The Dark Side
Boon or Bust?
Ambulances are an essential part of many EMS systems. However, our experience has shown us that donated ambulances don’t always have the desired effect, and can often create more problems than they solve. To be sure, ambulances can have a significant, positive impact in a developing community’s healthcare system. But in order to ensure this, a thorough analysis of intentions, capacity and culture is highly advised beforehand.
When first considering the donation of an ambulance be sure to determine what the goals are – “what’s going to happen because this ambulance has been shipped?” Ambulances are often donated near the end of their lives, and in many communities where they may end up, they’re regularly going off-road. There are situations – like ambulance mergers, buyouts or station closures – when good vehicles can be acquired, but conventional wisdom suggests that ambulances that can fetch a good return are sold, and those which can not are first in line to be donated. An easy and helpful way to estimate the remaining life of an ambulance is by comparing three factors: the condition of the ambulance; the donor’s roads; and the recipient’s roads. These simple considerations will help many save a lot of frustration and lost financing.
People instinctively know that reliable transportation is something that should be available for people during medical emergencies. And ambulances are known to do this well, near globally. However, in that translation, the lights and sirens can drown a lot out, and ambulances are sometimes misunderstood as EMS systems. Sitting down at the table with donors and recipients is always recommended.
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. 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.
Understanding as much as possible about the recipient community’s health care system will never work against you; get to know the people who’s lives will be impacted. Hospitals are always a good place to begin, and finding out about previous experience will also provide useful information. In many countries, divisions between public and private agencies and providers may be vague; professional and community obstacles may similarly arise by donating an ambulance to an agency which does not consistently provide patient transportation.
Ambulances may be good on the eyes, but they are tough on the wallet, no matter where they are. As a result, limited funds and supplies may be unnecessarily spent by trying to staff and stock an ambulance that lacks essential support. 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. In the world of political campaigns, ambulances are effective ways to get out the message.
If there’s one thing to take away, we hope it’s this: homework pays off. Evaluating available physical, financial and human resources in a given community can prevent them from becoming straddling 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? Large cities in many developing countries are giant webs of narrow, wandering alleys and one-lane streets that are inaccessible to North American ambulances. (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 & 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.
 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