Summary of evidence
To the best of our knowledge this review of short-term medical missions is the first to assess this subject, determine trends that have developed over the past 25 years, and provide recommendations for further research and expansion of knowledge in this field. Overall, this review revealed that relatively few articles are published on the topic of short-term medical missions, in some cases, fewer than 10 per year, and publications about mission sending are dominated by four countries (USA, Canada, United Kingdom, and Australia). Nearly all articles lacked information on potential biases, such as funding source and sending and/or receiving organizations. Existing articles are mainly descriptive in nature. Very few discussed the ethics, policies, standards or evaluations of short-term medical missions. Sending countries often have a political or economic tie to the destination countries. Key medical conditions addressed by medical missions are cleft lip and palate surgeries, oral and dental health, and vaginal fistulas.
Benefits of medical missions
Health care professionals stated they gained a great deal from the missions and referred to missions as opportunities to reconnect to the reasons why they decided to become doctors . Local community members often stated they felt medical missions demonstrated the outside world recognized their plight, and cited feeling a sense of solidarity when foreigners came to their communities to provide medical assistance: ‘they all replied that having a physician come, even for short periods of time, was extremely helpful to the community, as it put a human face on their problems and gave them hope that ongoing assistance would follow’ [11, 12]. Many health care professionals on missions felt an integral part of their role was to engage in or facilitate a transfer of skills and knowledge to local counterparts . This was reported through Operation Smile missions in Colombia,  and by the international NGO Interplast  both for cleft clip and palate surgeries.
Common critiques of medical missions
Several weaknesses of short-term medical missions were also discussed in the literature. Articles stated that foreign-led medical missions, while providing some short-term relief and aid to communities in LMICs, were ultimately not sustainable . Articles also conveyed a strong sense of the limited impact of medical missions Kasis et al. . One participant, in writing about a mission to Honduras questions the efficacy of these types of short term missions: ‘I can't help wondering however, that even though we really helped many of the people, for others all we really did was put a band-aid on a gaping wound. Now that we are gone will the wound just grow larger and larger?’ . Many others question if medical missions are an appropriate allocation of already scarce resources, both financial and human [11, 13, 19–21]. Maki sums up the problems of some medical missions when they state: ‘Paucity of follow-up data, poor relations with the local health care system, and lack of sustainability can challenge the good intentions of missions’ .
Tied in with the question of sustainability of medical missions is the question of cost-effectiveness. This is difficult to assess since most articles do not report how much missions cost or how they are funded . In view of the considerable costs involved in financing medical missions (airfare, accommodations, vaccinations, visa costs, customs fees for medicines and medical equipment etc.), it is often asked if money would be better spent donated directly to healthcare facilities in the destination country . When sharing accounts of his medical mission to Zimbabwe, Buchman wonders if ‘the money that was spent on my stay could have been better spent on medical equipment, medications, or even basics such as food and housing’ . Abdullah asks “what business did our team of 10 members (have in doing this, given the 10 members) have spent approximately $30,000 toward travel and hotel costs…. when the entire cost of building a new 30-bed wing for the hospital in Ghana was $60,000?” .
Of likely concern is the quality and efficacy of the medical care provided by foreign doctors who can be unfamiliar with local health needs, local culture and the strengths and limitations of the healthcare system in which they must leave their patients for follow up care. Doctors who are not qualified for a particular type of surgery in their home countries are often placed in situations during medical missions where they must provide care for which they are neither qualified nor confident to provide [25, 26]. Trainee doctors and surgeons may not receive the typical senior supervision they may have at ‘home’ while attempting procedures with which they are unfamiliar. This may result in patients developing serious medical complications and local doctors developing strong feelings of resentment towards medical missions . However, it may also be argued that this may be the best potential care that exists for a patient in a particular location, at a particular time.
There are also accounts of surgeons participating in medical missions for reasons termed ‘surgical tourism’. As certain conditions are rarely seen in high income countries, doctors are choosing to volunteer for medical missions to hone skills and see conditions which they might not otherwise encounter [10, 24, 28, 29]. One author describes with relish ‘What we read about in books during our residencies walks in the door…It is a veritable feast of interesting cases’ . In his 2006 article on medical missions to LMICs for the surgical repair of vaginal fistulas, Wall states ‘such projects may serve to promote ‘fistula tourism’ rather than significant improvements in the medical infrastructure of the countries where these problems exist’ .
Medical missions are often unable to provide the full-spectrum of care required for complex medical conditions. Patients with cleft lip and palate conditions, for example, need oral/maxillofacial surgeons for the initial surgical repair of the cleft lip/palate, with more post-surgical care often required. Patients can require follow-up visits to general physicians and/or plastic surgeons, future visits to orthodontists to repair damaged teeth and jaws, and possibly speech therapists to improve challenges with speech – care which they are unlikely to receive in their communities after the medical mission team departs [32, 33]. Zbar et al.  state ‘during the past three decades, it has become increasingly clear that successful cleft management requires a multidisciplinary, long-term, team approach. To send a cleft surgeon to a remote region of the world without consideration of a genetic, dental, speech, or hearing evaluation of the patient population is perhaps irresponsible or, at best, purely an aesthetic rather than functional undertaking,’ demonstrating the deficiencies of at least some short-term medical missions in fully addressing needs of patients in LMICs .
Attitudes of healthcare professionals on mission
Many health care professionals were not aware of the depth of poverty or limits of medical facilities in the regions they were visiting  and had little knowledge of the local social, economic, political contexts. One student on a short-term medical mission writes ‘I knew I was going to an area of extreme poverty, but as I looked at the conditions in which the family lived, I was not quite prepared for the reality of true poverty’ . This lack of awareness about the realities in LMICs often manifests itself by authors using inappropriate language that is insensitive to the local context and demonstrates a lack of respect for local health care professionals. For example, in this excerpt the author tries to explain differences in working conditions between the USA and Guatemala as staff having inadequate knowledge rather than a lack of resources: “Universal precautions were an unfamiliar concept…At the end of each day, the hospital staff would go through our trash and sharps containers, pulling out items that they could sterilize and use again” .
Political ties between sending and destination countries
Countries send missions to countries with which they have pre-existing political relationships. For example, the USA sends the majority of its missions to Honduras as well as Nicaragua, two countries with which it has significant socio-political ties. This pattern has been well documented in previous research. For instance, in their review of foreign aid distribution, Alesina & Dollar analysed the flow of bilateral aid reported by the Organization for Economic Cooperation and Development (OECD) and found a strong correlation between colonial status and the amount of foreign aid received .
Medical missions often treat rather than prevent conditions
During short-term medical missions, health care professionals often treat individuals with illnesses which could be prevented if detected earlier, but as people have little access to health care, illnesses arise and also become more severe and difficult to treat . Simply responding to the needs of the patient, while reducing individual suffering, does not address the health needs of the community as a whole. Prevention such as safe water, immunization, insecticide-treated bed nets for malaria, prevention of mother-to-child transmission of HIV, or seatbelts to reduce motor vehicle injury are more likely to reduce the burden of disease in a community. However, often due to scant financial and human resources locally and a lack of interest in delivering preventative programs by foreign, visiting short-term medical mission volunteers – missions are left treating illnesses rather than preventing them.
Strengths and limitations
This is among the first literature reviews of medical missions. Short-term medical missions have no internationally agreed upon definition and are rather difficult to define. This review limited included articles to those written in English and did not include articles describing long-term medical care (ie longer than 2 years), education or capacity development, missions occurring in a defined time period related to a complex humanitarian emergency or medical care provided to local citizens by a foreign military presence. Exclusion of these articles may have limited the discussion of medical missions overall but given their differences in reasons and length of engagement compared to short-term medical missions these were excluded to help retain the focus of this review. Only MEDLINE-indexed articles were searched as the feasibility of systematically addressing all grey literature was not possible.
Risk of bias in individual studies and across studies
The majority of articles reviewed in this study were descriptive there was little quantitative data to analyse. The articles included in this review were typically written by a health care professional participating in the mission and thus the articles are likely subject to several types of bias including selection bias and observer bias. This study was limited to articles which were available from University of Sydney Library. Publication bias may exist in the review of this literature. Articles may not have been published if they are too critical or portray missions negatively. In reviewing all 230 articles, most articles did not list all the information which this study was attempting to gather. The information which was most often absent was the funding source. Fifty six percent of the publications examined did not include how their mission to LMICs was funded.