"The siren of one ambulance can destroy Samaritan attitudes in an entire Chilean neighborhood"--Ivan Illich, Medical Nemesis
One of the more common development initiatives that EMS agencies undertake is the donation of ambulances. While at first this may seem like a worthwhile cause, realities on the ground offer significant evidence that these efforts are often far more detrimental to a health care system's progress than they are productive. To be sure, ambulances can have a significant, positive impact in a developing community's health care system. However, to ensure this, a thorough analysis of intentions, capacity and culture is absolutely necessary beforehand.
When considering the donation of an ambulance ask yourself, "Why are we donating this ambulance?" More often than not the response is, "Because we want to help." While that answer is typically true, in order to make sure the donation will in fact be helpful, it is best followed by the question, "Is this the best way we can help?" By honestly examining that question, an EMS agency can find solutions that will both fulfill its desire to help and to meet the needs of the community it wishes to support.
Experience has shown that ambulances are often donated because they have been replaced by a newer model. It's not because they no longer function, but rather they only have a few more years left in them, or they have a limited amount of miles on them before they are no longer serviceable. Of course, there are other situations including mergers, buyouts and station closures that can make ambulances available for donation. Nevertheless, conventional wisdom dictates that ambulances which can fetch a good return are sold, and those which cannot are prime candidates for donation.
Regardless of the event making the donation possible, it is important to first consider the functional utility an ambulance would have on North American roads, and then to compare what the same ambulance would have on roads which are far less accommodating, if they can be considered roads at all.
This is what should be reasonably expected by an agency that is about to commit to the significant time, effort and money it takes to donate an ambulance. The rest of this article will help to raise awareness of the challenges that developing communities experience as a result of donated ambulances, as oftentimes they are not aware themselves of the responsibilities and resources that running an ambulance demands.
Just as the first question involves self-examination, a correlating question needs to be asked about the recipient, "Why do they want this ambulance?" This can admittedly be a difficult question to answer. Different cultures have different communication styles, and many times the individual who has solicited the donation is doing so more out of the assumed benefits of having an ambulance as opposed to an informed understanding of the actual responsibilities involved in operating one. There are endless stories of how wealthy businesspeople came to North America, saw the EMS system at work, and then believed that ambulances would solve many of their community's problems, without having fully understood the complex infrastructure needed to support an ambulance.
While this scenario could easily be explained as an uninformed romanticism, it is also possible that the individual who has solicited the ambulance for the local underfunded public hospital is fully intending to sell it to the wealthy private hospital across town. Therefore, it is extremely important that any ambulance donation takes place between known, trusted parties with ample means to ensure accountability. For example, providing ambulances to government officials who are about to end their term in office is clearly ill-advised. Likewise, it is also helpful to have the donation take place at a formal, public ceremony. Attracting local media is not only encouraged, but also relatively easy in most foreign communities, including capital cities. Similarly, creating a long-term partnership with the community to offer periodic trainings and a semi-regular supply of provisions also helps to create accountability and assists in ensuring the local's involvement in the operations.
While these strategies are not foolproof, they can certainly help build a sustainable and effective program. Yet as unfortunate as these considerations are, it would be equally irresponsible to assume all governments and community leaders are corrupt. There are many, many people who truly want to make a difference in their communities.
Understand the Health Care System
One of the first steps in making a responsible donation is to understand the current state of the recipient community's health care system. Because organizations that accept ambulance donations are often disconnected from local hospitals (i.e., fire, police, civil guard, municipal government), it is important to understand how local health care facilities operate, and whether or not the ambulance might be better used if donated to the health facility itself. The answer is, typically, "yes." The idea of having non-health agencies provide care, like fire departments, is not common, and when it does happen, it is typically something borne of necessity, or a concept transplanted from the United States since local health care facilities are unable to do it themselves (therefore reinforcing the need to improve existing health care providers).
The saying, "An EMS system is only as good as the hospital it delivers to," resonates quite loudly in developing countries. For example, if a hospital is unable to transfer unstable cardiac patients or high-risk neonates to a tertiary care center due to a lack of adequate transportation, many profound professional and community problems may arise by donating an ambulance to a fire department which rarely transports patients and whose responders have virtually no medical training. In this case, the ambulance can have a far greater impact by being donated to the hospital. And it could also avoid creating new and unnecessary power struggles between competing interests.
On the same note, by providing an ambulance to an organization in a resource-constrained setting, there is a very good chance that limited funds and supplies will be wasted in trying to staff and stock an ambulance when those funds could be put to better use in established health facilities. In many developing countries the phenomenon of "technology hunger" exists, which suggests that bigger is better. Lights and sirens, and bells and whistles are given precedence over tested and true low-cost improvements, simply because the technology is more advanced. The basic assumption is that advanced technology improves outcomes. This is simply not the case. But these communities are not guilty in this thinking alone. We, too, commit this error every day in North America, as the allure of ALS interventions are often far more appealing than BLS skills, despite a lack of evidence proving their effectiveness.
Understand Local Resources
Perhaps the most common cause of a misguided ambulance donation is the simple failure to do the homework. As was discussed earlier, it is imperative to evaluate available physical, financial and human resources in a given community before straddling them with an ambulance. Several simple questions can help avoid disastrous consequences:
In what condition are the roads? Are they smooth, maintained asphalt like those we have in North America? Or, are they unpaved, pockmarked, washboard or pure vegetation? Ambulances are not off-road vehicles.
What are the weather patterns? North American ambulances serve little use during monsoon season.
How wide are the roads? Large cities in many developing countries are giant webs of narrow, wandering alleys and one-lane streets that are inaccessible by North American ambulances.
How bad is the traffic? The more widespread the congestion, the more useless an over-sized ambulance--think Calcutta.
How costly is fuel? North America traditionally enjoys very low fuel costs compared to most other countries, including those in Europe.
How easy are spare parts to obtain within the country?
How familiar are the local mechanics with these engines and electrical wiring?
Remember, for every ambulance a community acquires, it will need fuel, spare parts and specialized mechanics to maintain and repair it. This can become especially overwhelming as communities acquire multiple ambulances from multiple vendors and donors, leading to "a disparate fleet of vehicles of varying suitability, age and function." Unfortunately, many communities are so desperate to improve their health care access they will often continue to spend money to make use of the ambulance until they have wasted too much.
Aside from the financial considerations, we have to keep in mind that high-quality patient care is the ultimate goal. Everyone who has worked in an ambulance on smooth streets knows how bumpy the ride can be in the back. It often seems like even the smallest pebble can send you across the patient compartment. With that in mind, think about much worse it is for patients and providers working in the same ambulances on roads that are in no way comparable to those in developed countries. Without a doubt, patient care (not to mention provider safety) can be seriously compromised.
Understand How Ambulances Operate in North America
For us, the functional purpose of an ambulance, and the essential infrastructure needed to operate it, is commonly taken for granted. An ambulance implies that wherever emergency medical attention is required, we can move to get there. However, this is easier said than done. In order for this model to be effective, complex, robust communication capabilities are essential to receive incoming information from a specific location, and to then relay that information to responding units in an effective and efficient manner.
However, even the most basic elements of this system are often missing in developing countries. While many streets are named in urban centers, it is very common for most people to be unaware of the actual names, especially those who do not live in that immediate area. Likewise, even when street names exist and are known, most buildings and homes don't have easily identifiable numbers. In some countries, directions are given strictly according to geographical landmarks, e.g., 150 meters northeast of the Santa Lucia Community Center. In these settings, maps are often completely futile, if they even exist at all.
Shipping and Customs
Finally, if all of these factors have been evaluated and it still seems like a responsible endeavor to move forward with a donation, it is necessary to understand bureaucratic rules and regulations that are required to ship an ambulance. The number of forms and permits necessary to ship an ambulance can itself be enough of a hassle to discourage people from engaging the process, so it is important to form relationships with established and experienced shipping companies to ensure the ambulance gets where it ought be, and to do so before any formal announcement is made in the receiving community. A wise strategy would be to consult with shippers who have already worked specifically with this type of cargo. At this very moment, fleets of donated ambulances are stuck in ports across the globe as communities scramble to come up with the exorbitant pay-offs demanded by crooked customs officials, not realizing the high costs they're spending to get the ambulance through customs is only the beginning of their financial woes. At the same time, customs officials may be more than happy to keep the ambulances in port since ambulances are known to make great air-conditioned offices.
One last important consideration in any donation is to try to understand as thoroughly as possible beforehand the cultural impact an ambulance may have on a community. Ivan Illich, a Roman Catholic priest well known for his critique of Western medicine in Medical Nemesis, describes the "symbolic power" of an ambulance and the negative effect that lights and sirens can have on a community's fragile health care system. Generally speaking, Illich was pointing to the unintended consequences of providing ambulances where they had not previously existed, and how professionalization of a service will inevitably deter communities and individuals from participating in their own healthcare.
This process of "medicalization" is especially troublesome when promises are made that can't be kept, and when expectations are raised that can't be met. For communities who are desperate to "modernize," there can be any number of preconceived notions of what modernization means, and what it will provide to the community, things that well-meaning donors have no control over. While the hopes and expectations of a foreign culture are always difficult to determine at the outset, much of this information will come out during the careful process to answer all of the other questions discussed here, making it all the more important to move forward carefully, to remain completely transparent and not to make promises that can't be kept. Simply put, one ambulance does not constitute an "EMS system," and should not be treated as such.
It's useful to remember that failed programs aren't just worthless, they're often of negative value. Unintended consequences are rarely cost-free. Countless failed programs have been based on the assumption that progress can be obtained by transplanting Western programs and concepts of health care into communities that haven't previously participated in them. Just because it works in North America or Europe doesn't mean it will work in an underdeveloped community.
Listen to All Ideas
Donating an ambulance to a struggling health care system can be a tremendous help, allowing health care professionals to provide services that weren't previously available, or to reach patients that are difficult to access. However, it's essential the donation is the result of a well thought out process that has considered a wide variety of problems and obstacles. It is also important to be willing to listen to ideas that weren't previously being considered. After all, local health care professionals know their system's needs far more intimately than we do. For that reason, if possible, the donor should refrain from putting restrictions on how the ambulance is used, so long as it is used ethically. At the same time, it is our responsibility to do proper vetting beforehand to avoid straddling communities with more financial burden than they already have.
A responsible donation should be open to alternative uses for ambulances outside of emergency response. Some examples include mobile clinics, long-distance patient transport, acting as part of a cold-chain, and inter-facility transport. But even with those solutions, it is important to ask if something less expensive could do the same job. In Zimbabwe, ox-drawn wagons used as ambulances have produced impressive results simply by making transportation available to women in labor, despite the assumption that ox-drawn wagons are a step backwards.
Because of the significant challenges that fragile health care systems in developing countries face, it should be all the more important to seek solutions that can address the situation in its entirety. The well-worn justification that "donating something is better than nothing" is disproved on a daily basis in the global health community. The next time you hear of someone looking to donate an ambulance, please help out by assuring the donation is a responsible one and not just a junk dump disguised in the cloak of humanitarianism. More often than not, we can do far more good if we scrap the ambulance and just send the cash.
And, yes, in case you wondering, the same principles apply to fire apparatus … if not more so.
Jason Friesen, BA, NREMT-P, the founder/director of Trek Medics International and an MPH at the Mailman School of Public Health. He currently lives in Port-au-Prince, Haiti, where he is involved in a prehospital development program with Project HOPE. For more information, visit www.trekmedics.org, or www.projecthope.org.