This post has been adapted from an article originally published on EMSWorld.com
WHERE THE ROAD PAVED WITH GOOD INTENTIONS ENDS
There is a widespread belief that ambulances can solve the emergency transport problems of an entire community. They can’t. In fact, they will probably cause you problems than they will solve. And we know what we’re talking about because we’ve seen in countless countries. We’ve seen it in so many countries, Trek Medics has made it a policy to never donate used ambulances.
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 maintain these vehicles, we’ve also included a short list of issues we’ve seen and heard time and time again.
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. 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.
HONESTLY ASSESS LOCAL RESOURCES AND INFRASTRUCTURE
See the world as it is. Don’t ignore the red flags that are in front of you out of romantic ideas. Honestly evaluating the physical, financial and human resources in your community will prevent you from wasting resources and money on a vehicle that was not built for your infrastructure. Several simple questions can help avoid unexpected obstacles:
Do you have paved roads everywhere? 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? Most North American and European ambulances don’t do well in rain or snow.
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.
UNDERSTAND SHIPPING AND CUSTOMS
If you think those issues aren’t going to be a problem, there are many bureaucratic rules and regulations you will need to navigate 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, and impressive on TV, but they are tough on the wallet, and demoralizing when they are broken down, especially when limited funds and supplies are unnecessarily spent when they have little chance of serving their 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.
We’re not kidding. Passion and good intentions don’t make up for poor planning and incompatible infrastructure. We have seen it time and time again: One day, a local community member is a hero for getting a used ambulance; and literally the next day they are the laughingstock of the village because the ambulance is of no use to any one.
Just because there’s no ambulance, doesn’t mean there’s no emergency transport available. Identify the root problems, seek viable alternative solutions (like a pickup truck of a basic van) 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