The Dark Side
This post has been adapted from an article originally published on EMSWorld.com
WHERE THE ROAD PAVED BY GOOD INTENTIONS ENDS
If you’ve ever traveled to another country, you’ve probably noticed that the emergency vehicles on the roads are not the same as those on your own roads back home. This is particularly true for ambulances. Between the wealthiest nations, differences are largely owing to size and shape, and are often due to very practical reasons: the behemoth fire-rescue ambulances used by many American agencies would simply never fit down the tight alleys of most European cities, and their multi-purpose design would be overkill for many agencies in Australia where ambulance and fire services are distinct municipal entities.
The differences seen in emergency vehicles between rich and poorer countries, however, usually has to do with questions of quality and uniformity. Very few municipalities in developing countries have the resources needed to build, stock, fuel, operate and maintain the ambulance fleets that are a given in wealthier nations.
Nonetheless, there is a widespread belief that ambulances alone can solve the problem of limited access to emergency car. And we’ve seen in over twenty countries how this belief leads to patchwork ambulance fleets in the best of cases, and the end of the road of good of intentions in most others.
Included here is a gallery of photos we’ve taken from places around the world where good intentions have been put out to pasture. More often than not, these pastures are in rural communities, though cities certainly have their own ways of corralling what, in many respects, were lost causes. To help manage expectations and avoid the inherent problems of importing new or used ambulances in communities that don’t have the money or roads they need to be effective, we’ve also included a short list of issues we’ve seen and heard time and time again.
If after viewing this page you come to at least a few of the same conclusions that we have, we hope you’ll understand a bit more why we don’t donate ambulances. Ambulances have a definite use, in any community – we just want to demonstrate how those uses are not the same everywhere.
DEFINE THE MISSION
Everyone knows what ambulances are meant to be used for – to transport the sick and injured – and the lights and sirens do a good job of ensuring the community’s aware of them. However, the lights and sirens can also be very distracting, and sometimes convince people that they represent an EMS system. But this is not true. It’s important to make sure both recipients and donors agree what the intended purpose of the ambulance is, and if that purpose can be fulfilled with the recipient community’s full socio-economic status taken into consideration.
Ambulances are typically donated near the end of their lives, so the quality of the vehicle is often questionable from the outset. Conventional wisdom suggests that ambulances which can fetch a good return are sold, and those which cannot are first in line to be donated. While not always the case, the belief that “something is better than nothing” is commonly the deciding consensus when an ambulance of borderline quality is approved to be donated. While there’s rarely any intent of ill will in this regard, something is not always better than nothing. In the case of ambulances, something is often far, far worse than nothing.
Everyone knows what ambulances are for – the lights and sirens make sure you don’t miss them, either. However, the lights and sirens can also drown a lot out, and are often understood as EMS systems, in and of themselves. It’s always important to make sure both recipients and donors agree what the intended purpose of the ambulance is, and if that can be accomplished with the recipient community’s full socio-economic status taken into consideration.
Miscommunication is one thing. Corruption, of course, is another. Ambulances may be intended for one hospital, but ultimately park at another, and this is a concern for all equipment donations. Making sure you know who you’re working with ensures accountability after you’ve left. Donations to incoming government officials is always preferable, and formal, public ceremonies make for good public outreach opportunities and help to create a degree of accountability. Attracting local media is not only possible, but often a necessity. Committing to long-term partnerships with regular support also helps to create accountability and assist in ensuring local buy-in and mutual, long-term commitment.
Homework pays off. Evaluating available physical, financial and human resources in a given community can prevent them from becoming straddled with the high costs of a deteriorating ambulance. Several simple questions can help avoid unexpected obstacles:
What are the local road conditions? Are they smooth, maintained asphalt like those we have in North America? Or, are they unpaved, pockmarked, washboard or pure vegetation? (Ambulances never work well as off-road vehicles)
What are the weather patterns?? (North American ambulances do not do well during monsoon season)
How wide are the roads?(Big cities in many developing countries are giant webs of narrow, wandering alleys and one-lane streets – and inaccessible to North American ambulances)
How bad is the traffic? The more widespread the congestion, the more useless an over-sized ambulance—think, for example, of Calcutta or Port-au-Prince.
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?
For every different ambulance model a community acquires, there are recurring costs for fuel, spare parts, and specialized mechanics to maintain and repair the vehicle, which will be regular. This can become especially overwhelming when 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 access to healthcare that they may unwittingly continue to spend money trying to make use of the ambulance until they have wasted too much.
Above all, high-quality patient care is the ultimate goal, and safety must be a starting point. We can all attest to how bumpy it is working on an old.
SHIPPING AND CUSTOMS
After all this and it still seems like a worthwhile endeavor the last, and typically most challenging, is the bureaucratic rules and regulations required to successfully ship an ambulance across borders. There are many ambulances currently parked in ports around the world that serve as the only air-conditioned office in the whole shipyard. The sheer 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 form relationships with established and experienced shipping companies who can at least ensure the ambulance gets where it was intended to.
HEALTH SYSTEMS SAVE LIVES, NOT AMBULANCES
Understanding as much as possible about the recipient community’s health care system will never work against you; get to know the people whose lives could be impacted by this ambulance – and don’t always assume it’s going to “save” lives, just because it’s an ambulance. Someone who dies while waiting for an ambulance that’s never going to arrive may have survived if the ambulance was never in the community to begin with. As Ivan Ilyich wrote, “The siren of one ambulance can destroy Samaritan attitudes in an entire Chilean neighborhood.”
Hospital waiting rooms are always a good place to begin to learn about existing resources and how patients access emergency care (even if there is no ambulance). Respect these systems, and don’t assume the community leaders are going to cooperate with each other once the keys have been handed over. In many countries, divisions between public and private agencies and providers are often vague, and donating an ambulance to an agency which does not traditionally provide patient transportation has great potential to further fracture dysfunctional public health and safety systems.
Ambulances may be good on the eyes, but they are tough on the wallet, no matter where they are, causing limited funds and supplies to be unnecessarily spent by trying to staff and stock an ambulance that has little chance of serving its intended purposes. Lights and sirens, and bells and whistles are often given precedence over tested and true low-cost improvements simply because the technology is more advanced. Emergency transport vehicles, where they can be easily afforded, have evolved to reflect their local communities and the physical and environmental obstacles they present. Just as you wouldn’t send a snowmobile to a tropical island, nor should you expect that an ambulance will work where there’s no fuel, gas, mechanics or even roads.
Just because it’s not there, doesn’t mean it’s needed. And just because there’s no ambulance, doesn’t mean there’s no emergency transport available. Identify the root problems, and be assured an ambulance isn’t the only solution.
 At the time of writing (March, 2011) the average price for a gallon a gasoline in the U.S. was $3.30, in Haiti it was $4.50, and in the UK it was $5.40
 Pitt E, Pusponegoro A: “Prehospital Care in Indonesia.” Emerg Med J 2005;22:144-147