Expansion of Reconstructive Surgical Capacity in Vietnam: Experience from the ReSurge Global Training Program.

BACKGROUND: Building local surgical capacity in low-income and middle-income countries is critical to addressing the unmet global surgical need. Visiting educator programs can be utilized to train local surgeons, but the quantitative impact on surgical capacity has not yet been fully described. The authors' objective was to evaluate the effectiveness of training utilizing a visiting educator program on local reconstructive surgical capacity in Vietnam. METHODS: A reconstructive surgery visiting educator program was implemented in Vietnam. Topics of training were based on needs defined by local surgeons, including those specializing in hand surgery, microsurgery, and craniofacial surgery. A retrospective analysis of annual case numbers corresponding to covered topics between the years 2014 and 2019 at each hospital was conducted to determine reconstructive surgical volume and procedures per surgeon over time. Direct costs, indirect costs, and value of volunteer services for each trip were calculated. RESULTS: Over the course of 5 years, 12 visiting educator trips were conducted across three hospitals in Vietnam. Local surgeons subsequently independently performed a total of 2018 operations corresponding to topics covered during visiting educator trips, or a mean of 136 operations annually per surgeon. Within several years, the hospitals experienced an 81.5 percent increase in surgical volume for these reconstructive clinical conditions, and annual case volume continues to increase over time. Total costs were $191,290, for a mean cost per trip of $15,941. CONCLUSIONS: Surgical capacity can be successfully expanded by utilizing targeted visiting educator trips to train local reconstructive surgeons. Local providers ultimately independently perform an increased volume of complex procedures and provide further training to others.

An Assessment Tool for Hand Surgical Education Needs and Capacity in Resource-Limited Settings.

BACKGROUND: Hand surgeons have the potential to substantially decrease the surgical disability burden in the developing world through educator trips. The Lancet Commission supports contextually driven educator trips grounded in the needs of local hosts, yet few organizations perform a comprehensive assessment of learning interests or the hosting institutions' surgical capacity before the trips. METHODS: The authors adapted the Personnel, Infrastructure, Procedures, Equipment, and Supplies questionnaire, which was modified from the World Health Organization's validated Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. The authors revised each aspect of the questionnaire to reflect items pertinent to upper extremity surgery and hand trauma care. They added sections to gauge self-identified learning needs, local disease burden, operative resources, and current practices. The tool was distributed by means of Qualtrics; descriptive statistics were used to summarize data. The authors analyzed the data for all participants and performed two subgroup analyses to examine variation by regions and countries. RESULTS: The authors received 338 responses from 27 countries. There was wide variability in local surgical disease burden, learning interests, and skill level of upper extremity procedures. Although learners were most interested in learning tendon transfers and microsurgical techniques, the majority did not have adequate infrastructure at their institution to sustain capacity for microvascular procedures. CONCLUSIONS: Needs assessments can gauge how best to provide education during short-term visiting educator trips and optimize its impact in resource-limited settings. Understanding the needs, learning interests, and availability of resources of local learners is imperative to creating a sustainable global surgical workforce.

Assessment of Local Health Worker Attitudes toward International Medical Volunteers in Low- and Middle-income Countries: A Global Survey.

BACKGROUND: International Medical Volunteers (IMVs) positively and negatively impact host countries, and the goals of their trips may not always align with the interests of the hosts in Low- and Middle-Income Countries (LMICs). We sought to better understand local physicians' interest of hosting IMVs and what type of support they desired. METHODS: This study was a convenience sample survey-based needs assessment. The surveys were distributed to local physicians by 28 professional society groups in LMICs. FINDINGS: A total of 102 physicians from 51 countries completed the survey. Despite 61.8% participants having no experience with IMVs, 75% were interested in hosting them. Host physicians most desired clinical education (39%), research collaboration (18%), and Systems Development (11%). The most requested specialties were obstetrics and gynecology (25%) and emergency medicine (11%). Respondents considered public hospitals (62%) to be the most helpful clinical setting in which IMVs could work, and 3 months (47%) as the ideal length of stay.Respondents expressed interest in advertising the specific needs of the host country to potential IMVs (80%). Qualitative analyses suggested hosts wanted more training opportunities, inclusion of all stakeholders, culturally competent volunteers, and aid focused on subspecialty education, health policy, public health, and research. CONCLUSION: Hosts desire more bidirectional clinical education and research capacity building than just direct clinical care. Importantly, cultural competence is key to a successful host partnership, potentially improved through IMV preparation. Finally, respondents want IMVs to ensure that they stay within their scope of practice and training.

Reflections and interdisciplinary perceptions of pharmacy learners on an international medical brigade.

BACKGROUND AND PURPOSE: The Mountain Area Health Education Center, Inc. and Shoulder to Shoulder have partnered on medical brigades in rural Honduras since 2005, with pharmacy learner participation beginning in 2007. This study assesses the value of this experience to pharmacy learners and their contribution to a brigade's success. EDUCATIONAL ACTIVITY AND SETTING: Pharmacy learners and faculty, family medicine residents and faculty physicians, student volunteers, and other health care professionals participate in two-week medical brigades each February and August. Since 2011, brigades have been based out of Camasca, a small town in rural, southwest Honduras. February brigade teams conduct home visits, while August brigades consist primarily of mobile clinics. In both situations, the pharmacy team prepares, dispenses, and counsels on medications. Participants from three trips were surveyed. FINDINGS: All pharmacy learners agreed the brigade contributed to improvements in their skills and competence as pharmacists. Brigade members agreed that pharmacy learners made valuable contributions, particularly in counseling patients, maintaining an organized workflow, and assisting in activities outside of pharmacy services. All respondents agreed that pharmacy learners were necessary to a trip's success. SUMMARY: These international medical brigades were impactful educational experiences for pharmacy learners. Brigade participants viewed pharmacy learners as essential team members.

Clinical Tools for Working Abroad with Migrants.

There are an estimated 68.5 million displaced persons worldwide, about one-half of whom are under the age of 18 years. The health needs of migrants are complex and dynamic along their journey. When structuring health care services for migrants abroad, there is not a one-size-fits-all approach and programming must be adaptable, practical, relevant, sustainable, and ideally integrated into the host country's health care system. In this article, we the examine clinical and public health priorities for migrant health care abroad and practical resources for health care professionals who wish to put their ideals into practice in the field.

Foundation-Based Cleft Care in Developing Countries.

BACKGROUND: Cleft deformities of the lip and palate affect nearly one in 500 to 700 births, and lead to increased morbidity and mortality if untreated. Nevertheless, significant global disparities in access to timely and appropriate care still exist. The relatively basic infrastructure required to surgically correct these deformities and large unmet disease burden have resulted in a significant number of foundation-based cleft care initiatives focused on developing countries. In this study, the authors evaluate the peer-reviewed literature generated by these foundations in an attempt to assess their clinical, scientific, educational, and economic impact. METHODS: A comprehensive review of the literature was performed using key search terms, and the level of evidence of identified articles was determined. Data were then analyzed to determine the different models of foundation-based cleft care in developing countries, and their clinical, scientific, educational, and economic impact. RESULTS: A total of 244 articles were identified through the authors' search and reviewed. Foundation-based cleft care initiatives in developing countries have significantly contributed to a better understanding of disease epidemiology, barriers to care, safety considerations, complications and outcomes, and international and local cleft surgery education. The cleft care center model is more cost-effective than the surgical mission model and provides more sustainable care. CONCLUSIONS: Foundation-based cleft care prevents significant morbidity in developing countries and has provided valuable resources for capacity building. The surgical mission model should be considered as a transitory conduit for establishing the more effective and sustainable cleft care center model of care.

Affecting the Global Burden of Surgical Disease: Incorporating Surgical Training into International Missions: A Systematic Review.

The global burden of surgical disease is immense. Increasingly in the past several decades, international humanitarian medical missions have become more popular as a method of managing the sheer volume of patients requiring medical care worldwide. Medical education programmes have also had an increase in interest amongst medical students and surgical residents to participate in missions during training. The current review was planned to present the current body of literature on international experiences in residency training programmes. It comprised relevant literatur obtained from Medline (ubMed) using Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines. A total of 15 publications were reviewed with each falling into one of the threeidentified categories:programme design (goals/objectives), ethics, and post-experience analysis. The benefits of providing international missions opportunities for surgical trainees cannot be understated.

The Effectiveness of an International Cleft Mission Model in Asia: An Update.

BACKGROUND: Cleft lip/palate is a congenital craniofacial anomaly affecting patients physically and psychosocially and has contributed to the global burden of surgical disease, especially in underprivileged areas. For 20 years, Noordhoff Craniofacial Foundation (NCF) and the Chang Gung Craniofacial Center (CGCFC) have carried out missions to these areas. Rather than implementing short-term missions that lack proper follow-up care, the team has provided an effective, long-term, and multidisciplinary approach for the treatment of patients with cleft lip/palate. In this study, we evaluate the sustainability and effectiveness of the cleft mission model implemented by NCF and CGCFC. METHODS: Data from the years 1998-2017 were retrieved from the NCF database. All local centers were evaluated by a 3-stage categorization, levels 1 to 3, based on 4 criteria: (1) capacity to carry out independent missions, (2) diversity of cleft-care professionals, (3) diversity of surgical service offered, and (4) collaboration with local hospitals. Support and training of personnel were provided based on deficiency in these criteria. Noordhoff Craniofacial Foundation made close collaborations and partnerships with several organizations that shared its mission for comprehensive cleft care in developing countries. RESULTS: In all, 19 partner cleft teams in 9 different countries were established. In coordination with these teams, NCF and CGCFC have treated 1846 patients across 78 mission trips. To date, 158 personnel from 19 different countries have been successfully trained to provide cleft care in local centers. Most partner cleft teams centers have progressively reached category level 3, including those in the Philippines, Cambodia, and Mongolia. CONCLUSIONS: In order to establish and maintain sustainable cleft care in developing regions, commitment and compassion toward those who lack essential resources are necessary. Noordhoff Craniofacial Foundation and CGCFC have achieved a successful and practicable model through seeding medical personnel in order to provide effective and sustainable cleft care to the regions in need.

Establishing Sustainable Cardiothoracic Surgery Programs in Underserved Countries.

Congenital heart disease is the most common birth defect worldwide, and accounts for a high proportion of the world's infant mortality. About 9 of every 10 babies born each year are born in areas without adequate access to heart surgery; overcoming this problem will necessitate addressing the worldwide shortage of an estimated 3,700 pediatric cardiac surgeons. Establishing sustainable heart surgery programs requires more than an investment of money: political, social, and cultural issues unique to each environment need to be addressed. Organizations desiring to help develop cardiac surgical centers need to focus on communication and bidirectional education, and to make a long-term commitment to each site. By identifying and addressing obstacles, success rates are high.

Perspectives on global health amongst obstetrician gynecologists: A national survey.

Objective To characterize contemporary attitudes toward global health amongst board-certified obstetricians-gynecologists (Ob-Gyns) in the US. Methods A questionnaire was mailed to members of the American College of Obstetricians and Gynecologists. Respondents were stratified by interest and experience in global health and group differences were reported. Results A total of 202 of 400 (50.5%) surveys were completed; and 67.3% ( n = 136) of respondents expressed an interest in global health while 25.2% ( n = 51) had experience providing healthcare abroad. Personal safety was the primary concern of respondents (88 of 185, 47.6%), with 44.5% (57 of 128) identifying 2 weeks as an optimal period of time to spend abroad. The majority (113 of 186, 60.8%) cited hosting of local physicians in the US as the most valuable service to developing a nation's healthcare provision. Conclusion Despite high interest in global health, willingness to spend significant time abroad was limited. Concerns surrounding personal safety dovetailed with the belief that training local physicians in the US provides the most valuable service to international efforts. These attitudes and concerns suggest novel solutions will be required to increase involvement of Ob-Gyns in global women's health.

Humanitarian Surgical Missions: Guidelines for Successful Anesthesia Support.

Many anesthesiologists and CRNAs are provided little training in preparing for a humanitarian surgical mission. Furthermore, there is very little published literature that outlines how to plan and prepare for anesthesia support of a humanitarian surgical mission. This article attempts to serve as an in-depth planning guide for anesthesia support of humanitarian surgical missions. Recommendations are provided on planning requirements that most anesthesiologists and CRNAs do not have to consider on routinely, such as key questions to be answered before agreeing to support a mission, ordering and shipping supplies and medications, travel and lodging arrangements, and coordinating translators in a host nation. Detailed considerations are included for all the phases of mission planning: advanced, mission-specific, final, mission-execution, and postmission follow-up planning, as well as a timeline in which to complete each phase. With the proper planning and execution, the anesthetic support of humanitarian surgical missions is a very manageable task that can result in an extremely satisfying sense of accomplishment and a rewarding experience. The authors suggest this article should be used as a reference document by any anesthesia professional tasked with planning and supporting a humanitarian surgical mission.

Optimizing the Use of a Precious Resource: The Role of Emergency Physicians in a Humanitarian Crisis.

Emergency physicians (EP) are uniquely suited to provide care in crises as a result of their broad training, ability to work quickly and effectively in high-pressure, austere settings, and their inherent flexibility. While emergency medicine training is helpful to support the needs of crisis-affected and displaced populations, it is not in itself sufficient. In this article we review what an EP should carefully consider prior to deployment.

Academic-Community Partnership for Medical Missions: Lessons Learned and Practical Guidance for Global Health Service-Learning Experiences.

To facilitate an academic-community partnership for sustainable medical mis-sions, a 12-step process was created for an interprofessional, global health educational, and service-learning experience for students and faculty in a school of pharmacy and health professions. Lessons learned and practical guidance are provided to implement similar global health opportunities.

Medical resource preparation and allocation for humanitarian assistance based on module organization.

BACKGROUND: This research aims to associate the allocation of medical resources with the function of the modular organization and the possible needs for humanitarian assistance missions. METHODS: The overseas humanitarian medical assistance mission, which was sent after a disaster on the hospital ship Peace Ark, part of China's People's Liberation Army (PLA) Navy, was considered as study model. The cases used for clustering and matching sample formation were randomly selected from the existing information related to Peace Ark's mission. RESULTS: Categories of the reusable resources clustered by this research met the requirement of the actual consumption almost completely (more than 95%) and the categories of non-reusable resources met the requirement by more than 80%. In the mission's original resource preparing plan, more than 30% of the non-reusable resource categories remained unused during the mission. In the original resource preparing plan, some key non-reusable resources inventories were completely exhausted at the end of the mission, while 5% to 30% of non-reusable resources remained in the resource allocation plan generated by this research at the end of the mission. CONCLUSIONS: The medical resource allocation plan generated here can enhance the supporting level for the humanitarian assistance mission. This research could lay the foundation for an assistant decision-making system for humanitarian assistance mission.

Global surgery: A view from the south.

This article is based on the Hugh Greenwood Lecture delivered at the 2016 Congress of the British Association of Paediatric Surgeons. It presents the view of the global surgery movement from the bottom of the surgical food chain and proposes what HICs (high-income countries) can do for global surgery in a coordinated fashion. From the LMIC (low- and middle-income countries) surgeon perspective, global surgery is transitioning from the charity-based surgery model to codevelopment with multiple stakeholders. The caveats and current opportunities are described using two case studies. Surgeons may not play a pivotal role in the solutions. The future of the surgical workforce, innovation, workarounds, unmet burden of disease, and health metrics are discussed and multidisciplinary solutions proposed for the entire chain of surgical healthcare delivery in LMIC. A new breed of "essential surgeons", technology solutions for intellectual and physical isolation, competency-based credentialing, industry-driven innovation, task sharing over task shifting, prioritizing delivery based on surgical burden, and a rota-based overseas model of help are proposed as solutions for the issues facing global surgery. EVIDENCE LEVEL: Level V.

The Need for Formal Surgical Global Health Programs and Improved Mission Trip Coordination.

BACKGROUND: There is a dire need for more surgical services as part of improving global health. Conditions treatable with surgery account for 11% of the global burden of disease, with a disproportionate burden affecting low- and middle-income countries (LMICs). Less than 6% of the world's operations are performed in LMICs, with relief organizations performing nearly 250,000 operations annually in LMICs in addition to each country's domestic surgical capacity. Currently, surgical needs are not adequately met by the existing patchwork of federal and nongovernmental organizations' surgical services and surgical mission trips. Improving coordination between mission trips may have synergistic benefits for maximizing the efficacy of the individual trips and improving the overall quality of care. OBJECTIVES: To establish whether cooperation between surgical mission trips can lead to operational efficiency and to identify obstacles to cooperation. METHODS: In order to establish the veracity of cooperation translating into efficiency and to identify obstacles that prevent cooperation, a 50-question survey was created (see Supplement 1). The survey was sent to surgical program directors of the 147 major surgical programs in the United States and Canada with a follow-up telephone survey of 18 randomly selected programs. FINDINGS: The survey response rate was 14%. Although 90% of respondent programs mount at least 1 mission trip per year, only one-third confirmed the existence of global health or surgical global health programs at their institution (33%). There was significant interest in cooperating with programs at other institutions (80%). When asked why they do not communicate with humanitarian aid organizations doing similar work, 53% of respondents reported a "lack of knowledge of how to find similar organizations to mine doing similar work." An additional 21% of respondents were "unaware that coordination is possible." CONCLUSIONS: A minority of respondent surgery programs host formal, organized surgical global health programs with a structured leadership based at academic medical centers. Although most institutions have individuals leading international humanitarian missions to LMICs, these leaders do not function in an integrated fashion with their departments, institutions, or other academic medical programs. The majority of respondents were interested in coordinating their surgical trips with other groups. Respondents suggested the creation of a central database that would allow trip organizers to share information about upcoming trips, site logistics, and personnel or supply needs.

Averted health burden over 4 years at Médecins Sans Frontières (MSF) Trauma Centre in Kunduz, Afghanistan, prior to its closure in 2015.

BACKGROUND: On October 3, 2015, a United States airstrike hit Médecins Sans Frontières (Doctors Without Borders) Trauma Centre in Kunduz, Afghanistan. Our aim was to describe the care provided and estimate the health burden averted by surgical care at the hospital. We also report the benefit rendered by the Trauma Centre to the health of the local population prior to its destruction. METHODS: All operations performed in an operating theater at the Trauma Centre from its opening on August 30, 2011, to August 31, 2015, were described. Disability-adjusted life years averted by operative care over the same period were estimated. RESULTS: The Trauma Centre performed 13,970 operations, which included 17,928 procedures for 6,685 patients. The median age of patients who required operative intervention was 21 years (interquartile range 12-34 years). More than 85% of patients were men (12,034 patients; 86%). Of the 6,685 patients who required operative care, 4,387 suffered unintentional, non-violence-related injuries (66%), while 2,276 suffered violence-related injuries (34%). The perioperative death rate at the facility decreased from 7.2 deaths per 1,000 operations in 2011 to 1.3 deaths in 2015 (P = .03). More than 154,250 disability-adjusted life years were averted by operative care (95% confidence interval 153,042-155,465). CONCLUSION: The health burden averted by the surgical care provided at the Trauma Centre was large; it is critically felt by those still living in the region. Access to essential trauma care for all victims of armed conflict is a human right; as directed by International Humanitarian Law, we must guarantee special protection for the wounded, sick, and medical personnel and facilities during war.