Creating Consensus on HICs’ Global Surgery Efforts in the Developing World

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Brittney Okada

Brittney Okada

Brittney Okada graduated from the University of Utah School of Medicine's Department of Family and Preventive Medicine with a masters in public health (MPH). This is where she was introduced to the field of global surgery. She has been engaged in various global health projects in Cambodia and South Korea. Brittney currently works for the Utah Department of Health Office of Health Disparities where she manages programs for underserved communities aimed at improving health equity.

Today, 830 childbearing women will die from avoidable causes, mainly in the developing world, and mainly from lack of surgical intervention. (1,2) They are among the five billion people who do not have access to safe and affordable surgical care. (3) Meeting this need is paramount. Yet, how we meet the need is as vitally important of an issue. Developing guidelines for high-income countries (HICs) engaged in global surgery in low and middle-income countries (LMICs) will ensure more ethical, effective, and sustainable care.

Imagine patients in developing countries did receive care, but from an unsupervised medical student. In 2015, about 1 in 3 graduating medical students reported participating in an international health experience during their schooling. (4) Although enthusiastic about gaining training and experience, students will encounter ethical dilemmas. A first year medical student who volunteered in Mexico recounted, “While I was seeing patients by myself, other first year medical students were performing surgeries in the other clinics and later bragging about it.” (5)

However, these conundrums are not unique to medical students. Professionals also provide care in LMICs that exceeds their level of expertise. Dr. O. Gordon Robinson, in his 30 years of performing surgeries in Honduras, explains, “My pet peeve is for groups to come to our part of the world in Central America and perform surgery on patients they wouldn’t treat in the United States.” (6) All patients deserve qualified surgeons practiced in the surgeries being performed. Simply being a surgeon is “not a qualification per se.” (7)

Creating guidelines that clarify the scope of practice that medical students and volunteer surgeons must observe while working in LMICs would establish an ethnical standard of care and also reduce complication rates. In Southeast Asia, cleft palate surgery complication rates of inexperienced foreign surgeons are estimated to be above 30 percent, which is double the typical rate. (7,8)

Unsurprisingly, short-term surgical volunteers have been criticized for abandoning patients, especially those with complications. Roughly half of short-term medical mission teams are not working with host-country counterparts. (9)

Some countries like El Salvador have begun mandating visiting surgeons coordinate post-operative care through local providers. (10) Yet, many LMICs do not have the capacity to enforce these regulations. Guidelines directing volunteer surgeons to partner with local institutions would improve patient outcomes and facilitate continuity of care.

In the absence of partnerships, surgical volunteerism can actually displace local providers and health systems. A Guatemalan surgeon lamented, “Guatemalan patients, especially those with less education, tend to put more faith in a blonde-haired, blue-eyed, white skinned foreign physician than their own Guatemalan physicians.” (11)

Local surgeons should not have to compete with foreign surgeons for patients. Developing guidelines that stimulate partnerships focused on the transfer and exchange of knowledge and skills will enable volunteering surgeons to validate rather than debilitate local providers.

We need to reach consensus on how HICs engage in surgical care in LMICs to prevent ethical misadventures, improve patient outcomes, and build permanent surgical care services. Establishing guidelines will direct and align HICs’ contribution to addressing the large unmet surgical burden of disease in the developing world.

 

References

  1. WHO. Maternal Mortality Fact Sheet [Internet]. World Health Organization; 2015 [cited 2016 Apr 28]. Available from: http://www.who.int/mediacentre/factsheets/fs348/en/
  2. deVries CR, Price RR. Global Surgery and Public Health: A New Paradigm [Internet]. Jones & Bartlett Publishers; 2012 [cited 2016 Apr 20]. 300 p. Available from: https://books.google.com/books/about/Global_Surgery_And_Public_Health_A_New_P.html?id=8CbVNdBxmdIC&pgis=1
  3. Ng-Kamstra JS, Greenberg SLM, Abdullah F, Amado V, Anderson GA, Cossa M, et al. Global Surgery 2030: a roadmap for high income country actors. BMJ Glob Heal [Internet]. BMJ Specialist Journals; 2016 Apr 1 [cited 2016 Apr 28];1(1):e000011. Available from: http://gh.bmj.com/content/1/1/e000011.abstract
  4. Association of American Medical Colleges. Medical School Graduation Questionnaire: 2015 All Schools Summary Report [Internet]. 2015 [cited 2016 Apr 28]. Available from: https://www.aamc.org/download/440552/data/2015gqallschoolssummaryreport.pdf
  5. Shah S, Wu T. The medical student global health experience: professionalism and ethical implications. J Med Ethics [Internet]. 2008 May [cited 2016 Mar 16];34(5):375–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18448720
  6. Robinson OG. Humanitarian missions in the Third World. Plast Reconstr Surg [Internet]. 2006 Mar [cited 2016 Apr 28];117(3):1040–1; author reply 1041. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16525308
  7. Dupuis CC. Humanitarian missions in the third world: a polite dissent. Plast Reconstr Surg [Internet]. 2004 Jan [cited 2016 Apr 28];113(1):433–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14707671
  8. Abdurrazaq TO, Micheal AO, Lanre AW, Olugbenga OM, Akin LL. Surgical outcome and complications following cleft lip and palate repair in a teaching hospital in Nigeria. Afr J Paediatr Surg [Internet]. Jan [cited 2016 Apr 28];10(4):345–57. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24469486
  9. Chapin E, Doocy S. International short-term medical service trips: guidelines from the literature and perspectives from the field. World Health Popul [Internet]. 2010 Jan [cited 2016 Apr 28];12(2):43–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21157197
  10. Wolfberg AJ. Volunteering overseas–lessons from surgical brigades. N Engl J Med [Internet]. Massachusetts Medical Society; 2006 Feb 2 [cited 2016 Apr 20];354(5):443–5. Available from: http://www.nejm.org/doi/full/10.1056/NEJMp058220
  11. Green T, Green H, Scandlyn J, Kestler A. Perceptions of short-term medical volunteer work: a qualitative study in Guatemala. Global Health [Internet]. 2009 Jan [cited 2016 Apr 28];5:4. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2662818&tool=pmcentrez&rendertype=abstract