Intentional Exploration on International Service Learning Trips: Three Questions for Global Health

Going on short-term experiences in global health (STEGHs) is now a common occurrence among students and trainees in the health professions. STEGHs, also known as short-term international service learning trips, are characterized by individuals or groups from high-income countries traveling to lowand middle-income countries for periods ranging from weeks to months to participate in service, educational activities, or research activities. When seasoned clinicians, educators, and investigators temporarily go abroad to practice, teach, and conduct studies, respectively, they too are participating in STEGHs—one is never too old or too experienced to avoid growing, hopefully with the development of wisdom in mind—while involved in professional activities in foreign settings. Much of the literature around STEGHs increasingly focuses on ensuring benefits for host communities. Simultaneously, however, many scholars are questioning whether such benefits are realistically achievable through participation in STEGHs. This juxtaposition exposes obvious concerns regarding the value of STEGHs for all involved and highlights the obligation of participants from high-income countries to examine their ethical, interpersonal, and practice responsibilities in relation to their majority-world hosts. Without such examination, participants in STEGHs may be at risk for exploiting the very people living in the communities they intend to help. I have had the fortune to participate in several shortand long-term international trips over the course of my career as a practicing physician and educator in family medicine and public health. These experiences have cemented in my mind the vital need for all health professionals to develop such characteristics as cultural reflexivity, cultural humility, shared presence, social responsibility, and self-awareness. STEGHs can offer wonderful opportunities for participants to cultivate these attitudes and attributes, but only if they are willing to explore them in addition to acquiring the technical skills needed to work in resource-poor settings. Predeparture training supplemented by postreturn evaluation can be helpful in encouraging this kind of exploration. However, I believe these activities must be supplemented with ongoing reflection before beginning, during, and on the completion of any STEGH. My purpose here is to suggest 3 questions that reinforce the practice of such reflection, so as to help breed and sustain the kind of broad inquisitive quality of character that is crucial for living, working, and learning in any foreign context—or, for that matter, in any context at all.

I have had the fortune to participate in several short-and long-term international trips over the course of my career as a practicing physician and educator in family medicine and public health. These experiences have cemented in my mind the vital need for all health professionals to develop such characteristics as cultural reflexivity, 8 cultural humility, 9 shared presence, 10 social responsibility, 11 and self-awareness. 12 STEGHs can offer wonderful opportunities for participants to cultivate these attitudes and attributes, but only if they are willing to explore them in addition to acquiring the technical skills needed to work in resource-poor settings.
Predeparture training supplemented by postreturn evaluation can be helpful in encouraging this kind of exploration. 13 However, I believe these activities must be supplemented with ongoing reflection before beginning, during, and on the completion of any STEGH. My purpose here is to suggest 3 questions that reinforce the practice of such reflection, so as to help breed and sustain the kind of broad inquisitive quality of character that is crucial for living, working, and learning in any foreign context-or, for that matter, in any context at all. 14

E X P L O R AT I O N T H R O U G H R E F L E C T I V E P R A C T I C E
Because medical and cultural environments are often profoundly different than those to which STEGH participants are generally accustomed in highresource settings, they offer opportunities for transformative learning through experiential engagement. They offer opportunities to expand understandings of how historical, structural, and social patterns guide how people around the world think and behave in relationship to health and illness. 15 They offer opportunities for participants to examine, as well, their own beliefs about such issues as power, poverty, social suffering, solidarity, and resilience in the face of severe physical, psychological, and social challenges.
Such ends, however, mean work: the purposeful emotional and cognitive examination of old and new, known and unknown, and self and other. 16 There are many helpful ways to stimulate this work, 17 and many social and ethical concepts exist to aid in such an appraisal. 18 In this article, I put forward 3 easily remembered questions for ongoing consideration, questions I believe can help participants in STEGHs cultivate an open and inquisitive presence in foreign settings.
Highlighting context, learning, and service as acknowledged foci of STEGHs, 19 these 3 questions for global health (3Q s 4GH), asked of oneself and one's international hosts, include ( Fig. 1)  By asking this question, participants are also prompted to recognize how these conditions both influence and are expressed through their relationships to the natural, built, and interpersonal environments in which they live and work. 20 Question 2 speaks of service to others. Although there are many motivations for participating in STEGHs, the hope to be of service to others often tops the list. Because of imbalances of power, 21 however, many health care professionals from resourcerich countries risk overestimating their contributions in resource-poor settings. Swayed by this overestimation, they may miss how their efforts detract from the promotion of equitable, reciprocal, and dynamic interactions. They may, in fact, reinforce ideologies born of colonial domination. This question's focus on engagement offers an alternative to this pattern of thinking. Inviting an engaged presence during STEGHs, 22 through active listening and appreciative dialogue, is more appropriate to international activities and likely more lasting in overall effect than solely applying clinical skills or giving expert advice. The words "with whom I am working" suggest a stance of humility and solidarity rather than one of authority and privilege. They acknowledge, as well, how no one works in isolation from others. We live in a socially interdependent world. 23 Question 3 speaks to learning. The core of this question reinforces how the process of learning in STEGHs involves developing social relationships and suggests that inquisitiveness plays a significant role in nurturing an ability to grow. Competence is not the only goal to aspire to in STEGHs. Both the aptitude for adapting to new uncertainties in challenging cross-cultural circumstances and the capacity to express care appropriately under these same circumstances are aims of equal importance. By ending with a call to global health citizenship this question also emphasizes 2 key learning objectives that STEGHs ideally promote, understanding that (1) global signifies everywhere, and the root causes of inequalities in health outcomes around the world (as well as applicable responses) are similar wherever one happens to be, 24 and (2) in any global health work it is wise to consider how to practice from, and model for others, a conviction in the value of social accountability. 25

F U R T H E R C O N S I D E R AT I O N S
Some readers may perceive these questions as too simplistic, poorly representative of the many variables that can arise in STEGHs, let alone in any other kind of work in global health. Others may see them as overly self-centered, in that they speak to intentions rather than outcomes, avoiding issues such as capacity building and sustainability. Still others simply may prefer using global health competencies as guides for consideration. 26 I respond by noting that these 3 questions are not final stops on the path of global health inquiry, but points from which to initiate, and through repetitive reflection sustain, personal and professional development while participating in STEGHs. Absent deep personal reflection, outcomes are likely to be momentary and illusory, biased toward participants' wants, and more consistent with replicating cultural ideologies focused on assessment than with developing rich understandings of relational differences. 27 I welcome the input of others as they expand, reframe, and further refine these questions, as they see fit, to match their particular circumstances, interests, and goals.

C O N C L U S I O N
STEGHs offer wonderful opportunities for health care professionals to grow individually and collectively. Intentionally recalling 3 questions-1 targeted toward context, 1 toward service, and 1 toward learning-can help participants in STEGHs explore concepts key to enhancing their abilities to be thoughtful learners and practitioners in both domestic and international settings. I invite such participants to consider asking these questions of themselves and of their international hosts, wherever in the world they may be.

A C K N O W L E D G M E N T S
The author thanks the Brocher Foundation in Geneva, Switzerland, the Nelson Mandela Metropolitan University in Port Elizabeth, South Africa, and the Institute for the Medical Humanities, University of Texas Medical Branch, Galveston, for providing residential fellowships during which this essay was written. He is grateful to these institutions and to his colleagues at each one for their contributions to the preparation of this essay.