‘It’s about time universities review international internships’

Every year, plenty of students hop on a plane to do an internship on the other side of the globe. I understand this choice very well. It’s an amazing opportunity to see something of the world and learn about a discipline in the context of a different culture. Study programmes often assist students in arranging this internship abroad and the competencies acquired internationally can be used for the rest of one's life. Even back in the Netherlands. 

However, there is another side to this story. These internships can have negative and even harmful consequences for students, organisations, and others involved in the receiving country. Complex factors are at play, such as colonial history and the current climate crisis. These factors can influence the practice of international internships and the roles played by students, the receiving university, and the sending university. My research focuses on all these factors, roles, and tensions. So does my education. I think it's important to expose my students to challenges and new insights, and discuss them. These past few years, students have become increasingly vocal about their critical questions and dilemmas. What is equity, what is justice, and what is everyone’s role in this?

My PhD research at the University of Amsterdam focused on the micro level. I studied what happened at work in Ghana and Cameroon, referring to the collaboration between locals and visitors from other countries, like the Netherlands. These past few years, we at UMC Utrecht have been focusing on the mesa level, the institutional level. We try to find answers to questions like: 'What is a responsible international internship programme, why does it matter, and how can we best design it? What competencies do students learn during international internships and how do they apply this knowledge in healthcare in the Netherlands?' Long story short: it’s about theoretical and applied research, closely linked to our own education, for the benefit of a responsible, justifiable international internship programme. 

Machame Lutheran Hospital, Tanzania. Photo: Sophie Croon

Why the time of traditional international internships is over
The phenomenon of ‘international internships’ has been around for about twenty years, thanks in part to globalisation and affordable flights. Universities and universities of applied sciences in high-income countries – such as the Netherlands, Germany, Spain, Denmark, and the USA – started offering programmes with internship opportunities abroad. In the past fifteen years, we've learned more and more about the downsides of these internships and the consequences of those downsides both for the students and the local health workers and patients involved.

The risks vary per discipline. In health care, there’s the risk that students perform medical acts that they’re not trained for (yet). This can coincide with staff shortages, which can be very pressing in many low- and middle-income countries. It can also be because the local supervisor is not up to date about the content and set-up of the programmes for visiting students. After all, these differ per country. I remember one student who was shaking during a suture. She’d never done this before, but the surprised supervisor thought the student had ample experience with them. 

Other risks are about the lack of knowledge and interest in the cultural and socioeconomic context which often decides how healthcare works, and about working with less material and equipment, or different material and equipment. This can sometimes lead to a "hero complex" in which the student tries to apply the method that they learned in the Netherlands in the context of the host country, convinced it is a better way, without knowing whether or not it goes with the local practice. This can cause confusion and frustration, and impede the strengthening of work relations. And it’s exactly those relations that are so incredibly important for a mutual understanding of differences, medical or otherwise. 

Additionally, international internships don’t take place in a vacuum, but within a broad historical context of healthcare abroad. There are different eras we can distinguish. There’s the slave trade healthcare, to prevent the spread of infectious diseases, starting around the year 1400. There’s colonial healthcare, to ensure the colonisers, local administrators, and local workforce remained healthy, from around 1800. There’s mission care, to spread religion and Western medicine, also from around 1800. And there’s tropical healthcare, for the prevention and treatment of tropical illnesses, from 1900. Then there’s international care, where mainly rich countries told poor countries what to do, from around 1960. And that brings us to the era of global health and planetary health, which focuses on reducing health differences between countries and within countries, as well as within the boundaries of the planet. That’s incredibly important, but we’re not there yet. 

The common thread through many of these earlier eras is the sense of superiority of the white healthcare workers. That hasn’t only created a dominant narrative of the white saviour who cures the passive, poor Africans, but also a powerful "colonial mentality" in the recipients of that care. This interplay ensures a complex power dynamic, both between countries and organisations (at a national and institutional level) and at work, when students from rich countries go abroad on "tropical internships." Whether they want to or not, the students become a part of that complex power dynamic, and they help shape it. I saw it happen in Cameroon when Flemish and Dutch students were favoured over others by the Cameroonian nurses. They didn’t have to do the heavy lifting jobs, which angered the Cameroonian students. 

In "traditional" international internships, students travel without any preparation or training, while research shows that it’s important that students know the risks of the internships and can place them in a historical superiority context. We now know how important it is that students develop cultural and medical humility, and the power to reflect on it both during and after the internship. This will benefit patient safety, the creation of mutually beneficial work relations with local healthcare workers and students, the student's wellbeing, and a higher learning outcome for the student. Thankfully, it’s not as though students don’t apply any cultural and medical humility at all without any training in preparation. Some reflect well on their roles, look for more information, and ask open questions. But it doesn’t always go well automatically. Moreover, the responsibility doesn’t just lie with the student. It’s the responsibility of the sending university to ensure a responsible, justified international internship programme in the first place. 

How should we do it instead?
Universities must develop a programme that minimises the risks mentioned above and maximises the benefits for all involved. There are different ways of doing that. Since 2019, UMC Utrecht has offered Pre-Departure Training (PDT) every quarter. We’ve also developed a Code of Conduct that students commit to. Other university hospitals have also started working on an international internship programme, and we share information and insights about this. Literature shows that other high-income countries also implement and evaluate plenty. That’s positive, both for the students and the locals involved. 

But the elephant in the room is that it isn’t just the interns who are part of that complex "North-South" power dynamics. ISending universities in high-income countries also play a part. Where many of our students can gain educational and work experience across the globe, most of the students and healthcare workers in low- and middle-income countries do not have these opportunities. This glaring inequality of opportunity for professional growth is the result of multiple complex factors, such as political decision-making. It’s also the result of choices made by universities in countries like the Netherlands, which means the good news is that universities have an important key role in doing something about it. 

Utrecht University has made this very explicit, by writing in its ambition text: “When it comes to solving the problems of the world, we aim high. We want to give direction to necessary transformations. We see the university as a catalyst for change” (Mission and Strategy). Reducing inequality (Sustainable Development Goal 10) is one of the topics UU is committed to, both between countries and within countries. To me, that’s incredibly important, and it ensures that I feel at home at the university as a researcher and as a lecturer. Within the global health team, it means that we work on research and education from the core values of equality and reciprocity. That was also the foundation for the core team with which we started to redesign the international internship programme in 2019. 

On the road to equity and reciprocity
In 2021, we started a transdisciplinary study in close collaboration with various other parties in two hospitals our students go to for clinical internships, in Malawi and Suriname. The goal was to establish what equity and reciprocity meant for everyone. 

What I noticed is that creating internship opportunities in Utrecht was mentioned by the international parties, but it wasn’t the only thing that mattered. Reciprocity, it turned out, was also about encouraging professional growth in other ways, such as by working in international teams to create a scientific article. Reciprocity isn’t the same as two-way traffic; it rather means that you listen well to the other side. Of course, that’s the essence of equity as well. They also mentioned allowing access to scientific literature and setting up WhatsApp groups to be able to discuss issues with fellow specialists in other hospitals. Lastly, there was a desire to brainstorm together about the contents of the international internship programme, including what’s discussed during the Pre-Departure Training when the students prepare for their internships.

We then started designing equitable partnerships. In practice, this means that we’ve committed to a collaboration contract – with hospitals in Malawi, Suriname and Ghana so far – in which the institutional connection means a lot. We make certain commitments, such as that the receiving hospital arranges supervision, and arrange financial compensation as the sending university. This is custom work because the hospitals have wildly differing desires and needs, and we need to check whether – and how – UMC Utrecht can meet those. One thing I’m proud of is that a delegation of clinical officers from Malawi visited us for training this summer. That was something the partner desired and we managed to make it happen.

Malawi. Photo: UMC Global Health

I also love that the input from our partners, like those in Malawi, is woven into the Pre-Departure Training we offer. They feel it’s important that we teach our students cultural humility, an open approach to learning from working with less material. The Netherlands can learn plenty about this subject, for sustainability purposes. As long as we’re open to it. After all, this is also about recognising the value of knowledge and input from institutions and professionals in low- and middle-income countries. There’s inequality of opportunity there, too (epistemic injustice; a form of inequality in appreciating the other’s knowledge). Later this year, we’ll start our first Post-Return Training, aimed at strengthening the international and intercultural competencies students have learned, and how to translate them to Dutch healthcare. 

There are challenges too, the climate crisis being the most important one. UMC Utrecht's international internships are part of a broader framework of international education. Much of this education takes place online, through governmental subsidies for "Virtual International Collaborations" (also known as VIS projects). This isn’t just good for the climate, it also offers the option of intercultural learning to students in the Netherlands who do not have the financial means and/or help to go abroad. Both forms of education coexist. The climate crisis is also a reason for the university to not just facilitate international internships, but to regulate them within partnerships. The quality and added value of an international internship, both at individual and institutional levels, can be used in the decision-making process of whether the flight is worth it. Literature also shows that equitable partnerships, as opposed to transitional international internships, offer the option of making international internships more sustainable, for instance by making shared decisions on how long the internships should take.

Equitable international internship programmes
All universities are open to equity. But programme directors and deans aren’t always aware of the effects educational programmes can have, of course, nor of what’s needed to review them. That means it’s also up to the people involved – the lecturers, policy officers and the international office – to create internal support, by showing how the new approach connects to what the university stands for in words. It’s also important to start small. Talk to one of the places your students go to. Ask the people involved what it matters. That way, you can start a shared partnership and then develop it further based on the input from all involved parties. A new international internship programme demands of all those involved – from funding parties to the executives – a different way of thinking and working. In my view, no other way is possible. It’s a chance for universities to walk the talk. 

Learn more
On this page, you'll find reading tips, both for professionals within universities and for students considering an internship abroad: https://www.uu.nl/en/organisation/centre-for-global-challenges/reading-tips