International surgical missions: How to approach, what to avoid

October 3, 2013

This article discusses how urologists can help fill the need for surgical relief work, and offers some advice on ensuring your philanthropic trip is a successful one.

The focus in global health in past decades has been on the management and prevention of communicable diseases. Successful organizations, including Partners in Health and the Bill & Melinda Gates Foundation, are dedicated to treating, managing, and eradicating infectious diseases such as HIV, tuberculosis, and malaria, which are responsible for nearly 15 million deaths a year or nearly 26% of all worldwide deaths, according to the World Health Organization. The philosophy of these programs is that if you “treat one” patient with a communicable disease, you can “save many.” And because treating these diseases requires little specialized care (eg, low-skilled workers can be taught to administer immunizations), treatment programs are considered a safe investment when trying to maximize health outcomes with minimal costs (World J Surg 2008; 32:533-6).

 

Dr. Erickson performs a posterior urethroplasty with a local Palestinian physician, Dr. Waleed Zalloum. Dr. Erickson’s travel was supported by the Palestinian Children’s Relief Fund (www.pcrf.net). (Photo courtesy of Bradley A. Erickson, MD, MS)

Surgical diseases, on the other hand, are often thought of as a “treat one, save one” endeavor (though incorrectly, in most circumstances). They are expensive, labor intensive, require a large skilled work force that usually does not exist in developing countries and in resource-poor nations, and are generally a low health priority (Arch Surg 2005; 140:795-800). Many global health organizations, however, now consider surgery as the “neglected stepchild of global health” (World J Surg 2008; 32:533-6). While the scale of the HIV epidemic (nearly 23 million people living with HIV in Sub-Saharan Africa) commands attention and resources, it is often overlooked that nearly 500,000 women die each year from childbirth-a figure that would certainly be lower if skilled physicians/surgeons were available to perform Cesarean sections and stop post-partum hemorrhage.

This article discusses how urologists can help fill the need for surgical relief work, and offers some advice on ensuring your philanthropic trip is a successful one.

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Global health and urology

Specific urologic needs in global health are vast, but are considerably different than those faced in developed countries. Collectively, the bulk of the pathology in developed countries is chronic in nature. In contrast, the medical problems in developing countries tend to be more acute and direct, including congenital malformations (eg, hypospadias), maternal birthing trauma (eg, vesico-vaginal fistulas), and traumatic genitourinary injury (eg, urethral stricture, pelvic fracture urethral distraction defects).

Unfortunately, because many of these problems are not directly life threatening, few countries or non-governmental organizations (NGOs) have dedicated significant funding to managing them, despite the fact that these conditions inevitably lead to preventable chronic disabilities, which can significantly impact communities, both financially and emotionally (World J Surg 2008; 32:533-6; Arch Surg 2005; 140:795-800).

Urologic philanthropy

A recently conducted joint survey by the AUA, the European Association of Urology, and the International Society of Urology showed that nearly half of responding members had conducted some type of “urologic philanthropic activity” within the past 10 years. The vast majority provide service for 1 week at a time and do so without the assistance of a formally established group such as International Volunteers in Urology. The most common continents traveled to were also the largest: Asia and Africa. But the country most commonly receiving care was one of the poorest: Honduras. Encouragingly, when asked about their willingness to serve on philanthropic trips in the future, over 90% of members from each organization answered yes.

As we become increasingly connected and the world in which we live effectively shrinks, it seems our desire to help those in need, especially those in countries where opportunities for health and health care are lacking, is increasing. This acute awareness is demonstrated by the multitude of standing medical school clinics in developing countries such as Haiti (World J Surg 2011; 35:739-44) and in a recent poll of incoming surgical interns that showed nearly 40% had already served on philanthropic trips upon graduating from medical school and over 90% desired to perform relief work in their training. There has perhaps never been a time when the medical resource disparities between rich and poor countries have been so vast, which may be facilitating this increase in enthusiasm.

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Considerations for a successful trip

Before embarking on an international philanthropic trip, there are many important factors to consider. Short-term medical philanthropy, especially involving surgery, has received a significant amount of recent criticism within the international community for a multitude of complicated reasons (World J Surg 2010; 34:466-70). However, following a few simple rules can help make the trip a successful one for the community, providers, and patients.

· Go for the right reasons. Individuals expecting a “break,” a vacation, or a chance to travel might be disappointed after the third day of rice and beans and cold showers. The rewards from these trips come from the sacrifice, with the means being an end in themselves. Proceed on these missions with pure motives and a well-thought-out plan for success.

· Leave the community in better shape than you found it. When traveling to communities in need, leaving them with spent resources, surgical complications, and complex postoperative follow-up regimens can ultimately mean the trip did more harm than good. In general, complex cases should not be performed on a routine basis unless a clear and tested pre- and postoperative care plan has been established. Instead, a focus on relatively minimally invasive procedures that improve quality of life, relieve discomfort, and require little follow-up are probably best, especially during shorter trips.

· Work with the local officials, community leaders, NGOs, and local physicians in whatever capacity possible. Working with local officials ensures that you are addressing local needs. Your group may bring highly specialized urologic expertise, but if the community needs open simple prostatectomies and stone work, that’s what your group needs to do. Working with local NGOs and community leaders also helps to ensure that resources are not duplicated. Competitive humanitarianism can be very wasteful and harmful, and groups must prioritize the local needs over their own agendas. Cooperation among groups and NGOs is the key to achieving successes that could not be reached by any single group.

Ideally, contact with local officials should be made well in advance of your arrival so discrepancies between the group’s abilities and local needs are minimal. In some circumstances, it’s possible to obtain a patient list with pathologies months before the trip, especially when working with the local urologists or surgeons. In these circumstances, preoperative workup can often be performed in a manner that will lead to fewer surprises when the work begins. 

· Teach. The International Volunteers in Urology’s motto is “teach one, reach many,” which is a wonderful motto to keep in mind with surgical philanthropy. While the complexity and dimension of the problems encountered may often feel insurmountable, empowering local surgeons to continue your work after you leave can have a significantly greater impact than performing all the surgery yourself.

· Bring your own supplies, but bring the right supplies. Whenever possible, the humanitarian groups should bring their own equipment to supply their operations and leave it all behind for the communities to use after they leave. However, performing the operations with equipment and in a manner that will empower and not disenfranchise the local physicians is vital. Unfortunately, I’ve witnessed laparoscopic equipment, worth thousands of dollars, gathering dust in the corner of an operating room in the Middle East that will almost certainly never be used. The equipment was donated by a well-intentioned NGO that didn’t understand the local needs or capabilities of surgeons.

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· Remember, you’re a guest. These trips are a sacrifice for everyone involved, including the locals. In nearly all circumstances, the local community welcomes the humanitarian groups with open arms, but these trips also represent a significant disruption to their lives. This is especially true in hospitals where the humanitarian groups effectively take over the local hospital for the week. Just try to imagine a similar occurrence at your home hospital, and you’ll begin to appreciate some of the complicated emotions surrounding these types of endeavors.

On an equally important note, take advantage of being a guest. Accept as many invitations to tea, coffee, dinner, and tours of the city and country as possible. These brief moments of exploration can be some of the most rewarding on the trip and give you a chance to understand the people you’ve traveled to help in a much deeper way.

· Seek mission “successes” in places other than the operating room. It is tempting to judge a successful mission by the number of operations performed or by being the “first” to do a particular case in a certain country. Such barometers, however, are misguided and potentially harmful. Instead, successes should be judged by the relationships made, the teaching instilled, and the lasting impression you’ve made on the local community. In the end, all of these trips seek the same goal: lasting, positive change in communities in need. Change takes time and this must be respected.

· Maintain communication with local officials after you leave. Maintaining an indefinite, clear line of communication with the local physicians and officials you work with serves many important purposes: It helps to ensure your patients are receiving the appropriate follow-up; it helps to solidify any teaching introduced during the trip; and it shows them that you truly care about their community, raising the likelihood that you will be invited back.

· Go back and go often. Resist the temptation to explore new medical frontiers just for the sake of exploration. Instead, go back to the places you’ve been. Not only does this allow for better continuity of care, it fosters stronger relationships with local physicians, increasing the likelihood of making a durable impact each time you return.

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· Bring knowledge back home. There is a lot to learn on these trips medically, culturally, and personally. Be sure to watch the local physicians manage complex disease without modern technology; listen to your patients talk about their lives and their difficult situations; and analyze how your personal situation aligns with theirs to help clarify what role you can perform in making the world a better place. When you get home, be sure to share your experiences with your residents and colleagues, and spread your enthusiasm to others.

 

Summary

In summary, medical humanitarian work can be very rewarding on many levels. But these trips are not as simple as buying a plane ticket and packing a pair of scrubs. To be successful, learn from the lessons of others who have gone before you, and be sure to have a solid plan for success. We are truly entering a new era of humanitarian medicine where surgery is taking an increasingly important role, of which we all will have the opportunity to become a part. To quote the late Amram Cohen, MD, a surgeon who helped found the Save a Child's Heart humanitarian project: “There are no dollars and cents in it, but it is worth a fortune.”UT 

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