Planning a medical missions trip to another country? Unsure which medications to put on the formulary? Concerned about how to handle malpractice and other regulatory requirements? Looking for inexpensive medication, equipment, and supplies? Need to know what other services would be useful to make available? Wanting to integrate telemedicine?

By Mark D. Harris

Christ told His disciples to go into all the earth and make disciples of all nations. For millennia, medical care has been a reliable and fruitful way that Christians have obeyed His commands. Medical missions, however, are increasingly fraught with difficulties. Can we make the standard of care in the developing world the same as the developed world? Will we undermine the local medical system and economy by providing treatment that the locals would have otherwise done? What if the locals cannot provide the same standard of care that foreigners can? How can our doctors, often US-based, practice medicine on patients they cannot understand in countries in which they are not licensed?

Sample Formulary

Medications are a large part of clinical medicine. Health care providers do more with medications than just about any other intervention. Patients often expect medication when they walk out. This sample formulary should be modified to meet the needs of the people at the trip location.

Allergy, Respiratory, and Topical drugs

Albuterol/Salbutamol Inhaler – 2 puffs 4x/day prn wheezing and dyspnea
Cetrizine (10mg) – 5-10 mg daily. Allergy.
Diphenhydramine (Benadryl) (25 mg) – 25-50 mg 4x/day prn. Rash, itching, allergic reaction.
Hydrocortisone cream 1% – Apply to affected area 1-2x/day for rash.
Prednisone (10 mg) – Take up to 50 mg x 5 days, then taper over 16 more days.
Triple antibiotic ointment – Apply to affected area 1-2x/day for skin infection.

Antibiotics

Albendazole (400mg) – 400 mg twice per day with meals for a 28-day cycle followed by a 14-day drug-free interval, for a total of 3 cycles.
Amoxicillin/sulbactam (Augmentin) (875/125 mg) – Every 12 hours x 5-7 days, sinusitis, pneumonia, ear infections, bronchitis, urinary tract infections, and infections of the skin.
Azithromycin (500 mg) – 500-1000 mg daily for 5-10 days, respiratory infections, skin infections, ear infections, eye infections, and sexually transmitted diseases.
Ciprofloxacin (100, 500 mg) – osteomyelitis, pneumonia, anthrax, joint infection, shigellosis, tularemia
Doxycycline (100 mg) – 100 mg daily or twice per day. Atypicals including actinomycosis, lyme disease, chlamydia, malaria, trachoma, amoebiasis, bartonellosis, anthrax, rickettsia,
Flagyl (metronidazole) (250 mg) – 250 to 500 mg orally 3 times a day x 7-10 days. Bacterial, amoebic, and parasitic infections.
Fluconazole (100, 400 mg) – 100 to 800 mg orally once a day for 7 days. Fungal infections of the mouth, throat, esophagus, lungs, bladder, genital area, and the blood
Gentamicin 0.3ml ophthalmic drops 5ml – 1-2 drops into the affected eye(s) every 4 hours. Eye infections
Ivermectin – 0.2 mg/kg orally once. Worms.
Sulfamethoxazole/Trimethoprim (800mg/160mg) – 15 to 20 mg/kg/day (trimethoprim component) orally in equally divided doses every 6 hours for 14 to 21 days. Toxoplasmosis, pneumocystis, cystitis, travelers diarrhea

Cardiac/Hypertensive drugs

Lisinopril (5, 10, 20 mg) – 120-80 mg daily for high blood pressure.
Enalapril (5, 10, 20 mg) – 5-40 mg daily to twice daily for high blood pressure
Amlodipine (5, 10 mg) – 5-10 mg daily for angina and high blood pressure
Bisoprolol (5, 10 mg) – 5-10 mg daily for high blood pressure
Carvedilol (12.5, 25 mg) – 3-100 mg for high blood pressure and heart failure.
Losartan (25, 50 mg) – 25-100 mg daily for high blood pressure
Furosemide (40 mg) – 20-160 (max 600) mg daily for kidney and liver disease, heart failure with swelling, and high blood pressure.

Endocrine drugs

Metformin (250, 500 mg) – 500 mg orally twice a day or 850 mg orally once a day. Maximum dose: 2000-2550 mg/day
Levothyroxine (50, 100 mcg) – 25 to 500 mcg daily

Gastrointestinal drugs

Antacids (bismuth subsalicylate (262-1050 mg/15 ml liquid) – take 1-2 tbsp every 4 hours with a maximum of 4 grams in 24 hours. Use for diarrhea and dyspepsia.
Docusate (Doculase) (100 mg) – 50-400 mg daily for constipation
Famotidine (20 mg) – 20-40 mg daily for heartburn
Loperamide (2mg) – 4 mg orally after the first loose stool, then 2 mg orally after each unformed stool, Maximum dose: 16 mg per day. Diarrhea.
Promethazine (25mg) – Oral or Rectal: 6.25 to 12.5 mg orally or rectally before meals and at bedtime, if necessary, OR 25 mg orally or rectally once a day at bedtime. Nausea.
Omeprazole (10, 40 mg) – 10-40 mg daily for heartburn, ulcers, gastritis

Mental Health, Insomnia, Neurology, and Pain drugs

Acetaminophen (500 mg) – 1 tablet four times per day as needed for pain.
ASA (100 mg) – 1 tablet four times per day as needed for pain.
Gabapentin (300 mg) – 300-2400 mg daily in divided doses daily for nerve pain, seizures, epilepsy, or restless legs syndrome.
Ibuprofen (200, 400 mg) – 1 tablet four times per day as needed for pain.
Melatonin (3 mg) – 1.5 to 6 mg in the evenings for insomnia.
Valerian Root (30 mg) – 30 mg daily up to 4-8 weeks for anxiety or insomnia
Zoloft (50, 200 mg) – 50-200 mg/day for anxiety, depression, or chronic pain.

Supplements

Calcium (carbonate) (650-1250 mg) – 1-2 tabs daily.
Iron (ferrous sulfate) (600 mg) – 600-1000 mg/day ferrous sulfate (120-200 mg/day elemental iron) for 3 months.
Multivitamin (adult, child) – daily

Symptomatic

Cough syrup – 5 cc up to four times per day for cough

Where to get medications, supplies, and equipment?[1]

Medication, supplies, and equipment can be very expensive. Many organizations exist to provide medication, supplies, and equipment to churches and other groups sending teams to meet medical needs of underserved populations. Planners and leaders should contact the organizations listed below to obtain what they need for their trip.

Kingsway Charities (https://www.kingswaycharities.org/)
Missions for All People International (https://www.map.org/) – medications, ethicon suture, JJvision, BauschVision, heart valve, patientcarepackage. Short dated medication (6 months or less). 912-280-6627.
Blessings International (Phone: 918-250-8101, E-mail: info@blessing.org, Web: http://www.blessing.org)
International Dispensary Association (IDA) – Slochterweg 35 1027 AA, Amsterdam, The Netherlands Telephone: + 31 20 4033051 E-mail: info@idafoundation.org Web: idafoundation.org.
IMA World Health – .PO. Box 429 New Windsor, MD 21776 Phone: 877-241-7952 imainfo@imaworldhealth.org Web: imaworldhealth.org.
Heart to Heart International, Inc. (HTHI) – 401 South Clairborne, Suite 302 Olathe, KS 66062 Phone: 913-764-5200 info@hearttoheart.org. Web: hearttoheart.org.
Crosslink International – 427 North Maple Ave. Falls Church, VA Phone: 703-534-5465 info@crosslinkinternational.net, crosslinkinternational.net.
Fellowship of Associates of Medical Evangelism (FAME) – PO. Box 33548 Indianapolis, IN 46203 Phone: 317-358-2480 medicalmissions@FAMEworld.org, FAMEworld.org.
Worm Project – Franconia Mennonite Conference, Harleysville, PA Contact: Claude Good at: 267-932- 6050 Ext. 136 info@wormproject. orgmailto:cgood@franconiaconference. Org, wormproject.org.
Vitamin Angels – Santa Barbara, CA 93105 Phone: 805- 565-9919 info@vitaminangels.org vitaminangels.org.

Telemedicine Equipment

The scope of equipment used in telemedicine is large and growing. Stethoscopes, pulse oximeters, 12 lead EKGs, ultrasound probes, and scopes (iris scope, otoscope, endoscope, and dermatoscope) improve information gathering and patient care. Thermometers, glucometers, weighing scales, blood pressure monitors, and Fitbit watches add to patient monitoring. Teams should test each piece of equipment that they are planning to use on the trip individually and together before leaving for the trip. Power is paramount, so provide extra batteries and redundant power supplies which conform to local requirements (plug type, voltage).

Addressing malpractice and regulatory threats

Medical personnel typically provide free medical care while serving on the mission field. Malpractice and other litigation is uncommon but not impossible.[2] National, regional, and local government officials want, need, and deserve information on what is happening in their areas of authority. Likewise, officials must often give approval for foreign initiatives such as medical missions trips.

Medical Professional Liability Coverage, Short-Term Medical Professional Volunteer Coverage – Individual and Group. https://www.ajg.com/us/-/media/files/us/programs/cge/medical-malpractice-short-term-individual.pdf.
Medical Professional Liability Coverage, Medical Professionals on Short-Term Medical Outreaches – https://wideopenmissions.org/go-short-term/medical-professional-liability-coverage.

Mission trips to overseas locations have many other legal issues. Organizers must consider who is in charge, who is going, who is paying, whether the trip tax deductible, and what to do if something bad happens, to name only a few concerns. Participants themselves will have medical needs and may need insurance. In the world of social media, what will be on Instagram or YouTube, and have people given consent for it?[3] In one case, a youth drowned in the ocean on a church sponsored mission trip to Costa Rica. The church was found liable, and their insurance policy did not cover extraterritorial claims.[4]

United States law applies to US physicians while practicing in the US. However, other nations sometimes mimic or informally adopt US requirements, especially with regard to US providers. The Health Insurance Portability and Accountability Act (HIPAA) requires medical personnel to follow strict guidelines regarding protected health information and personally identifiable information. It is possible that a court could find against medical personnel, no matter how well meaning and competent the medical personnel. DoxyMe provides a telemedicine portal which is free or inexpensive and HIPAA compliant. In a telemedicine environment, the provider is still on home turf (like the US) and therefore falls under US regulations even though the patient does not.

Other ethical issues arise. While most agree that a physician should never operate outside of his training, whether a physician may operate outside his US scope of practice is less clear. If a physician is skilled and experienced in caesarian deliveries, for example, should he perform them in Africa when he does not in America? In life threatening situations, can a provider do what he feels needs to be done, such as a needle cricothyroidotomy, even though he has never done one before?

Overseas medical missions activities should be done for the benefit of those served, not those who are going.[5] The local community, community leaders, and often regional and national leadership, should be aware of and invite the caregivers in.[6] Planners should maximize short- and long-term benefits and minimize costs. The World Health Organization prohibits using expired medications on trips due to unintended harms and an ethical double standard, even though the medications may remain good after their expiration date. Local licensing requirements must be followed. Visiting teams should affirm and not disparage the local medical system as much as possible. Local communities may provide transportation, lodging, food, and a host of other services. Generally, visiting teams should calculate and reimburse for these services. Teams should try to fairly allocate services between community partners.

Providing the most effective services

Medical missionaries have long evaluated their work and tried to improve it for the sake of patients, funding sources, medical teams themselves, and the overall mission for Christ. Short term medical missions, in which follow up is difficult, have attracted special concern. What kinds of services are most medically effective?

Vaccination – as long as patients are basically healthy, vaccinations prevent serious disease later on.
Vitamins and minerals – in places where deficiency is a concern.
Eye care – diagnosing poor vision and providing durable glasses can make a long-term difference.
Some surgeries – cataract, cleft lip and palate, and similar surgeries do not require intensive resources for post operative care.
Physical therapy – teaching patients to perform their own physical therapy can improve their lives after injuries, strokes, cancer, and a variety of neurological, pulmonary, cardiovascular, and other health events.

Conclusion

Followers of Christ have been using medicine to meet human needs and introduce Jesus to people who need Him for 2,000 years. While circumstances and technology have changed, these needs are as great as ever. Planners, leaders, and donors for these trips seek the best medications, supplies, and equipment for the lowest price. They look for skilled, healthy, and willing workers. They protect all those involved. Finally, planners and leaders care for all their stakeholders. Remember that discipleship is the mission, and health care is a means to that end. Eternally, these efforts glorify God and help us enjoy Him forever.