Indication.

Should the indications for therapies differ from one nation to the next? What are the reasons behind controversial therapeutic variations? What roles do cultural history and authoritarian conflict among clinicians play in the adoption of therapies? When I worked at a rural hospital in Kenya, a woman experiencing obstructed labor made me ponder many questions-but only after our emergency ended in the death of her newborn son. In recounting and learning from this episode, I listened to the disparate Kenyan voices of the patient, the hospital's director, the consultant obstetrician, and to the even more controversial voices of evidence-based medicine. In reflecting on this process, I have learned at least 3 lessons-about the transmissibility of arrogance, the role of guests in other countries, and the nature of science.

Balance of trade: export-import in family medicine.

North American family physicians leaving for less-developed countries (LDCs) may not be aware of internationally validated diagnostic and treatment technologies originating in LDCs. Thus they may bring with them inappropriate models and methods of medical care. More useful "exports" are based in sharing our collaborative vocational perspective with dedicated indigenous generalist clinicians who serve their communities. More specifically, Western doctors abroad can promote local reanalyses of international evidence-based medicine (EBM) studies, efficient deployment of scarce clinical resources, and a family medicine/generalist career ladder, ultimately reversing the "brain drain" from LDCs. Balancing these exports, we should import the growing number of EBM best practices originated in World Health Organization and other LDCs research that are applicable in developed nations. Many generalist colleagues, expatriate and indigenous, with long-term LDC experience stand ready to help us import these practices and perspectives.

Partnerships creating postgraduate family medicine in Kenya.

Culminating a decade-long process, the first family medicine residency program in Kenya, among the first in Africa outside Nigeria and South Africa, was launched in 2005. Three diverse stakeholders are collaborating in their individual and joint missions: Moi University Faculty of Health Sciences (MUFHS), educating medical students to serve rural Kenyans; the Institute of Family Medicine (Infa-Med), a church hospital-based non-governmental organization aiming to introduce family medicine in Kenya; and the Ministry of Health (MoH), working to create an efficient government health care workforce for 32 million Kenyans. MUFHS brings central facilities, enthusiastic academic leadership, and long-term vision. Infa-Med contributes start-up resources, expatriate family medicine faculty, and well-established hospitals for training. MoH is giving political support to the new specialty as well as scholarships to MoH medical officers entering the 3-year residency program leading to the degree of Master of Medicine in Family Health. Among the lessons learned through this process are the importance of melding the missions of all partners, of integrating clinical with community care of the underserved, and of deriving curriculum from African and international evidence on how to marshal available resources to meet Kenya's national needs. Opportunities continue for internal and international collaboration.