Pediatric anesthesia outreach in low and middle-income countries: Models, motives, and moral misalignments.

BACKGROUND: A lack of anesthesia and surgical capacity leaves approximately 1.7 billion children per annum without access to surgical and anesthetic care. REVIEW: Over the past 50 years, the predominant strategy to address this lack of access has been to provide surgical capacity primarily from high-income countries (HICs) to low and middle-income countries (LMICs) in the form of short-term surgical missions. More recently, the international medical community has recognized the need to build sustainable surgical capacity in resource-constrained settings. This article reviews three models of surgical aid: the vertical model (short-term surgical missions); the horizontal model (system-wide capacity building); and the diagonal model, which is a hybrid of the first two. At their core, medical aid interventions exist on a spectrum ranging from providing surgical capacity to building surgical capacity. DISCUSSION: The skills, attitudes, and behaviors that drive success in providing medical capacity are fundamentally different from those that drive success in building medical capacity. The root cause of this difference is a shift in the moral duty of the visiting physician from a duty solely to the patient in front of them (based on the primacy of the doctor-patient relationship) to include a duty to the local physicians and the local medical system, and by extension to the next 10 000 patients in need of care. CONCLUSION: Failure to address the conflicts engendered by this fundamental moral shift risks undermining capacity-building efforts in all models of medical aid.

Global Neurology: The Good, the Bad, and the Ugly.

Global health programs engaging in isolated or short-term medical missions can and do cause harm, reinforce health care disparities, and impede medical care in the regions where it is so desperately needed. Related ethical, medical, and legal concerns are reviewed in this article. The authors recommend abandoning these ill-considered missions and focusing attention and resources on advancing neurology through ethically congruent, multisectoral, collaborative partnerships to establish sustainable, self-sufficient training programs within low- and middle-income countries.

Sustainable surgical resource initiative for Haiti: the SSRI-Haiti project.

In response to the 2010 earthquake and subsequent cholera epidemic, St Luke's Medical Center was established in Port-au-Prince, Haiti. Here, we describe its inception and evolution to include an intensive care unit and two operating rooms, as well as the staffing, training and experiential learning activities, which helped St Luke's become a sustainable surgical resource. We describe a three-phase model for establishing a sustainable surgical centre in Haiti (build facility and acquire equipment; train staff and perform surgeries; provide continued education and expansion including regular specialist trips) and we report a progressive increase in the number and complexity of cases performed by all-Haitian staff from 2012 to 2022. The results are generalised in the context of the 'delay framework' to global health along with a discussion of the application of this three-phase model to resource-limited environments. We conclude with a brief description of the formation of a remote surgical centre in Port-Salut, an unforeseen benefit of local competence and independence. Establishing sustainable and collaborative surgery centres operated by local staff accelerates the ability of resource-limited countries to meet high surgical burdens.

The importance of a local cleft mission and its spread.

OBJECTIVES: Cleft lip or palate are very usual birth defects. This study aims to discuss a local cleft mission performed in Angola and some specifics on the topic. METHODS: This retrospective study assessed the main features of a local cleft mission conducted in September 2022. The mission was carried out at the Hospital Josina Machel in Luanda, Angola. Data was retrieved and analyzed. The Shapiro-Wilkes test and Pearson correlation were used and considered significant only at 95% confidence interval. RESULTS: Cleft missions are a difficult task. Logistical and financial problems are exacerbated by the extreme difficulty of recruiting patients, particularly in remote regions, far from major centers. Despite successful widespread, some surgeries have been postponed due to comorbidities, common in Africa. CONCLUSION: The organizers of the mission must be aware of the difficulty of attracting patients and must use different media such as television and radio. The internet needs to be used to the maximum and could reach a higher number of prospects.

Opportunities, barriers and expectations toward international voluntary medical missions among health trainees in Saudi Arabia.

The objective is to assess the feasibility, barriers, expectations and motivation of health trainees in Saudi Arabia regarding medical missions. This study seeks to fill the gap in global health curricula and regulations, as well as provide guidance for trainees participating in international health electives in Saudi Arabia. This cross-sectional survey of health trainees (in medical, surgical and other allied health professions) was conducted across Saudi Arabia from March 2017 to February 2018 using a standardised survey adapted to assess expectations, barriers, awareness of available opportunities and the effect of mentorship in improving motivation toward medical missions. A total of 589 respondents completed the survey, with a response rate of 83.7%. Most respondents were under 35 years old, with an equal sex distribution. Furthermore, the respondents primarily had medical and surgical specialties training and graduated from the western region of Saudi Arabia. Health trainees who considered volunteering during training but did not have previous experience in missions acknowledged that the presence of a staff member experienced in missions in their training environment positively affected their interest in missions (p = 0.038). The most common reasons for interest in volunteerism were to enhance one's own technical and clinical skills and help others in need. Interest in tourism and learning about new cultures are additional reasons. Only 7/589 participants had experience and expressed the barriers they faced during volunteerism. Interestingly, their colleagues who did not have a similar experience perceived almost the same barriers. A major barrier faced by experienced participants was the 'lack of elective time', compared to the 'lack of available organised opportunities' by the inexperienced group. In conclusion, coordinating health trainees' missions through a unified authoritative body would provide better opportunities, override challenges and improve their perceptions and participation in these missions.

Incorporating hearing screening to an otolaryngology surgical mission in the rural Dominican Republic.

INTRODUCTION: Hearing loss disproportionately affects low- and middle-income countries. Children with undiagnosed hearing loss may have difficulty with learning, language development, and behavior. The aim of this study was to understand the extent of hearing loss and common otologic disorders among school-age children in the rural western region of the Dominican Republic and to chronical the early stages of a limited-resource, locally-sustained hearing screening program in tandem with a bi-annual surgical mission. METHODS: Hearing screenings were performed for 528 school-age children (1056 ears, age 5-17 years old) over 5 days in a village hospital in Peralta, DR. Testing initially included otoscopy and screening audiometry. Children who referred or could not be conditioned underwent distortion product otoacoustic emissions (OAEs), and tympanometry. Children who referred following both screening audiometry and OAEs were considered to have hearing loss. Those with normal tympanograms were considered potential hearing aid candidates. RESULTS: Abnormal ear examination/otoscopic results were present in 43 children (8.1%) and included: microtia/atresia, impacted cerumen, ear canal foreign body, serous otitis media, otitis externa, and tympanosclerosis. 55 of 528 school-age children referred following screening audiometry and 7 were unable to condition. Of these 62 children, 56 tolerated OAEs and 20 referred following OAEs (3.8%). Fourteen children had type B or C tympanogram and 6 school-age children who were determined to have chronic otitis media with effusion (COME) underwent myringotomy and pressure equalization tube placement. Ten of 528 children (1.9%) had normal tympanometry and otoscopy, and referred following screening audiometry and OAEs suggesting the patients may be potential hearing aid candidates. CONCLUSIONS: The prevalence of hearing loss in this cohort of children in the rural, western Dominican Republic was high at roughly 4% with roughly 2% of children being potential hearing aid candidates. Nearly 10% of children screened had an abnormal otologic examination; sometimes easily remedied by otolaryngologic intervention. With the support of local leadership, it is feasible to incorporate hearing services into otolaryngology outreach and build locally sustainable programs.

Dr. Aníbal Zambrano: un médico peruano con corazón de oro / Aníbal Zambrano, M.D: a Peruvian physician with a heart of gold

RESUMEN El objetivo del artículo es describir y analizar la trayectoria de vida y las contribuciones humanitarias del Dr. Zambrano, médico egresado de la Escuela de Medicina de San Fernando, quién fue presidente del Centro de Estudiantes de Medicina en una época políticamente álgida en la educación universitaria pública. Emigró a los Estados Unidos en 1970, bajo el contexto de crisis sociopolítica económica en el Perú y en el mundo, donde se convirtió en un renombrado médico internista y cardiólogo del St. Luke's Hospital. A pesar de su lejanía, mantuvo un lazo estrecho con el Perú organizando múltiples misiones médicas para el beneficio de poblaciones vulnerables, capacitación al personal médico e implementación tecnológica del Hospital Regional de Cajamarca. En 2011 se inauguró el Centro Médico Educativo en Chincha, siendo Zambrano uno de los líderes para su construcción. A pesar de padecer una enfermedad invalidante dedicó hasta los últimos días de su vida a brindar ayuda a los más necesitados. Su trayectoria de vida nos muestra un ejemplo de compromiso con el Perú y de un ejercicio de la medicina comprometida con la solidaridad y el desarrollo de la medicina en su país de origen.

ABSTRACT The objective of the article is to describe and analyze the life trajectory and the humanitarian contributions of Dr. Zambrano, a physician who graduated from San Fernando Medical school, and was president of the Center for Medical Students at a politically critical time in public university education. He emigrated to the United States in 1970, in the context of sociopolitical crisis in Peru and the world, where he became a renowned internist and cardiologist at St. Luke's Hospital. Despite the distance, he maintained a close relationship with Peru, organizing multiple medical missions for underserved populations, training medical personnel, and providing technological implementation to Cajamarca Regional Hospital. In 2011, the Educational Medical Center was inaugurated in Chincha, with Zambrano being one of the leaders for its construction. Despite suffering from a disabling illness, he dedicated until the last days of his life, providing help for those most in need. His life trajectory shows us an example of commitment to Peru and practice of Medicine committed to solidarity and the development of Medicine in his country of origin.

Guidelines for short-term medical missions: perspectives from host countries.

BACKGROUND: In the past decade, there has been increasing guideline development for short-term medical missions (STMMs) traveling from high-income to low- and middle-income countries for the purpose of supporting health care services. The ethics of STMMs is criticized in the literature and there is frequently a lack of host country collaboration. This typically results in guidelines which are developed through the lens of the sending (high-income) countries' staff and organizations. The aim of this paper is to evaluate an existing best practice guideline document from the perspective of host country participants with knowledge of STMMs from Honduras, Malawi, and the Philippines. METHODS: The guideline used for the evaluation consisted of nine best practice elements that were discerned based on literature and the experience of those working within the field. Semi-structured interviews were conducted in a cross-sectional study with participants (n = 118) from the host countries. Thematic analysis was conducted by two researchers and the results were assessed by working group members to confirm interpretations of the data. RESULTS: Overall, participants expressed a strong interest in having more structured guidance surrounding STMM practices. There was a positive response to and general acceptance of the proposed STMM guidelines, although participants found the 24-page document onerous to use; a companion checklist was developed. The key themes that emerged from the interviews included collaboration and coordination, care for hard-to-reach communities, capacity building, critical products and essential medical supplies, and opportunity and feasibility. CONCLUSIONS: Host input suggests that the guidelines provide structured regulation and coordination of the medical mission process and have the potential to improve the way STMMs are carried out. The guidelines have also proven to be a useful tool for the actual implementation of STMMs and can be a tool to strengthen links and trust between mission teams and local health staff. However, local contexts vary considerably, and guidelines must be adapted for local use. It is recommended that STMM teams work in conjunction with host partners to ensure they meet local needs, increase capacity development of local health workers, and provide continuity of care for patients into the local system.

ANTECEDENTES: En la última década, ha habido un incremento en el desarrollo de guías para las misiones médicas de corto plazo (STMM) que viajan desde países de ingresos altos a países en vías de desarrollo con el fin de apoyar los servicios de atención médica. La ética de las (STMM) es criticada en la literatura y hay una falta frecuente de colaboración entre los países anfitriones. Esto normalmente da como resultado directrices que se desarrollan a través de la lente del personal y las organizaciones de los países que envían (países de altos ingresos). El objetivo de este documento es evaluar un documento guía de mejores prácticas existente desde la perspectiva de los participantes del país anfitrión con conocimiento de las misiones médicas de corto plazo (STMM) de Honduras, Malawi y Filipinas. MéTODOS: la directriz utilizada para la evaluación consistió en nueve elementos de mejores prácticas que se discernieron en base a la literatura y la experiencia de quienes trabajan en el campo. Se realizaron entrevistas semiestructuradas en un estudio transversal con participantes (n = 118) de los países anfitriones. El análisis temático fue realizado por dos investigadores y los resultados fueron evaluados por miembros del grupo de trabajo para confirmar las interpretaciones de los datos. RESULTADOS: En general, los participantes expresaron un gran interés en tener una guía más estructurada en torno a las prácticas de las misiones médicas de corto plazo (STMM). Hubo una respuesta positiva y una aceptación general de las pautas de las misiones médicas de corto plazo (STMM) propuestos, aunque los participantes encontraron oneroso el uso del documento de 24 páginas y se desarrolló una lista de verificación complementaria. Los temas clave que surgieron de las entrevistas incluyeron colaboración y coordinación, atención a comunidades de difícil acceso, desarrollo de capacidades, productos críticos y suministros médicos esenciales, y oportunidad y viabilidad. CONCLUSIONES: Los comentarios del anfitrión sugieren que las directrices proporcionan una regulación y coordinación estructuradas del proceso de la misión médica y tienen el potencial de mejorar la forma en que se llevan a cabo las misiones médicas de corto plazo (STMM). Las pautas también han demostrado ser una herramienta útil para la implementación real de de las misiones médicas de corto plazo (STMM) y pueden servir para fortalecer los vínculos y la confianza entre los equipos de misión y los sistemas de salud locales. Sin embargo, los contextos locales varían considerablemente y las pautas deben adaptarse para el uso local. Se recomienda que los equipos de las misiones médicas de corto plazo (STMM) trabajen en conjunto con los socios anfitriones para garantizar que satisfagan las necesidades locales, aumenten el desarrollo de la capacidad de los trabajadores de salud locales y brinden continuidad de atención a los pacientes en el sistema local.

Implementing electronic health records on a medical service trip improves the patient care process.

Background: The efficiency of the patient care process of short-term medical service trips is often not assessed. The Gregory School of Pharmacy has organized annual medical camps in rural Uganda, however, the paper health records used for documentation and communication between stations have shown several limitations that hinder an optimal patient care process. Therefore, our objective was to implement an electronic health record system in these medical camps to improve the workflow and optimize the patient care process. Methods: An electronic health record system that functioned over a battery-operated local area network was developed and implemented. Patient health information was entered and reviewed at the different stations using mobile devices. The impact of electronic health records (used in 2019) on the patient care process was assessed using the number of patients served per physician per hour and the number of prescriptions filled per hour and comparing these to paper records (used in 2017). Results: Electronic health records were successfully implemented and communication across stations was fluid, thus improving transitions. Importantly, 45% more patients were served per physician per hour and 38% more prescriptions were dispensed per hour when using electronic (2019) compared to paper records (2017), despite having a smaller team in 2019. Conclusion: Implementation of electronic health records in rural Uganda improved the patient care process and the efficiency of the medical camp.

Dr E W Price, the discoverer of podoconiosis.

A straightforward biography of Dr E W Price, the discoverer of podoconiosis, a medical missionary who was also the first to elucidate plantar ulcers in leprosy.

The humanitarian aid of neurosurgical missions in Peru: A chronicle and future perspectives.

Background: The unmet neurosurgical need has remained patent in developing countries, including Peru. However, continuous efforts to overcome the lack of affordable care have been achieved, being neurosurgical missions one of the main strategies. We chronicle the humanitarian labor of organizations from high-income countries during their visit to Peru, the contributions to local trainees' education, and the treatment of underserved patients. Furthermore, we discuss the embedded challenges from these missions and the future perspective on long-term partnerships and sustainability. Methods: This is a narrative review. We searched the literature in PubMed and Google Scholar about neurosurgical missions conducted in Peru. Results: Since 1962, twelve organizations from high-income countries have delivered humanitarian help in Peru by training local neurosurgeons, treating low-income patients, and providing surgical instrumentation. Out of the three main regions of Peru, cities on the coast and highlands have hosted most of these missions, with no reported outreach in the amazon area. About 75% of the organizations are headquartered in the United States, followed by Canada, Luxembourg, and Spain. In addition, 50% of the organizations have an active partnership. The predominant focus of these missions has been pediatrics, neuro-oncology, and spine surgery. Conclusion: Neurosurgical missions have represented a strategy to close the disparity in education and treatment in Peru. However, additional efforts must be conducted to improve long-term partnership and sustainability, such as adopting standardized indicators for progress tracking, incorporating remote technologies for continuous training and communication, and expanding partnerships in less attended areas.

Mete Tèt Nou Ansanm (Putting our heads together): Global health capacity building within short-term medical missions.

Short-term medical missions (STMMs) have the potential to increase local health care capacity in low resource settings. Few studies have examined capacity building within STMMs from the perspective of both donor and host providers. A qualitative study using a transcendental method for research with human subjects examined the experiences of 21 North American 'donor' and Dominican 'host' health care providers who participated in STMMs in the Dominican Republic. Perry and Ojemeni's levels of capacity building for human good provided the theoretical framework, proposing a three-level approach: (1) augmenting local health care delivery capacity (2) assisting local communities to develop their own capacities and (3) transforming barriers to capacity. Findings are grouped into five themes and their subthemes: (1) making a difference (2) education and knowledge transfer, (3) acknowledging barriers, (4) host empowerment and (5) personal and interpersonal development. An overarching paradigm of 'Mete Tèt Nou Ansanm', or 'putting our heads together', emerged from the data, reflecting a dynamic process in which donor and host participants evolved their collaborative partnerships. STMMs have the potential for addressing global health capacity at all three levels. Mission compatibility with the local health system, host empowerment and repeated interactions over time are noteworthy determinants for STMMs sustainability.

A qualitative narrative review of protocols for women's health on short-term medical missions in Latin America and the Caribbean.

BACKGROUND: Women's health conditions are commonly encountered on short-term medical missions (STMMs) in Latin America and the Caribbean. There have been no previous attempts to describe women's health protocols used by volunteer clinicians. This qualitative study aimed to describe areas of agreement between unpublished women's health protocols from different North American STMM organizations and assess their concordance with published WHO guidelines. METHODS: A systematic web search was used to identify North American STMM sending organizations. Clinical protocols were downloaded from their websites and organizations were contacted to request protocols that were not published online. The protocols obtained were summarized, analysed thematically and compared to existing WHO guidelines. RESULTS: Of 225 organizations contacted, 112 (49.8%) responded and 31 of these (27.7%) had clinical protocols, of which 20 were obtained and analysed. Nine (45%) discussed sexually transmitted infections, six (30%) discussed pelvic inflammatory disease, two (10%) discussed prenatal care and two (10%) discussed menstrual disorders. None were the product of systematic literature searches and most were not referenced. CONCLUSIONS: To avoid ineffective treatment and related harms to women, volunteer clinicians would benefit from the adaptation and distribution of guidelines for STMMs that are based on existing WHO guidance and acceptable to clinicians, patients and organizations.

A History of Development of Medical Missions and Catholic Evangelization in Sub-Saharan Africa From the Early Twentieth Century to the Present: Tracing Some Representative Founders and Orders in the Context of the Twentieth Century Church.

Although the care of the sick has been a charism of Catholic community since the beginning, and hospitals as we know them have developed since the fourth century, religious orders began to develop hospitals as part of their mission work during the colonial expansion of the seventeenth century. These early efforts, however, were primarily a response to the needs of the colonists as well as recognition that the poor who were sick required care in these regions. It can be argued that medical missions developed during the twentieth century as a response to the outreach of Protestants as well as the exposure of physicians to the needs in mission territories, and that their advancement and success impacted the attitudes of the popes and bishops of the twentieth century. This article examines several individuals and organizations who have contributed to the development of medical missions in Africa in modern times and trace the approach of the Church toward medical missions by exploring missionary religious orders, especially women's religious orders, and papal and council documents. It primarily considers the role of medical missions in areas that had only a limited Catholic presence prior to nineteenth and twentieth centuries, and where Catholic health care and the local Catholic Church essentially developed together, and considers ways in which the growth of medical missions and the thinking of the Church developed together.

Long-Term Impact of Interprofessional Medical Mission Service Trips in Sierra Leone.

Objective: The purpose of this study was to evaluate the impact of capacity-building short-term mission service trips to Sierra Leone on local health education and perspectives. Methods: This was a prospective, mixed-methods study. During three mission trips between June 2017 and December 2019, health professional students taught multiple locally selected patient care-related topics. Local staff completed knowledge questionnaires and were surveyed or interviewed on mission service impact along with the cultural competence of missionaries. Mission team members completed the Intercultural Effectiveness Scale (IES) and surveys to determine their cultural competence. Results: After initial education, 90% passed the knowledge questionnaire with at least a 50% and the correct response rate was 57.9 vs. 66.7% after 6 months and 2.5 years, respectively (p = 0.40). Local staff ranked education/training as most valuable (84%) and highly desired (53%). Mean IES score and survey responses of both missionaries and local staff rated mission team cultural competence as average. Conclusions: Education-focused mission trips in Sierra Leone seem to have long-lasting benefits and a positive impact on local staff, though improved intercultural competence is needed.

The impact of complex facial surgery provided on a short-term surgical mission.

The long-term consequences of performing facial surgery on patients living in rural Ethiopia are largely unknown. A review of 36 patients who had been treated on a short-term surgical mission (STSM) in the previous 2 years was conducted to evaluate the outcomes of the surgical interventions performed. There was a significant reduction in social isolation following a surgical intervention. Improvements in postoperative self-reported changes were found for facial appearance, facial function, and quality of life. Positive outcomes can be achieved when surgical treatment is performed on a STSM.

Reliability of the Service Trip Audit Tool to assess the quality of short-term medical missions.

BACKGROUND: We aimed to assess the adherence of short-term medical missions (STMMs) operating in Latin America and the Caribbean (LAC) to key best practices using the Service Trip Audit Tool (STAT) and to calculate the inter-rater reliability of the data points. This tool was based on a previously published inventory of 18 STMM best practices. METHODS: Programme administrators and recent volunteers from 335 North American organizations offering STMMs in LAC were invited to complete the STAT anonymously online. Adherence to each of 18 best practices was reported as either 'yes', 'no' or 'not sure'. Fleiss' κ was used to assess inter-rater agreement of the responses. RESULTS: A total of 194 individuals from 102 organizations completed the STAT (response rate 30.4%; 102/335 organizations) between 12 July and 7 August 2017. Reported adherence was >80% for 9 of 18 best practices. For 37 non-governmental organizations (NGOs) with multiple raters, inter-rater agreement was moderate to substantial (κ>0.4) for 12 of 18 best practices. CONCLUSIONS: This is the first study to evaluate adherence to STMM best practices. Such an objective evaluation will be valuable to governments, volunteers and NGO donors who have an interest in identifying high-quality partners. Assessment and monitoring of STMMs through self-audit may be foundational steps towards quality improvement.

Effectiveness of Short-term Medical Missions on Chronic Disease in Underserved Communities.

A retrospective chart review study was conducted to evaluate health outcomes after a nurse-led short-term medical mission group provided free health care in four communities in Kingston, Jamaica over a four-year period. Participants were adult patients who had visited short-term medical mission clinics at least twice and were diagnosed with hypertension and/or diabetes. Blood pressure (BP) and blood sugar (BS) results along with factors including adherence and control per guidelines were analyzed using descriptive, t-tests and chi-square analysis. The data revealed that overall BP and BS measurements trended down, and there was a significant decrease in BP in patients with uncontrolled hypertension at the first visit. Medication adherence between the visits and gender had a statistically significant impact on BP and BS control. Outcomes suggest short-term medical missions are an effective model to address hypertension and diabetes in developing countries when using a sustainable approach.

Short-term medical service trips: what is the cost of patient care and student training?

BACKGROUND: Evaluations of the costs and effects of medical service trips (MSTs) are increasingly necessary. Estimates of costs can inform decision making to determine if participation is likely to be a wise use of resources. METHODS: This study estimates the costs and effects of a 1-week MST for 20 health professions students and seven providers to the Dominican Republic. Costs were defined as direct costs for students and providers and opportunity costs for providers. Effects were defined as the cost to treat one patient and the cost to train one student. Students were surveyed about their costs before and after the MST. Most provider costs were assumed to be the same as those of the students. RESULTS: The mean direct cost per student was US${\$}$1764 and US${\$}$2066 for providers. Total opportunity costs for seven providers was US${\$}$19 869. The total cost for the trip was US${\$}$69 612 to treat 464 patients. With and without provider opportunity costs, the cost to treat one patient was US${\$}$150 and US${\$}$107, and the cost to train one student was US${\$}$3481 and US${\$}$2487, respectively. CONCLUSIONS: Short-term MSTs may be more expensive than previously thought. The cost to treat one patient was similar to a medical office visit in the USA.