang leaders controlling the territory. Such negotiations can be tricky, my informant argued, not because the gangs wish to deny their followers health care, but because control of a community may be shifting from one gang to another. There is little evidence that brigade participants have been endangered by gang violence, although Médecins sans Frontières recently suspended operations in San Salvador because of an attack on an ambulance, allegedly by neighborhood gangs (MSF, 2021). Moreover, context is important to understanding the health care needs of local communities. For examples, traveling health promoters (promotores) in El Salvador do not enter certain areas of the country because they fear personal harm from gangs or the police (Hernández, 2019).⁵

Even as the local political and economic situation is ignored or poorly understood, brigade organizers and sponsors may approach legitimate figures of apparent power and authority, as they would at home, to achieve mission goals. Such contacts are generally informal; NGOs operate in both El Salvador and Honduras with little integration or collaboration with the government (El Heraldo, 2014). Large and influential NGOs generally have informal contacts in government that facilitate in particular the delivery of supplies and equipment to clinics. An informant told me proudly of her brigade’s experience making contact through a local doctor with Ana Rosalinda Garcia Carcías, wife of Honduran president Juan Garcia Hernandez, who facilitated the delivery of pharmaceuticals to Honduras. However, as the coordinator of a midwestern university-led medical brigade to Honduras noted, “informality comes with expectations,” citing communities that refused brigades because pharmaceuticals had run out during the course of early brigades’ visits.⁶

Misunderstood problems, failed solutions

The narrow focus on the performative dimension of travel imaginaries lessens needed attention to specific national and community demands. I would argue further that patient care suffers without a clear understanding of the larger social issues in play in El Salvador and Honduras. I found that most brigade coordinators and participants were acutely aware of concerns about the efficacy and ethics of short-term medical visits. One described the brigade as “always a work in progress,” hoping that “this is a good thing” but also concerned about the degree of community dependence on the brigade for health care. Another told me that “one way or another” the entire community was dependent on the brigade, the services, and the work that it brought. However, their solutions were embedded in the brigade model and medical practices of their own country. They expressed little if any concern about how social and economic circumstances of their host countries explained the problem and dictated alternatives.

The most frequent criticism I heard from brigade participants and organizers is that medical care offered is episodic, with follow-ups not readily available for diagnosed illnesses or medicine adjustment. That is, after the brigade leaves, there may be no way for patients to access further care or continued medicine. One Honduran informant who had worked with visiting brigades noted that “everyone says that the brigade won’t be back.” Even when brigades dutifully make follow-up arrangements with local practitioners, patients may be unable to access that care (Bellows, 2014; Catholic Health Association, 2015; Green et al., 2009; Lasker, 2016; Martiniuk et al., 2012; Welling et al., 2010).

Several strategies have developed in response. Some groups make a concerted effort to return to the same areas visited on previous trips annually or semi-annually. Theoretically, records can then be maintained and visiting physicians and patients able to get to know each other. I asked one organizer who had returned with a group of medical professionals to the same area over several years whether this actually allowed follow-up specific patients or increased health compliance. She countered that physicians complain of these same issues in the United States, where getting even continuing patients to adhere to physicians’ counsel and to follow-up with questions and concerns is difficult. While there is truth in this response, the difficulties of reaching even established clinics have contributed over time to poor health outcomes in Central America’s rural communities. Paved roads and public transportation differentiate U.S. patients from those in rural Honduras. More significantly, the notion of a visiting medical brigade acting as a continuing rescue mission for a rural community rather than a conduit to local capacity development and sustainability is evident in the organizer’s response.

Related to commitments to receiving communities are attempts by incoming groups to keep comprehensive patient records and to share them with their partnering NGOs. This approach is often stymied by the lack of consistency and the absence of a technology infrastructure. One brigade organizer complained that her group made a special effort to maintain treatment records, something rare among brigades. Another described a thoughtful effort to scan treatment records, but lacked staff in El Salvador or the United States to analyze the data. In this case, neither the brigade-defined problem nor the solution recognizes the virtual absence of computer technology and internet connectivity in much of rural El Salvador.

The well-documented lack of brigade engagement with Honduran and Salvadoran actors outside of broker NGOs limits knowledge of local medical problems and practice (Bellows, 2014; Green et al., 2009; Lasker, 2016; Welling et al., 2010). Indeed, critics argue that dependence on visiting volunteer medical professionals drives the definition and scope of disease and the kind of treatment to be accessed. As one informant told me, the very availability of particular professional skills and specialties, while welcome by the receiving NGO, also sets the agenda and creates a “self-limiting” public health response (see also Bellows, 2014; Welling et al., 2010). With little understanding of local medical culture or problems, brigades from developed countries treat the diseases that dominate in their own populations, with less attention to the complex disease profiles of the poor in Central America. That is, a growing incidence of diseases associated with development are found alongside substantial incidents of drug abuse, domestic violence, teen pregnancy, infant, and maternal mortality and HIV/AIDS (Pan American Health Organization [PAHO], 2017a, 2017b). Screening, treatment, and appropriate referrals for the latter conditions is seldom included in the group protocol and a referral elsewhere would be necessary. The emphasis on some conditions also reflects the influence of religious institutions in opposing reproductive services. We see here once again the disinclination of medical brigade organizers and participants to fully understand the locations they have chosen to visit, beyond the vague notion of a backward international place requiring their assistance.

Conclusions

Medical brigades have been studied in terms of participant recruitment and their organization and relationships to local communities. A more critical literature on medical brigades in Central America has developed, emphasizing the reproduction of hierarchical relationships that mirror colonial ones and the changing demands of the neoliberal global economy. Lacking in these analyses is an understanding of how place and its interaction with traveler performance, as expressed in imaginaries, frame volunteer tourism. Looking here at the messaging used by brigade organizers and NGOs to recruit participants to El Salvador and Honduras, both an indistinct, generalized sense of place along with a strong valorization of task performance by medical personnel are expressed. Extreme international poverty, described in words and visual content and suggesting the vulnerability and helplessness of receiving community, is used to draw medical professional volunteers to brigades.

My interviews and review of organization websites indicate virtually no information conveyed to prospective volunteers about the socio-economic circumstances that have created the health-care gaps in El Salvador and Honduras that have drawn short-term medical brigades to rural areas. As a consequence, the efforts of brigade organizers and related NGOs to improve brigade efficiency and efficacy discussed in interviews were inappropriate to the Honduran and Salvadoran settings and reflected home country standards and practices.

Some academic observers have asked how volunteer tourism can be reformulated to decommodify humanitarian aid and repoliticize it in progressive terms (Mostafanezhad, 2013; Vastri, 2013), or to reenvision volunteer travel between countries of the Global North and South in terms of mutual benefit (Everingham, 2015; Wearing et al., 2017). My emphasis on shared travel imaginaries and the deeply performative behavior of volunteers in short-term medical missions suggests the challenge of revisioning this form of volunteer tourism. That El Salvador and Honduras are at risk without the skills of visiting medical professionals from, in this case, the United States, is foundational to short-term brigades. By the same token, breaking the connection between travel and humanitarian aid by sponsoring organizations seeking financial support during the recent pandemic has not ended the use of images and descriptions of poor countries as urgently in need of international rescue. Dismantling these powerful imaginaries, rooted in hierarchical colonial relationships and reflecting a sense of Western superiority in knowledge and its application expressed in short-term medical brigades, is the challenging start to creating new terms for global humanitarianism.

Footnotes

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Marietta Morrissey

Notes

Author biography

Marietta Morrissey is Professor Emerita in the Department of Sociology and Anthropology at the University of Toledo. She has written extensively about economic development and inequality in the Caribbean and Central America.

Organization websites cited

A Broader View Volunteers, (accessed 10 September 2021)

Austin Smiles, (accessed 10 September 2021)

Bridge of Hope International, (accessed 11 February 2021)

Central American Medial Outreach, (accessed 7 September 2020)

Christ for the City, (accessed 10 September 2020)

Christian Medical Missions, Inc, (accessed 7 September 2020)

E3 Partners, (accessed 10 September 2021)

Familias Saludables, (accessed 9 September 2020)

Foundation for International Medical Relief of Children, (accessed 8 September 2020)

Global Health Outreach Christian Mission and Dental Association, (accessed 10 September 2020)

Helping Hands for Honduran Children, (accessed 8 September 2020)

Honduras Good Works, (accessed 10 September 2020)

International Medical Relief, (accessed 8 September 2020)

Isaiah’s Connection, (accessed 8 September 2021)

Love Volunteers, (accessed 11 September 2020)

Medwish Medical Brigades, (accessed 9 September 2020)

Operation Mobilization-UM, USA, (accessed 9 September 2020)

Samaritan’s Purse, (accessed 8 September 2020)

Servants for Sight, (accessed 7 September 2020)

References

Alexander

(2012) ‘International Volunteer Tourism Experience in South Africa: An Investigation Into the Impact on the Tourist’, Journal of Hospitality Marketing & Management 21(7): 779–99.

Ambrosius

(2018) Deportations and the Roots of Gang Violence in Central America’. Criminal Justice, Borders and Citizenship Research Paper No. 3225314, 20 August. Available at: https://ssrn.com/abstract=3225341 (accessed 7 September 2021).

Baillie Smith

Laurie

Hopkins

, et al. (2013) ‘International Volunteering, Faith and Subjectivity: Negotiating Cosmopolitanism, Citizenship and Development’, Geoforum 45: 126–35.

Bandyopadhyay

(2019) ‘Volunteer Tourism and ‘The White Man’s Burden’: Globalization of Suffering, White Savior Complex, Religion and Modernity’, Journal of Sustainable Tourism 27(3): 327–43.

Banks

Hulme

Edwards

(2015) ‘NGOs, States, and Donors Revisited: Still Too Close for Comfort?’, World Development 66: 707–18.

Bellows

J. W.

(2014) Replace Short-Term Medical Missions With Long-Term Local Investment’. The Washington Post, 5 September. Available at: https://www.washingtonpost.com/opinions/replace-short-term-medical-missions-with-long-term-local-investment/2014/09/05/2c72b232-3232-11e4-9e92-0899b306bbea_story.html (accessed 8 September 2021).

Benson

Osbaldiston

(2016) ‘Toward a Critical Sociology of Lifestyle Migration: Reconceptualizing Migration and the Search for a Better Way of Life’, Sociological Review 64(3): 407–23.

Berry

N. S.

(2014) ‘Did We Do Good? NGOs, Conflicts of Interest and the Evaluation of Short-Term Medical Missions in Sololá, Guatemala’, Social Science & Medicine 120: 344–51.

Bonner

L. J.

Hopper

Gore Martin

, et al. (2013) ‘Pilot Surveys of Ethics and Short-Term Medical Mission Work: University of Wyoming Agua Salada Clinic, Honduras’, Universal Journal of Public Health 1(3): 86–96.

10.

Bradke

(2009) The Ethics of Medical Brigades in Honduras: Who Are We Helping? MA Thesis, The University of Pittsburgh, Pittsburgh.

11.

Caldron

P. H.

(2017) ‘‘Fit’ for Service: Contrasting Physician Profiles and Motivations for Short-Term Medical Missions and Médecins Sans Frontières’, Journal of Compassionate Health Care 4(1): 1–7. DOI: 10.1186/s40639-017-0038y.

12.

Caldron

P. H.

Impens

Pavlova

, et al. (2016) ‘Economic Assessment of US Physician Participation in Short-Term Medical Missions’, Globalization and Health 12(1): 45.

13.

Cardoso

F. H.

Faletto

(1979) Dependency and Development in Latin America. Berkeley: University of California Press.

14.

Carmenate Milian

Herrera-Ramos

Ramos Caceres

, et al. (2017) ‘Situation of the Health System in Honduras and the New Proposed Health Model’, Archives of Medicine 9(4): 1–8. DOI: 10.21767/1989-5216.1000222.

15.

Catholic Health Association (2015) Short-Term Medical Mission Trips Survey Results’. Available at: https://www.chausa.org/store/products/product?id=3169 (accessed 8 September 2021).

16.

Caton

Santos

C. A.

(2009) ‘Images of the Other: Selling Study Abroad in a Postcolonial World’, Journal of Travel Research 48(2): 191–204.

17.

Chayes

(ed.) (2017) When Corruption is the Operating System: The Case of Honduras. Washington, DC: Carnegie Endowment for International Peace. Available at: https://carnegieendowment.org/2017/05/30/when-corruption-is-operating-system-case-of-honduras-pub-69999 (accessed 7 September 2021).

18.

Cole

(2012) The White-Savior Industrial Complex’. The Atlantic, 21 March. Available at: https://www.theatlantic.com/international/archive/2012/03/the-white-savior-industrial-complex/254843/ (accessed 16 September 2021).

19.

Deaton

(2013) The Great Escape: Health, Wealth and the Origins of Inequality. Princeton, NJ: Princeton University Press.

20.

El Heraldo (2014) ‘Cancelarán más de 6,000 ONG en Honduras’. El Heraldo, 7 April. Available at: https://www.elheraldo.hn/pais/582196-214/cancelaran-mas-de-6000-ong-en-honduras (accessed 9 September 2021).

21.

Ernst

Malkin

(2018) New York Times, 17 January. Available at: https://www.nytimes.com/2018/01/27/world/americas/honduras-president-inauguration-protests-juan-orlando-hernandez.html (accessed 8 September 2021).

22.

Everingham

(2015) ‘Intercultural Exchange and Mutuality in Volunteer Tourism: The Case of Intercambio in Ecuador’, Tourist Studies 15(2): 175–90.

23.

Foucault

(2008) The Birth of Biopolitics: Lectures at the Collège de France 1978-1979. Hampshire: Macmillan.

24.

Glaser

B. G.

Strauss

A. L.

(1967) The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, IL: Aldine.

25.

(2013) ‘Fanon’s Postcolonial Cosmopolitanism’, European Journal of Social Theory 16(2): 208–25.

26.

Green

Scandlyn

, et al. (2009) ‘Perceptions of Short-Term Medical Volunteer Work: A Qualitative Study in Guatemala’, Globalization and Health 5(4): 4–13.

27.

Guttentag

(2011) ‘Volunteer Tourism: As Good as It Seems?’, Tourism Recreation Research 36(1): 69–74.

28.

Hallberg

L. R. M.

(2006) ‘The ‘Core Category’ of Grounded Theory: Making Constant Comparisons’, International Journal of Qualitative Studies on Health and Well-Being 1(3): 141–8.

29.

Hardiman

(2008) Missionaries and Their Medicine: A Christian Modernity for Tribal India. Manchester: Manchester University Press.

30.

Hayes

(2014) ‘‘We Gained a Lot Over What We Would Have Had’: The Geographic Arbitrage of North American Lifestyle Migrants to Cuenca, Ecuador’, Journal of Ethnic and Migration Studies 40(12): 1953–71.

31.

Hernández

(2019) Promotores de salud, guardianes anónimas en las comunidades’. ElSalvador.Com. Available at: https://historico.elsalvador.com/historico/659705/promotores-de-salud-guardianes-anonimos-en-las-comunidades.html (accessed 8 September 2021).

32.

Kadomskaia

Brace-Govan

Cruz

A. G. B.

(2018) ‘Parallel Practices of Visual Domination and Subversion’, pp. 636–7 in Gershoff

Kozinets

White

(eds) NA: Advances in Consumer Research. Vol. 46. Duluth, MN: Association for Consumer Research.

33.

Kascak

DasGupta

(2014) #InstagrammingAfrica: The Narcissism of Global Voluntourism’. Sociological Images. Available at: https://thesocietypages.org/socimages/2014/12/29/instragrammingafrica-the-narcissism-of-global-voluntourism/ (accessed 7 September 2021).

34.

Lasker

J. N.

(2016) Hoping to Help: The Promises and Pitfalls of Global Health Volunteering. Ithaca, NY: Cornell University Press.

35.

Laurie

Baillie Smith

(2018) ‘Unsettling Geographies of Volunteering and Development’, Transactions of the Institute of British Geographers 43(1): 95–109.

36.

Lean

G. L.

(2012) ‘Transformative Travel: A Mobilities Perspective’, Tourist Studies 12(2): 151–72.

37.

McLennan

(2014a) ‘Networks for Development: Volunteer Tourism, Information and Communications Technology, and the Paradoxes of Alternative Development’, PoLAR: Political and Legal Anthropology Review 37(1): 48–68.

38.

McLennan

(2014b) ‘Medical Voluntourism in Honduras: ‘Helping’ the Poor?’, Progress in Development Studies 14(2): 163–79.

39.

Martiniuk

A. L.

Manouchehrian

Negin

J. A.

, et al. (2012) ‘Brain Gains: A Literature Review of Medical Missions to Low and Middle-Income Countries’, BMC Health Services Research 12(134): 134.

40.

Miguel Cruz

(2019) ‘The Politics of Negotiating With Gangs: The Case of El Salvador’, Bulletin of Latin American Research 38(5): 547–62.

41.

Moodie

(2010) El Salvador in the Aftermath of Peace: Crime, Uncertainty, and the Transition to Democracy. Philadelphia: University of Pennsylvania Press.

42.

Morrissey

(2018) ‘Imaginaries of North American Lifestyle Migrants in Costa Rica’, Population Space and Place 24(8): e2168.

43.

Mostafanezhad

(2013) ‘The Geography of Compassion in Volunteer Tourism’, Tourism Geographies 15(2): 318–37.

44.

MSF (2021) MSF (Médecins sans Frontières) Suspends Work in San Salvador Area After Ambulance Attacked’. Aljazeera, 31 January. Available at: https://www.aljazeera.com/news/2021/1/31/msf-suspends-work-in-san-salvador-area-after-ambulance-attacked (accessed 8 September 2021).

45.

Muñoz

(ed.) (1981) From Dependency to Development: Strategies to Overcome Underdevelopment and Inequality. New York: Routledge.

46.

Nouvet

Chan

Schwartz

L. J.

(2018) ‘Looking Good But Doing Harm? Perceptions of Short-Term Medical Missions in Nicaragua’, Global Public Health 13(4): 456–72.

47.

Pan American Health Organization (PAHO) (2017a) Country Report’. El Salvador. Available at: https://www.paho.org/salud-en-las-americas-2017/?page_id=119 (accessed 10 September 2021).

48.

Pan American Health Organization (PAHO) (2017b) Country Report’. Honduras. Available at: https://www.paho.org/salud-en-las-americas-2017/?_id=133 (accessed 10 September 2021).

49.

Said

(1978) Orientalism. New York: Pantheon Books.

50.

Salazar

N. B.

Graburn

N. H. H.

(2014) ‘Introduction’, pp. 1–28 in Salazar

N. B.

Graburn

N. H. H.

(eds) Tourism Imaginaries: Anthropological Approaches. New York: Berghan.

51.

Schech

Mundkur

Skelton

, et al. (2015) ‘New Spaces of Development Partnership: Rethinking International Volunteering’, Progress in Development Studies 15(4): 358–70.

52.

Schneider

M. J.

(2018) ‘Exotic Place, White Space: Racialized Volunteer Spaces in Honduras’, Sociological Forum 33(3): 690–711.

53.

Sin

H. L.

(2010) ‘Who Are We Responsible To? Locals’ ‘Tales’ of Volunteer Tourism’, Geoforum 41(6): 983–92.

54.

Skinner

Lester

(2012) ‘Humanitarianism and Empire: New Research Agendas’, The Journal of Imperial and Commonwealth History 40(5): 729–47.

55.

Smith

(1996) Resisting Reagan: The U.S. Central American Peace Movement. Chicago, IL: University of Chicago Press.

56.

Smith

(2015) The Costs of Volunteering: Consequences of Voluntourism. Unpublished Senior Thesis, University of Pennsylvania.

57.

Smith

(2013) ‘Hurricane Mitch and Honduras: An Illustration of Population Vulnerability’, International Journal of Health System and Disaster Management 1(1): 54–8.

58.

Spalding

A. K.

(2013) ‘Lifestyle Migration to Bocas del Toro, Panama: Exploring Migration Strategies and Introducing Local Implications of the Search for Paradise’, International Review of Social Research 3: 67–86.

59.

Spivak

G. C.

(1988) ‘Can the Subaltern Speak?’, pp. 271–313 in Nelson

Grossberg

(eds) Marxism and the Interpretation of Culture. Basingstoke: Macmillan.

60.

Sykes

K. J.

(2014) ‘Short-Term Medical Service Trips: A Systematic Review of the Evidence’, American Journal of Public Health 104(7): e38–48.

61.

Todd

(2021) Long Journey to Justice: El Salvador, the United States and Struggles Against Empire. Madison: University of Wisconsin Press.

62.

United Nations Office of the Coordination of Humanitarian Affairs (UNOCHA) (2021) Humanitarian Principles’. Available at: https://www.unocha.org/sites/dms/Documents/OOM-humanitarianprinciples_eng_June12.pdf (accessed 9 September 2021).

63.

Vastri

(2013) Volunteer Tourism in the Global South: Giving Back in Neoliberal Times. New York: Routledge.

64.

Vaughan

(1991) Curing Their Ills: Colonial Powers and African Illnesses. Palo Alto: Stanford University Press.

65.

Watkins

(2015) ‘Spatial Imaginaries Research in Geography: Synergies, Tensions and New Directions’, Geography Compass 9(9): 508–22.

66.

Wearing

McGehee

N. G.

(2013) ‘Volunteer Tourism: A Review’, Tourism Management 38: 120–30.

67.

Wearing

Young

Everingham

(2017) ‘Evaluating Volunteer Tourism: Has It Made a Difference?’, Tourism Recreation Research 42(4): 512–21.

68.

Welling

D. R.

Ryan

J. M.

Burris

D. G.

, et al. (2010) ‘Seven Sins of Humanitarian Medicine’, World Journal of Surgery 34(3): 466–70.

69.

World Bank (2020) Open Data’. Available at: https://data.worldbank.org (accessed 11 September 2021).

70.

Zahra

McIntosh

A. J.

(2007) ‘Volunteer Tourism: Evidence of Cathartic Tourist Experiences’, Tourism Recreation Research 32(1): 115–9.

71.

Zahra

McGehee

N. G.

(2013) ‘Volunteer Tourism: A Host Community Capital Perspective’, Annals of Tourism Research 42(July): 22–45.

72.

Zane

(2016) Barbie Challenges the White Savior Complex’. BBC News, 1 May. Available at: https://www.bbc.com/news/world-africa-36132482 (accessed 13 September 2021).