OUTLINE:

Chapter 1: Getting Started – Volunteering for FIENS

Chapter 2: FIENS Paperwork A. FIENS Introduction Letter B. FIENS Volunteer Information C. Guidelines for Volunteers D. Volunteer Agreement and Release E. Appendix H / Volunteer Report of Terms of Service F. Host Evaluation of Volunteer Services

Chapter 3: Teaching Aids A. AANS Grand Rounds B. University of Wisconsin Curriculum C. SNS Resident Boot Camp

Chapter 4: Useful Resources A. Publications B. Past Volunteers See Appendix I – Seven Sins Of Humanitarian Medicine See Appendix II – When Illness Strikes See Appendix III – Ethical Challenges in International Surgical

Education, for Visitors and Hosts

Chapter 1: Getting Started – Volunteering for FIENS

GETTING STARTED – VOLUNTEERING FOR FIENS

Travel Insurance / Health Insurance http://medjetassist.com/

Vaccinations / International Traveling http://www.travelclinicsofamerica.com/travel_vaccines.html

Safety for Travel / US Department Travel Advisory http://travel.state.gov/ http://travel.state.gov/travel/cis_pa_tw/tw/tw_1764.html

Chapter 2: FIENS Paperwork

A. FIENS INTRODUCTION LETTER

Re: Volunteers for International Neurosurgical Education Program

Dear Doctor:

Welcome to the Volunteers for International Neurosurgical Education Program. Thank you for considering participation in the Program. This letter is designed to help you understand the relationship of the various parties and the respective obligations of each.

Overview

The Volunteer Program is based on the principle of volunteerism where individuals volunteer to participate in activities of various local host programs (the “Host Program”) for a minimum of four weeks. Volunteers in the Program further the development and improvement of neurosurgical training programs worldwide by assisting local faculty members, by cooperating in the neurological education in medical schools, and by assisting in neurosurgery training programs. There is no financial remuneration for this service.

Activities and Role of the Host Program, FIENS and the Committee

The volunteer is supported by the Host Program according to the terms and conditions of each particular Host Program. All aspects of your work as a volunteer shall be determined by you and representatives of the Host Program. The manner in which you perform your work will also be determined by the Host Program. The Host Program and volunteer are responsible for all licensing, medical, and legal concerns.

Typically, local housing accommodations are provided by the Host Program. Because this may represent a significant financial cost to the host, it is usually provided in guest housing at host facilities. Any additional costs, such as international standard hotel or housing for additional members of a family, are usually the responsibility of the volunteer. The Host Program typically provides local transportation to the place of work.

In special circumstances, FIENS may be able to provide the volunteer round-trip economy airfare, which may be reimbursed upon receipt of tickets or photocopies of such.

Activities and Role of the Volunteer

The purpose of the volunteer service is primarily educational and will involve cooperation and working with local faculty members to achieve the educational aims of the Host Program. Many of the people that each volunteer will encounter will be highly skilled and capable professionals; therefore, professional, personal and cultural sensitivity are important issues to consider. Volunteers may find it helpful to prepare themselves by reading appropriate information in standard travel guides. Volunteers primarily work with local faculty, residents and neurosurgical trainees, medical students, nurses and other allied health care professionals.

In most situations, volunteers will be dealing with limited resources in terms of facilities, equipment, and supplies. There will be significant cultural differences from the volunteer’s home perspective, and work can therefore be challenging and stressful at times.

To help insure the best utilization of the volunteer’s time and skills, volunteers may want to consider meeting early with members of the Host Program to arrange a schedule of activities. Pre-trip communication by email is also very useful. Volunteers are typically asked to see patients in the emergency and out-patient departments, to review diagnostic imaging, and to help in the operating room. Volunteers might consider taking on the role of assistant/teacher rather than merely acting as the principal operator for the cases they handle. Again, the volunteer and Host Program should determine the appropriate activities for the volunteer.

The hosts are likely to be very hospitable and generous, and it is important that volunteers respond to this generosity. It is often culturally acceptable to take gifts along as a token of appreciation for their hospitality.

Evaluations

In order to assist future volunteers and each host program, volunteers will be asked to provide feedback on their volunteer service. Volunteers are asked to provide a report of their time of service and to give an assessment of the Program. We also ask volunteers to provide an evaluation of the Host Program and to provide recommendations to assist future volunteers.

In order to assist future volunteers, each volunteer’s rotation of service will also be evaluated by the Host Program.

The FIENS Volunteer Program has prepared several documents to help in each volunteer’s evaluation. Relationship of the Volunteer to FIENS and the Committee

Volunteers participating in the Program are neither employees nor agents of FIENS.

Volunteer Agreement and Release

All volunteers participating in the FIENS Program are required to read and sign the Volunteer Agreement and Release (the “Agreement”). The Agreement sets forth all agreements between the parties, solidifies the relationships and responsibilities of the parties, sets forth release and indemnification obligations relating to the volunteer’s participation in the FIENS Program, and contains other legal information. To the extent there is any discrepancy between this letter or anything you may be told about the FIENS Program and the Agreement, the Agreement controls.

Contact Information

If you have any questions, please feel free to contact the following persons:

Michael Haglund, MD Duke Global Neurosurgery and Neuroscience Division of Neurosurgery/Department of Surgery Duke University Medical Center Box 3807Durham, NC 27710 C/O Erin DelionbachPhone: (919) 684-5762erin.delionbach@duke.edu

Robert J. Dempsey, M.D., Chairman Foundation for International Education in Neurological Surgery, Inc. University of Wisconsin – Madison 600 Highland Avenue, K4/818 CSC Madison, Wisconsin 53792-0001 Phone: (608)265-5967 Fax: (608)263-1728 dempsey@neurosurg.wisc.edu

Daniel Kelly, M.D. Vice Chairman, FIENS2200 Santa Monica Boulevard Santa Monica, California 90404 Phone: (310) 582-7450 Fax: (310) 582-7495 kellyd@jwci.org

Again, thank you for considering participation in the FIENS Volunteer Program.

Best regards, Michael Haglund, MDVolunteer Coordinator Foundation for International Education in Neurological Surgery

B. FIENS VOLUNTEER INFORMATION

DATE OF CONTACT: ________________________________

PHYSICIAN/VOLUNTEER’S NAME: ________________________________

EMAIL ADDRESS: ________________________________

COUNTRY OF TRAVEL: ________________________________

DATES OF TRAVEL: ________________________________

Documents Needed:

Application form for FIENS Curriculum Vitae (Resume) 2 Letters of Reference

1. __________________________ 3. __________________________

2. __________________________ 4. __________________________

AANS and/or CNS Member

Once Approved:

Send the following documents: • FIENS - Cover Letter for Volunteer Agreement.doc• FIENS - Volunteer Agreement and Release.doc• FIENS - Volunteer Report of Service.doc• FIENS - Can I Help You.doc• FIENS - Host Evaluation.doc• FIENS - Guidelines for Volunteers.doc• FIENS - You Want to Save the World.doc• FIENS - MedjetAssist - Evacuation by Wheelbarrow.doc• FIENS - MedjetAssist - Executive Overview 2009.doc• FIENS - MedjetAssist - Rules & Regs.doc• Website: www.medjetassistance.com

Once Travel has been Completed:

Report from Volunteer Report from Host Country/Physician

C. GUIDELINES FOR VOLUNTEERS

Dear Doctor:

Welcome to the Volunteer Program of the Foundation for International Education in Neurological Surgery (FIENS). The purpose of this effort is to cooperate in the development and improvement of neurosurgical training programs worldwide by assisting local faculty members, by cooperating in the neurological education in medical schools, and by assisting in neurosurgery training programs. The program is based on the principle of volunteerism where volunteers participate in activities of the local host program for a minimum of four weeks. There is no financial remuneration for this service.

FIENS will provide roundtrip economy airfare upon approval of the itinerary, which may be issued in advance or reimbursed upon receipt of tickets or photocopies of such.

The volunteer is supported by the host program in the following ways. Local housing accommodation is provided, if possible. Because this may represent significant financial cost to the host, it is usually provided in guest housing at host facilities. Any additional costs, such as international standard hotel or housing for family members, are the responsibility of the volunteer. The host program should provide local transportation to the place of work and is responsible for licensing and medical-legal concerns.

Activities and Role of the Volunteer

The purpose of the volunteer service is primarily educational and will involve cooperation and working with local faculty members to achieve the educational aims of the program. Many of the people you encounter will be highly skilled and capable professionals, therefore professional, personal and cultural sensitivity are required. You should prepare yourself by reading appropriate information in standard travel guides. You should ask the FIENS volunteer coordinator for reports of previous volunteers working at this site. Your work will primarily be with local faculty, residents and neurosurgical trainees, medical students, nurses and other allied health care professionals.

Expectations

In most situations, you will be dealing with limited resources in facilities, equipment and supplies. There will be significant cultural differences from your home perspective and therefore work can be challenging and stressful at times.

It is important that your time and skills are well utilized. To insure the best utilization of these, it is wise to meet early with your host and arrange a schedule of activities. Pre-trip communication by email is also very useful. You will probably be asked to see patients in the emergency and outpatient departments, to review diagnostic imaging and to help in the operating room. You are encouraged to take on the role of assistant/teacher rather than become a principal operator for the cases you do.

Your hosts are likely to be very hospitable and generous. It is important that you respond to this generosity. It is often culturally acceptable to take gifts along with you as a token of your appreciation for their hospitality.

Guidelines for Resident Volunteers (If applicable)

The volunteer program of FIENS offers residents an extraordinary educational experience as well as the opportunity to make a contribution to neurosurgical education in developing countries. FIENS encourages senior residents (level PGY4 or above) to volunteer at many of its sites. The Chairperson of the Volunteer Committee can assist residents in selecting appropriate host programs. Resident volunteers are encouraged to present educational talks on neurosurgical topics and to participate in clinical activities at the discretion of the host program’s faculty. It is important to note that, despite a lack of faculty supervision in some programs abroad, resident volunteers are expected to function as residents under the supervision of host faculty members rather than as fully-trained neurosurgeons.

Evaluations

In order to assist future volunteers and your host program, you will be asked to provide feedback on your volunteer service. You are asked to provide a report of your time of service and an assessment of the FIENS procedures for volunteers. We also ask you to provide an evaluation of the status of the local program and to provide recommendations to assist future volunteers.

In order to assist future volunteers, your rotation of service will also be evaluated by the host program.

The Volunteer Committee has prepared several instruments to help in your evaluation.

If there are any concerns or problems, please be free to the following person:

Michael Haglund, MD Duke Global Neurosurgery and Neuroscience Division of Neurosurgery/Department of Surgery Duke University Medical Center Box 3807Durham, NC 27710 Phone: (623) 261-6764 C/O Erin Delionbacherin.delionbach@duke.edu

D. VOLUNTEER AGREEMENT AND RELEASE

This Agreement and Release (the “Agreement”) is entered into as of the date last written below between the Foundation for International Education in Neurological Surgery (“FIENS”), and Dr. _____________________________________ (“Volunteer”).

RECITALS

A. FIENS is based on the principle of volunteerism whereby individuals volunteer to participate in activities of various local host programs (the “Host Program”) for a minimum of four weeks. Volunteers further the development and improvement of neurosurgical training programs worldwide by assisting local faculty members, by cooperating in the neurological education in medical schools, and by assisting in neurosurgery training programs.

B. Volunteer wishes to participate and agrees to do so according to the terms and conditions stated in this Agreement.

AGREEMENTS

NOW, THEREFORE, for valuable consideration, the receipt and sufficiency of which is hereby acknowledged, it is agreed as follows:

1. FIENS agrees to provide Volunteer with roundtrip economy airfare, whichmay be issued in advance or reimbursed upon receipt of tickets or photocopies of such.

2. In order to assist future volunteers and each Host Program, Volunteeragrees to provide feedback on his or her volunteer service, including (i) a report of his or her time of service, (ii) an evaluation of the Host Program, and (iii) recommendations to assist future volunteers.

3. Volunteer agrees and acknowledges that he or she is neither an employeenor an agent of FIENS. Volunteer understands that he or she may not take actions on behalf of this group, nor represent that he or she has any authority to act on behalf of it.

4. FIENS shall not exercise control over the methods or manner in which theVolunteer performs his or her tasks or work-related activities while with the Host Program. Volunteer agrees that his or her activities shall be according to the terms and conditions of each particular Host Program. All aspects of Volunteer’s work shall be determined by Volunteer and representatives of the Host Program. The Host Program and Volunteer are responsible for all licensing, medical, and legal concerns.

5. In exchange for the consideration provided by FIENS, the Volunteer, along with his or her heirs, assigns, and successors, agrees to release and hold harmless FIENS and all of its directors, officers, employees, agents, successors, and assigns and any and all persons connected with FIENS from all claims, demands, causes of action, obligations, expenses, judgments, costs or damages, of any kind or nature whatsoever, known or unknown, including, but not limited to, any claims for personal injury, defamation, property damage, infringement, death, or any other injury, including attorneys’ fees, incurred in connection with being a FIENS Volunteer. 6. Volunteer agrees to indemnify FIENS and its employees, agents, successors, and assigns from any and all claims, demands, causes of action, and obligations that arise or are asserted in relation to any aspect of the Volunteer’s involvement in the FIENS program. 7. The undersigned parties hereby agree that this Agreement constitutes the entire agreement between Volunteer and FIENS and that it supersedes all other oral or written agreements, and/or understandings between the parties, and may not hereafter be modified except in writing signed by both parties. 8. The parties agree that they have had the opportunity to consult with an attorney regarding this Agreement and that they fully understand the terms, conditions, and agreements contained herein. VOLUNTEER SPECIFICALLY ACKNOWLEDGES THAT THIS AGREEMENT CONTAINS A RELEASE OF HIS OR HER RIGHTS TO ASSERT CLAIMS AGAINST FIENS OR THE COMMITTEE RELATING TO THE VOLUNTEER PROGRAM. 9. All aspects of this agreement between the Volunteer and FIENS shall be construed, interpreted, and governed in accordance with the laws of the State of Minnesota. 10. This Agreement may be executed in counterparts, and shall not become effective until both parties required to execute the Agreement shall have done so. AGREED TO this ___ day of ___________, _______.

11. Guidelines for Resident Volunteers (If applicable)

The volunteer program of FIENS offers residents an extraordinary educational experience as well as the opportunity to make a contribution to neurosurgical education in developing countries. FIENS encourages senior residents (level PGY4 or above) to volunteer at many of its sites. The Chairperson of the Volunteer Committee can assist residents in selecting appropriate host programs. Resident volunteers are encouraged to present educational talks on neurosurgical topics and to participate in clinical activities at the discretion of the host program’s faculty. It is important to note that, despite a lack of faculty supervision in some programs abroad, resident volunteers are expected to function as residents under the supervision of host faculty members rather than as fully-trained neurosurgeons. by: ___________________________ by: ___________________________ Name, Title Volunteer Name Foundation for International Education in Neurological Surgery by: ___________________________ Program Director,

If Volunteer is a Resident

APPENDIX H

E. VOLUNTEER REPORT OF TERM OF SERVICE Dear Doctor: To assist the FIENS Volunteers Committee and the host program we request a brief report of your term of service. The following guidelines are suggested. 1. Professional Experience

A. Overview: Please provide an overview of what you encountered. What type of

patients and volume did you encounter and what were your overall impressions?

B. Facilities: Please comment on patient care facilities, diagnostic facilities, operating

room, equipment, critical care etc. Are there specific equipment needs? C. Faculty and Personnel:

Please comment on personnel: neurosurgical faculty, anesthesiologists, radiologists, intensivists, nurses, physiotherapists etc.

D. Training Program: Please provide your observations and comments on the training programs. E. Educational resources:

What educational resources are available (library, journals, internet access)?

2. Personal Experience

A. Accommodation and local transport B. Time Utilization:

Was a schedule prepared for you and was your time well utilized? How could this have been improved?

C. Teaching: Were your objectives achieved? How were you most effective: i.e. formal

sessions, clinic, ward, operating room.

3. Cultural/Social Issues Were there cultural/social issues that you encountered and how can other volunteers be better prepared?

4. Recommendation Are there specific needs in the program? Would you recommend this term of service to others?

F. HOST EVALUATION OF VOLUNTEER SERVICES

Dear Host Coordinator: To ensure that the Volunteer program meets the needs of our host programs you are requested to provide an evaluation for us of our volunteer services. Please be as objective and complete as possible. The following guidelines are offered to assist you. Name of Volunteer: _____________________ Date of Volunteer Service: _________ 1. Overview: Did the volunteer participate and contribute in a positive way to your program and what are your general feelings? 2. Teaching Skill: Were the volunteer’s contributions practical for your local needs? Did the volunteer interact cooperatively with faculty, residents and students? Did he/she participate in the numerous day-to-day activities of your department? 3. Experiences: Did the volunteer have appropriate experience to support his/her teaching role? 4. Commitment: Did the volunteer appear committed to educational improvement and the betterment of your patients? 5. Adaptability: Did the volunteer adapt to the local infrastructure, level of resources and your pattern of medical practice (i.e., patient numbers, investigational capabilities and surgical equipment)? 6. Social Skills: Did the volunteer act sensitively to your local social and cultural situations? 7. Attitudes: Were the volunteer’s attitudes appropriate and did he/she fulfill your expectations? Although it is very difficult in some situations to be objective, your input is very helpful to developing our ongoing program of volunteers. Would you welcome back this volunteer to your institution?

Chapter 3: Teaching Aids TEACHING AIDS

A. AANS Grand Rounds https://www.aans.org/Education%20and%20Meetings/Master%20Series/AANS%20Operative%20Grand%20Rounds.aspx B. University of Wisconsin Curriculum https://secure.neurosurg.wisc.edu/dropbox/uploads/1541009192013/ C. SNS Resident Book Camp http://www.societyns.org/BootCamp/BootCampCourses.asp PGY1 – (Peter can you help with this?) PGY2 – (Peter can you help with this?) Simulation – (We will insert link to the October 2013 Neurosurgery supplement on Simulation when available next week. Moji, can you add content/links here?) Chapter 4: Useful Resources

USEFUL RESOURCES

A. Publications 1. Profiles in volunteerism Dr William B. Walsh and the SS HOPE. Surg Neurol. 2008

Mar;69(3):325-6. 2. To retire or not to retire, that is the question! Surg Neurol. 2007 Dec;68(6):686-7. 3. Volunteering as a visiting professor. Surg Neurol. 2007 Nov;68(5):577. 4. International neurosurgery--not a luxury, but a need! Surg Neurol. 2007

Sep;68(3):358 5. Volunteerism-a way to make a difference. Surg Neurol. 2007 Jul;68(1):115. 6. Making your life count. Surg Neurol. 2007 Jul;68(1):114. 7. Seven Sins Of Humanitarian Medicine - See Attachment 8. When Illness Strikes – See Attachment 9. Ethical Challenges in International Surgical Education, for Visitors and Hosts – See

Attachment

B. Past Volunteers

VOLUNTEERS THAT TRAVELED

2010 • Daniel Ahlberg

Belize April 2010 ahlbe001@umn.edu

• Timir Banerjee Ethiopia May 2010 TimirB@aol.com

• Mark Bernstein Ghana April 2010 mark.bernstein@uhn.ca

• Robert Dempsey Africa January 2011 dempsey@neurosurg.wisc.edu

• Elizabeth Fontana Uganda July 2010 ejf2024@columbia.edu Steve Freidberg Ethiopia January-February 2010 stephen.r.freidberg@lahey.org

• Andrew Kaufman

Ethiopia December 2010–January 2011 akaufman@kc.rr.com

• Evgueni Kouznetov

Nepal October 2010 ekouznetsov@toh.on.ca

• Fassil Mesfin Ethiopia April 2010 mesfinfb@mail.amc.edu

• Tetsuo Tatsumi Tetsuo Tatsumi

Guatemala Honduras/Guatemala October 2010 May 2010 tatsumi@verizon.net

• Josue Vialogo Nepal June 2010 jvialogo@hotmail.com

• Sarah Woodrow Ethiopia November 2010 sarah.woodrow@gmail.com

2011 • Daniel Ahlberg Daniel Ahlberg Daniel Ahlberg

Kenya Belize Belize February – March 2011 April – May 2011 January 2012 ahlbe001@umn.edu

• Sachin Baldawa Ethiopia August 2011 sachin_baldawa@yahoo.co.in

• Timir Banerjee Timir Banerjee Nicaragua Ethiopia May 2011 June 2011 TimirB@aol.com

• Mark Bernstein Nigeria November 2011 mark.bernstein@uhn.ca

• Arnold Calica Peru August 2011 calicaster@gmail.com

• Stephen Freidberg Ethiopia January – February 2011 stephen.r.freidberg@lahey.org

• Andrew Kaufman Ethiopia December 2011 – January 2012 akaufman@kc.rr.com

• Patrick Kelly Vietnam September - October 2011 Patrick.Kelly@nyumc.org

• Dennis McDonnell Vietnam January - April 2011 mcdondel@gmail.com

• Sunit Mediratta Peru July – August 2011

sunit_medi@yahoo.com

• Jack Rock Ghana April 2011 jrock1@hfhs.org

• Philip Rosenthal Nicaragua October 2011 conn8di@aol.com

• Raymond Taniguchi Nepal March 2011 rmtaniguchi@yahoo.com

• Tetsuo Tasumi

Honduras October 2011 tatsumi@verizon.net

• Sarah Woodrow

Ethiopia November – December, 2011 sarah.woodrow@gmail.com

2012

• Timir Banerjee Timir Banerjee Mongolia Nicaragua July 2012 January 2012 TimirB@aol.com

• Mark Bernstein Mark Bernstein Ethiopia Nigeria December 2012 May 2012 mark.bernstein@uhn.ca

• Robert Dempsey Uganda January 2013 dempsey@neurosurg.wisc.edu

• Stephen Friedberg Ethiopia March 2012 stephen.r.freidberg@lahey.org

• David Pitkethly Kenya March 2012 dtpit@u.washington.edu

• Hans-Peter Richter Myanmar November 2012 hp.richter@t-online.de

• Philip Rosenthal Nicaragua April 2012 conn8di@aol.com

• Paul Turner Paul Turner Ethiopia Ghana April 2012 March 2012 pturner@salud.unm.edu

• Craig Winter Nepal November 2012 craigdw1@gmail.com

2013 • Timir Banerjee, M.D.

Mongolia July 2013 TimirB@aol.com

• Mark Bernstein Ethiopia March 2013 mark.bernstein@uhn.ca

• Jonathan Grossberg, M.D. Nepal April 2013 jonathan_grossberg@brown.edu

• Jack Rock, M.D. Yangon March 2013 jrock1@hfhs.org

• David Semenoff, M.D. Nicaragua March 2013 semenod@mail.amc.edu

Appendix I – Seven Sins of Humanitarian Medicine

ORIGINAL SCIENTIFIC REPORTS AND REVIEWS Seven Sins of Humanitarian Medicine David R. Welling • James M. Ryan • David G. Burris • Norman M. Rich Published online: 9 January 2010 Socie´te´ Internationale de Chirurgie 2010 Abstract The need for humanitarian assistance throughout the world is almost unlimited. Surgeons who go on humanitarian missions are definitely engaged in a noble cause. However, not infrequently, despite the best of intentions, errors are made in attempting to help others. The following are seven areas of concern: 1. Leaving a mess behind. 2. Failing to match technology to local needs and abilities. 3. Failing of non-governmental organizations (NGO’s) to cooperate and help each other, and and accept help from military organizations. 4. Failing to have a follow-up plan. 5. Allowing politics, training, or other distracting goals to trump service, while representing the mission as ‘‘service’’. 6. Going where we are not wanted, or needed and/or being poor guests. 7. Doing the right thing for the wrong reason. The goal of this report is to discuss these potential problems, with ideas presented about how we might do humanitarian missions more effectively. Introduction The Catholic Church during the Middle Ages had a list of seven cardinal sins [1]. Commission of any of these sins was considered to be a severe act. The list addressed many of our human foibles and included extravagance, gluttony, greed, sloth, wrath, envy, and pride. These ‘‘deadly’’ sins were more serious than the ‘‘venial’’ sins that we all commit more regularly. Forgiveness from the seven sins required confession, penitence, and extraordinary efforts. When considering the topic of humanitarian medicine, it has occurred to us that we could craft a list of seven areas of concern, seven mistakes that are common and continue to challenge those who go forth on humanitarian missions (Table 1). With each area mentioned, we provide examples. Finally, we propose the ideal humanitarian mission, with its features. Almost invariably, applicants for medical school when asked why they have decided to become a physician, give as an answer: ‘‘…the desire to help others.’’ Humanitarian medicine provides the almost perfect opportunity to do just that. To go to an area where good care is not available, to provide services that can make a huge difference in the health and welfare of a fellow human being, to provide this service freely and without personal gain—surely these sorts of activities can be life-altering for both provider and recipient of care. And yet we do not always successfully accomplish our goals of providing safe, modern, successful, appropriate care. This article is in no way meant to denigrate the good works of those who participate in humanitarian missions. We salute all those in these sorts of activities, realizing that there

often is real sacrifice made, including the sacrifice of time, money, and equipment. Occasionally, humanitarian missions can even expose us to serious disease, accidents, or assaults. We have great respect for all who go forth to serve. Surely those who aspire to help others almost always do so with honorable intent, and almost never set out to satisfy selfish desires. However, despite our good intentions, mistakes continue to be made, which we attempt to demonstrate in this paper. In our view, there are (at least) seven major opportunities for improvement in the art and science of humanitarian medicine.

The following are major reasons for failures in humanitarian medicine: Sin #1: Leaving a mess behind. Complications can ruin everything. The death of a child can quickly erase the memories of a thousand successful operations. A good example of this principle is found in reviewing the story of Operation Smile. Operation Smile had been described as a ‘‘model charity.’’ It was founded in 1982, to increase vastly the ability to treat cleft palate and cleft lip cases throughout the developing world. This humanitarian effort quickly gained popularity and traction. Supporters of this organization have even included Mother Theresa, Goldie Hawn, and Bill Gates. It became a well-funded charity. The problems with Operation Smile began in 1998 with the death of a child in China. It was alleged that ‘‘…It was the direct result of a poorly run mission with far too much attention being paid to publicity and not enough to patient safety and standard operating techniques.’’ Medical professionals at the Beijing hospital where Operation Smile conducted the mission also were severely critical, saying ‘‘There was a high number of serious complications where children suffered from excessive bleeding or had to have emergency surgery because their palates had collapsed.’’ Besides the criticism of the Chinese mission, there was a child who died because the oxygen supply had run out in Kenya, and another child died in Viet Nam of unrecognized asthma. This sort of adverse publicity has had a predictable, negative effect upon the organization, which continues to operate missions throughout the world. Major contributors withdrew offers of support, and the organization has undergone some serious restructuring and

introspection as a result of these accusations. ‘‘After Operation Smile came to Bolivia, several children needed extensive follow-up care at San Gabriel Hospital, according to Dr. Roberto Rosa, a pediatric surgeon there who was sharply critical of Operation Smile and other charities. ‘‘This is a form of neo-colonialism,’’ argued Dr. Rosa, saying that Operation Smile had committed ‘‘surgical safaris against our children,’’ who are from poor families who are unlikely to complain [2]. Perhaps some of the difficulty encountered by Operation Smile revolved around the complexity of the cases they attempted. As a rule, the more difficult cases should not be routinely done by humanitarian medicine transient teams, in our view. Sometimes ‘‘No’’ is the best answer when pressed. Surely it is wise to always review the capabilities of the team and never allow providers to do more than they should be doing, given limitations of equipment, time, etc. Numbers of cases performed should not be allowed to trump patient safety and proper monitoring. Large and complex cases should be reviewed and only performed when the team is convinced that the case can be done safely, and that the patient will receive good care when the humanitarian team is no longer on the scene. This implies a great degree of trust and cooperation with local health care providers, which Operation Smile apparently did not always have. We also believe that ideally, visiting surgeons should be teaching local surgeons how to do the operations and have them fully onboard in the decision-making and care, especially if the visitors plan to leave patients with unresolved issues. If local surgeons feel that they lack expertise in a particular operation and ask for training by the visiting surgeons, then certainly that sort of training is sensible and more likely will have a positive outcome. One good rule is to offer the types of procedures that are minimally invasive, to relieve immediate discomfort, and that require little follow-up care, especially for missions that are short-term. Thus, removal of abscessed teeth, removal of ingrown toenails, fitting of eyeglasses—simple acts of this sort will create good will and a positive memory of the care given, with little risk of leaving a mess behind [3]. Sin #2: Failing to match technology to local needs and abilities. Despite what we may think, a vast part of our world does not have high-speed Internet access, or even electricity, or potable water. As we prepare to go off on a mission to a disadvantaged country, we ought to be asking ourselves how we might best go about helping. Generally, bringing the latest and the greatest new technology into a society that is impoverished can be more a cruel joke than a boon for the people. Yet, as we prepare to go, we generally like to surround ourselves with equipment that we normally use, and so this error is very easily understood. Here is a telling quote from a Belgian plastic surgeon, Dr. Christian Dupuis, who has volunteered to go to South East Asia for several months each year since the 1970s: ‘‘I have seen professors from fancy American universities teaching endoscopy skills in Laos to internists who don’t have access to an endoscope.…’’ [4] Perhaps this foible is somewhat tied into the desire to do a ‘‘first,’’ as in doing the first laparoscopic adrenalectomy in the Amazon basin. It is more about bragging rights than about solid, needed care that will be sustainable after we leave. Sin #3: Failing of NGOs to cooperate and help each other, and to cooperate and accept help from military organizations. Nongovernmental organizations (NGOs) are in a constant battle with each other as they compete for funding for their particular cause. If

they can somehow show that their particular organization is doing more operations, or pulling more teeth, or treating more patients, this degree of activity can translate into getting more funds from the donors. It is well known that these organizations get into contests with each other, and spend a good deal of energy and resources trying to look better than the competition. To quote Dr. Anthony Redmond, a British Professor of Accident and Emergency Medicine: ‘‘…Teams must cooperate with each other. Competitive humanitarianism is destructive and very wasteful of resources, both human and material. There can be pressure, either real or imagined, to be seen to be doing something in the eyes of those who have sponsored the team. This must be resisted. Much useful work can be done away from the glare of publicity in support of the work of others’’ [5]. One area that certainly could be improved is the attitude of NGOs toward the military. Both U.S. and non-U.S. military capabilities for transportation of supplies and personnel, for setting up tent hospitals, for bringing in operating room capabilities and blood banks—this sort of amazing capability is available and has been proven effective throughout the world. And yet at times the NGOs would appear to rather go without than to be seen working with someone in a military uniform. Ultimately, that attitude hurts the mission. We believe that both sides, military and nonmilitary, could do more to foster cooperation in this regard. Perhaps some progress is being made. Very recently, Navy Captain Miguel Cubano, who is presently serving as the U.S. Southern Command Surgeon, reported that NGOs have been offered operating room time on board the USNS Comfort, and a number of NGOs were onboard as the ship was to sail into the Caribbean on its next mission, which began in April 2009 (Dr. Miguel Cubano, personal communication). This sort of planning, which is innovative and unusual, should be congratulated and encouraged in the future. Sin #4: Failing to have a follow-up plan. A good example of this foible has been the activity of the United States military in Africa during the past several decades. We have had a yearly mission to a given area, a humanitarian effort, which is a wonderful and unforgettable opportunity for those lucky enough to be chosen to go along. The problem with these missions is that they have generally never gone back to the same place twice; thus perversely, instead of helping people, perhaps these effortsactually cause the good people of Africa to resent our well-intentioned efforts. One of us (DRW) was involved in a humanitarian mission, called Operation Red Flag, to northern Cameroon in March 2000. This mission lasted almost a month. It involved several hundred medical and support military personnel, mainly stationed in Germany, who were transported via C-17 and B-747 aircraft to Garoua, Cameroon. Tons of supplies were brought in, as well as vehicles and other ancillary equipment. We presented the hospital with a vast array of new equipment, including autoclaves and operating room tables. Our teams built an xray suite at the military hospital. Teams went to villages, where wells were drilled, vaccinations were given, teeth pulled, and eye glasses distributed. We were very kindly hosted by the local populace, and when we finally left, dinners were held in our honor, toasts were made, and we said goodbye to our new friends. But what must the good people of Garoua think of those Americans now? Surely the supplies are long gone, and the equipment needs maintenance or replacement. Those who had our care no doubt need follow-up. It was almost a cruel joke, tantamount to taking a little child to Disneyland for 15 minutes, and then getting back into the car and leaving forever. We

had given the citizens of Garoua just a taste of modern medicine, just a brief look at what might be. And then we left. Surely we should never have one-time-only missions. We should have an ongoing, regular visit schedule. We should see our patients again and again. We should know and have ongoing dialogue with our medical colleagues in these countries. None of this was done after the Cameroon mission. It is much better to pick one country and continue to serve it well, than to hopscotch all over Africa, going everywhere and truly getting nowhere. Sin #5: Allowing politics, training, or other distracting goals to trump service, while representing the mission as ‘‘service.’’ The U.S. Navy has two large hospital ships, the USNS Comfort and the USNS Mercy. The Comfort is berthed in Baltimore, MD, and the Mercy in California. Our Navy has fairly frequently used these ships to go on ‘‘humanitarian’’ cruises, as well as for response to natural and manmade disasters. For humanitarian missions, the Comfort usually goes to the Caribbean, while the Mercy goes to the South Pacific. Typically, at the end of a cruise, the Navy will announce the results of these missions, with invariably positive publicity. For example, a 2007 Caribbean tour by the Comfort involved more than 500 personnel and lasted several months; 98,000 patients were seen, 1,170 surgeries were performed, 32,322 shots were given, 122,245 prescriptions were filled, 24,242 eyeglasses were fitted, 3,968 teeth were pulled, and 17,772 animals were treated. Schools were built, and even the U.S. Navy Show Band participated [6]. On another mission, the Mercy left in May 2008, on a South-East Pacific voyage, and after several months, reported that their providers had examined 468 World J Surg (2010) 34:466–470 123 more than 90,000 patients and had performed almost 1,400 operations [7]. Obviously, for those aboard for these missions, this was a remarkable experience. But truly it was more about photo opportunities, training, diplomacy, and ‘‘showing the flag’’ than about service. These huge ships (894 feet long) are not well-suited to these missions. At times in the Caribbean, the Comfort was required to anchor a dozen miles offshore, relying on helicopters and smaller boats to ferry patients back and forth. Each port in the Caribbean was visited for about a week, and the visits were not always well-coordinated with local organizations, which at times were not even consulted. Thus, resources were not maximized. Even Fidel Castro weighed in on this mission and was quoted as saying this about our efforts, and he has a good point: ‘‘You can’t carry out medical programs in episodes’’ [8]. Interestingly, President Barack Obama, while attending a summit of the hemisphere’s leaders in Trinidad and Tobago in April 2009, seemed to validate what Castro had previously inferred. President Obama felt the that United States could learn a lesson from Cuba, which for decades has sent doctors to other countries throughout Latin America to care for the poor. The policy has won Cuban leaders Fidel and Raul Castro deep goodwill in the region [9]. Apparently, the Cuban doctors have correctly realized that by staying in one place for a prolonged period of time, they can have maximum impact with the local populace. For a small and poor country, Cuba has made remarkable contributions to reducing infant mortality and helping disaster victims throughout the world. During the past four decades, some 52,000 doctors and nurses have been sent to 95 needy countries. Recently large numbers of doctors and nurses have been sent to Venezuela, with some subsequent discontent voiced by Cuban citizens, who now are noticing increased waiting times, and difficulty gaining access to routine care [10]. Cuba also has helped to establish medical schools in a

number of third-world countries [11]. These Navy missions must be great for training, and for projecting power, and showing the flag, but probably could be modified by using smaller ships and more frequent missions to the same places. The Comfort and the Mercy have never been proven able to reach a disaster site in a timely manner, and their attempts at humanitarian medicine have not always been convincing in the aggregate. The last USNS Comfort mission to the Caribbean began on April 1, 2009 [12]. Sin #6: Going where we are not wanted, or needed and/or being poor guests. Dr. Anthony Redmond teaches us that we need an official request to go into an area in need, asking for our specific help. He states this: ‘‘The pressure to do something immediately can be considerable. Emotive television and press reports galvanize public opinion into demands for immediate action. However, without recognized terms of reference and a clear mandate to enter and work in another country, foreign teams will at best be stranded at airports and at worst add considerably to the problems of an already beleaguered nation. Time spent in securing a safe passage through and identifying a task to be completed will result in a shorter journey to the scene [5].’’ Dr. Redmond also talks about the necessity of doing what the local officials want, instead of what we think they may need. ‘‘If assistance is to be most effective it has to be organized. Local officials are in charge and must be allowed to develop and execute their plans with foreign teams there as a resource and not a threat. When a team has gained local confidence and developed good local relationships they will have a better knowledge of local requirements. This process of ‘bedding in’ to the local network can be completed within 24 hours [5].’’ Mr. Jim Ryan, a surgeon from the United Kingdom and someone well-experienced in humanitarian medicine, relates seeing a whole team from Scandinavia, which had, with the very best of intentions, responded to the tsunami disaster in Sri Lanka without first getting permission from the government. Despite their great expertise and extensive equipment, they were sequestered and were not allowed to leave their compound, let alone go out and help the victims. As to how one should conduct oneself when on a humanitarian mission, a dose of humility might get us off on the right foot as we begin. Anything that looks like boorish behavior, or condescension, or a patronizing attitude—any such behavior is detrimental to our efforts and will leave an unpleasant memory of us for those who would be our patients and our colleagues. We need to be very careful with local customs and mores. How we dress, how we act, what we drink—all of these activities will define us to our hosts. We can learn much from third-world providers, as they maximize what they have in supplies, and innovate to give their patients the very best care possible. We should go with the desire to see a different way to render care, instead of insisting that our way is the only correct way possible. Sin #7: Doing the right thing for the wrong reason. In Murder in the Cathedral, T.S. Eliot wrote about the various temptations that Thomas the Archbishop suffered through, and the very last was the most difficult. As Thomas proclaimed: ‘‘The last temptation is the greatest treason: To do the right deed for the wrong reason [13].’’ The list of wrong reasons to go off on a humanitarian mission is potentially a long list, and no doubt would vary somewhat from person to person. To name a few reasons not to go, one might

include the desire to go on an unusual vacation, bragging rights for having done a ‘‘first,’’ the desire to perform a large number of complex cases quickly (without the niceties of informed consent, proper monitoring, planned follow-up, and without training the local surgeons to do the procedures themselves), to gain fame, to have a free trip to an exotic land, or to somehow get an advantage in academia. The corollary to this last observation would be that we should go forth with pure motives, with a well-thought-out plan of action, including host nation physicians, avoiding the types of operations that lend themselves to long-term complications, and with a teachable, humble attitude. Summary We have listed some of the common mistakes and pitfalls that can beset those who would go on humanitarian missions, with thoughts about how we might improve in this regard. The importance of doing humanitarian medicine properly cannot be overemphasized. To maximize our effectiveness as humanitarian providers, more time should be spent thinking about the details of a given mission. Motives should be questioned. We ought to aggressively plan activities that will do the most good for our patients, and we ought to shun those activities that are more designed for our own personal aggrandizement. There is an inexhaustible demand for modern medicine throughout the world, and we face that demand with finite resources and human foibles. How we go about doing humanitarian medicine can define us, for better or for worse. Acknowledgments The authors wish to acknowledge the teaching, mentorship, and example of Drs. David C. Wherry, J. Leonel Villavicencio, Stanley L. Minken, and Arthur L. Trask, who helped in the formation of the ideas presented in this report. References 1. http://en.wikipedia.org/wiki/Seven_deadly_sins. Accessed 26 Mar 2009 2. http://www.nytimes.com/1999/11/24/world/charges-of-shoddypractices- taint-gifts-of-plastic-surgery.html?sec=health&spon=&pagewanted=1. Accessed 26 Mar 2009 3. Minken SL, Colgan R, Barish RA, Doyle J, Brown PR, Welling DR (2008) Waging peace: a medical military mission to Bosnia- Herzegovina. Surg Rounds 31:128–135 4. Wolfberg AJ (2006) Volunteering overseas: lessons from surgical brigades. N Engl J Med 354:443–445 5. Lumley JSP, Ryan JM, Baxter PJ, Kirby N (1996) Handbook of the medical care of catastrophes. Royal Society of Medicine Press Limited, London, p 37 6. http://www.southcom.mil/AppsSC/factfiles.php?id=6. Accessed 20 April 2009 7. Davis KD, Douglas T, Kuncir E (2009) Pacific Partnership 2008: U.S. Navy Fellow provide humanitarian assistance in Southeast Asia. Bull Am Coll Surg 94:14–23 8. http://www.flacso.org/hemisferio/al-eeuu/boletines/02/86/rel_07. pdf. Accessed 20 April 2009 9. Wilson S (2009) Obama closes summit, vows broader engagement

with Latin America. Washington Post, April 20:A6 10. http://www.boston.com/news/world/latinamerica/articles/2005/08/ 25/as_cuba_loans_doctors_abroad_some_patients_object_at_home/. Accessed 20 May 2009 11. http://www.medicc.org/ns/index.php?s=46&p=12.Accessed 20 May 2009 12. http://www.southcom.mil/appssc/factfiles.php?id=103. Accessed 20 April 2009 13. Eliot TS (1964) Murder in the cathedral. In: Brooks C, Purser JT, Warren RF (eds) An approach to literature, 4th edn. Appleton- Century-Crofts, New York, p 816 470 World J Surg (2010) 34:466–470 123

Appendix II - When Illness Strikes By Alfred Borcover Special to the Chicago Tribune Published October 5, 2003 As people prepare to go on vacation, they worry about what clothes to pack, about leaving home, their flights, their reservations, the weather, myriad things. What most people don't worry about is getting injured or sick on their vacation. Why worry about such nasty stuff when the main focus is to have fun? Hearing about the following incidents, however, can give everyone pause. Ed Rosner, 60, a semi-retired attorney from Charlotte, N.C., and his wife, left in April from Ft. Lauderdale on a 21-day Holland America cruise to the southern Caribbean. A few days into the cruise, Rosner said he began to experience recurring chest pains. On the eighth day of the cruise, after spending several days in the infirmary, Rosner was told by the ship's doctor he should be treated ashore. "Since we do a lot of travel, my wife thought it would be a great idea to sign up for MEDJET ASSISTANCE [a membership program that provides its customers with air medical evacuation from almost anyplace in the world]," Rosner said. "My wife called MEDJET ASSISTANCE and they took over." The firm's doctors spoke with the ship's doctors and arranged for Rosner and his wife to be picked up in Grenada. Rosner said a ship's nurse and paramedic accompanied him to shore, where an ambulance was waiting to transport him to a private hospital. "While we waited for a MEDJET ASSISTANCE plane to arrive, the medical crew, with their equipment, stayed with me. "When MEDJET ASSISTANCE arrived, their nurse and paramedic took over. They were top-notch," Rosner said. A medically equipped Learjet flew him and his wife from Grenada, via San Juan, to Charlotte-Douglas International Airport, where an ambulance was waiting to take them to a hospital. "The medical crew was in constant contact with my cardiologist and even had photocopies of my medical records." Linda Sunderlage, 54, of Woodstock and her husband were on a bicycle trip in the Czech Republic in August. While walking in a small town near Prague, Sunderlage

tripped on a cobblestone street and broke her kneecap. When they got back to Prague, Sunderlage's husband called MEDJET ASSISTANCE, which advised them to get Linda admitted to a hospital. The Czech doctor who stabilized her leg spoke little English, but MEDJET ASSISTANCE got an interpreter on the phone in minutes to speak with the attending physician. In short order they arranged to have Sunderlage transported by another medically equipped Learjet from Prague back to Chicago's O'Hare International Airport. An ambulance was standing by at O'Hare to take her and her husband to Northern Illinois Medical Center in McHenry. "Everybody was very professional," said Sunderlage, who is still on crutches. "They went far beyond our expectations." Sunderlage, who works with her husband in a consulting business, said she had heard about MEDJET ASSISTANCE from a friend and joined because they both travel for business and pleasure. "We honestly thought the membership would never pay off. We never dreamed they would do all this, but they did exactly what they said they would do." "We have a system that works very well," said Roy Berger, president of MEDJET ASSISTANCE, based in Birmingham, Ala. "We have about 90 affiliates in over 20 countries around the world. So depending upon where our member is, and where they need to go, we would use the closest affiliate, which makes a lot more sense than launching an airplane from Birmingham." MEDJET ASSISTANCE sells annual memberships--$295 for families, $195 for an individual. Recently added are short-term travel protection plans for 7, 14 and 21 days, whose rates range from $69 to $199. If you are hospitalized more than 150 miles from home, MEDJET ASSISTANCE will bring you back to the hospital of your choice. The medical evacuation/repatriation services require only that you be hospitalized as an inpatient and need hospitalization upon reaching your destination. (For more information, call 800-963-3538 or see www.medjetassistance.com.) "Our biggest competitor is travel insurance products," Berger said. "The difference between what they do and what we do is most conventional travel insurance will evacuate you to the closest appropriate medical center. Our program repatriates you. We'll bring you back home." What happens, typically, is that there are three people involved in the initial transport diagnosis and recommendation: the attending physician, the member's personal physician back home and a physician at the University of Pittsburgh Medical Center, who serves as the company's medical director, Berger explained. The three of them talk to determine the severity of the illness or injury, the need for hospitalization and when and if the member can be moved, he continued.

MEDJET ASSISTANCE, which has about 26,000 members, doesn't like to talk about the number of people it evacuates annually, but Berger described last August, with 17 airlifts, as "a very busy month for us." He said 60 to 65 percent of the transports are domestic because more people are traveling in the U.S. rather than overseas. What's jarring about medical evacuations is how costly they are. Rosner's medevac would have cost about $22,800, Sunderlage's $50,000. This doesn't mean that every traveler should rush to buy medevac or travel insurance, for that matter, but it does mean that people should take time to realistically evaluate their needs and what their personal health insurance covers. Seniors must be aware that Medicare does not cover them outside the U.S. And, as Berger pointed out, travel insurance doesn't necessarily provide what MEDJET ASSISTANCE does. But there are always variables. At Wisconsin-based Travel Guard International, which recently increased medical evacuation coverage to $300,000, its travel insurance policy provides evacuation to "the nearest adequate medical facility or home if medically required." "It's one of those situations where there's a number of factors that come into play," said Travel Guard spokesman Dan McGinnity. "One factor is the need for expediency. In some cases, medically it might make more sense to take the person to the nearest medical facility. And in other cases the decision might be to send the person home. It's a determination made among the attending physician, medical consultants for Travel Guard and the personal physician, if that person is involved, something we attempt to do." McGinnity related a recent case in which a Los Angeles woman on a Princess cruise in Alaska experienced chest pains. The ship's doctor didn't have the equipment to make a detailed diagnosis so, at the next port of call, the woman was taken by ambulance to Providence Hospital in Anchorage. She was diagnosed with congestive heart failure. After a few days, the attending physician determined the woman was stable enough to return home. McGinnity said Travel Guard booked Business Class seats on Alaska Airlines for her and a medical escort, arranged for oxygen on the flight and ambulance transport to her hospital, all covered by her Travel Guard policy. (For more information, call 800-826-4919 or see www.travelguard.com.) "At Access America [a travel insurance firm based in Richmond, Va.], we get the people to the nearest place where he or she can get good medical care," said Beth Godlin,

senior vice president for sales and marketing. "And we bring them back home once they are stabilized. We do get them home, absolutely." Godlin said all the decisions are made by medical professionals, using doctors at the University of Maryland. "We'll have medical people talking to medical people to find out the nature of the illness or injury, what the local care protocol is, and we'll monitor the case. We'll use private air ambulances or commercial airlines, and we'll put medical people with them." (For more information, call 866-807-3982 or see www.accessamerica.com.) Cruise lines, for example, deal with medical emergencies fairly regularly. Bill Wright, a captain for Royal Caribbean International and a spokesman for Cruise Lines International Association, a marketing arm for major lines, said ships have well-staffed and -equipped medical facilities on board staffed with doctors and nurses. Wright, who currently is senior vice president for safety, security and environment for RCI and will become captain of the line's newest (no name or launch date yet) ship, explained the protocol that cruise lines use: "What normally would happen is that the ship's doctor would make [the captain] aware that there's a guest or a crew member that has a medical condition, presumably life-threatening, in need of immediate medical attention. We start working. It depends on where the ship is in determining what options we have. We would normally contact our office in Miami and it would facilitate contact with the Coast Guard, if helicopter evacuation was an option. We would review where we are relative to ports that we know have hospitals and the ability to get someone to a hospital relatively quickly. It might require a diversion from the ship's itinerary." Added Wright: "I've always felt that if you have to get sick, especially a serious illness, a heart attack--from my experience the most common medical emergency--a cruise ship is actually a pretty good place to have it. You have doctors and nurses with equipment on the scene within a couple of minutes, which will beat most big city emergency medical services." While medical emergencies in the U.S. normally can be addressed with a 911 call, it's not the case overseas. Americans traveling abroad are advised to check out the State Department's Bureau of Consular Affairs Web site, travel.state.gov/medical.html. Being aware of all the medical options should you need them can take some of the serious worry out of your trip.

Appendix III – Ethical Challenges in International Surgical Education, for Visitors and Hosts

Objective

Contributing to medical practice in developing countries has become increasingly prevalent. Primary care and preventative health initiatives have been most visible, although attention has recently shifted to surgical disease, which represents a large burden in resource-poor settings. Typically dominated by individual efforts, there is now a more concerted approach, with surgical care being included in the comprehensive primary health care plan set by the World Health Organization. Although ethical dilemmas in international surgery have been discussed sporadically in the context of specific missions from the visiting surgeon/team perspective, we are missing a comprehensive evaluation of these issues in the literature. Here we have chosen to systematically categorize ethical issues confronted while teaching and operating in a developing country into 2 broad categories: venue (i.e., host) and visitor related.

Methods

For each category, topics within follow an ordinal sequence that one might use when designing a surgical education mission. Illustrative examples are provided, as well as a depiction of the ethical principles or theories involved.

Results and Conclusions

This article provides a discussion written from visiting and host surgeon perspectives on diverse ethical challenges for which there is limited literature, including location selection, unmet needs at home, role of sponsors, and personal gain. In addition to candid discussion and a solutions-focused approach, the reader is provided with an “ethical checklist” for international surgical education, akin to the World Health Organization surgical safety checklist, to serve as a framework for the design of surgical missions that avoid ethical pitfalls.

• Peer-Review Article

Key words: Education, Ethics, Surgery, World health

Abbreviations and Acronyms: DALY, Disability adjusted life year, WHO, World Health Organization

Introduction

Interest in making contributions to medical practice in developing countries or resource-poor settings has become increasingly prevalent. Perhaps most recognizable have been

the primary care and preventative health measures applied toward maternal and child health, vaccination strategies for infectious diseases, and targeting the HIV/AIDS pandemic. In recent years, more attention has shifted to include addressing surgical disease, which represents a significant burden in resource-poor counties. Although typically dominated by individual missions or groups, there is now a more concerted effort, with surgical care being included in the comprehensive primary health care plan set by the World Health Organization (WHO) (31). Although the WHO mandate is a significant step in mobilizing much-needed surgical initiatives, individuals, institutions, and health care teams now more than ever need to openly and comprehensively discuss the ethical issues surrounding international surgery.

Ethical dilemmas in international surgery have been discussed sporadically in the context of specific missions [e.g., Operation Smile (18), otolaryngologists in Ethiopia (12), neurosurgery in Indonesia (2)]. Here we have chosen to systematically categorize ethical issues confronted while teaching and operating in a developing country in 2 broad categories: venue (i.e., host)- and visitor-related (Table 1). Despite dichotomization in the tables and the text, many of the issues could easily fall into either category. For each issue, we follow an ordinal sequence that one might use when thinking through the design of a surgical education mission, beginning with an illustrative ethical challenge and where appropriate, include a depiction of the ethical principles or theories involved. Although the list of ethical challenges is not exhaustive and issues cannot be examined comprehensively, we aim to provide a discussion that can serve as a much-needed platform for additional dialogue. Finally, we leave the reader with a potential paradigm for consideration as an “ethical checklist” in international surgery (Table 2).

Table 1. Ethical Dilemmas in International Surgical Education Venue-Related Issues Visitor-Related Issues Surgery vs. Primary care Team selection Location The “white knight” Sustainability Unmet needs at home Misrepresentation Role of sponsors/who should pay Informed consent Expired equipment Unfair expectations Taxing of local resources Operating-room circus Situational sensitivity Misapplication of teachings Doing second best Determining end points Personal gain

Table 2. Ethical Checklist for International Surgery Before Mission

Has a needs assessment been done? (e.g., location, services, barriers, applicability) Has there been communication with the host country to discuss feasibility?

Should there be a site visit to determine individual/community/institutional commitment?

Has there been a comprehensive discussion regarding expectations, goals, and objectives?

Has an appropriate team been selected and prepared? Is there support for the mission from colleagues/institutions/family? Has sponsorship been declared by both parties?

During Mission Is there an ongoing needs assessment? Is there ongoing open communication about objectives and sustainability? Is there an open dialogue about case selection, consent, operation room

arrangements, etc.? Is there knowledge/skills translation? (e.g., direct involvement of host staff in

performing procedure) If we are leaving equipment behind, is there adequate technical support?

After Mission Is there ongoing communication? (e.g., patient outcomes, pathology, complications) Is there evidence of sustainability? Is everyone satisfied that the goals and objectives have been met? Is there a plan to return?

Although surgical education in developing countries is a wonderful practice, it is imperative that it is done as ethically as possible for obvious reasons. For this reason, we must aim to achieve the maximum “bang for the buck” in terms of ensuring that the human and fiscal resources expended are used in the best and most ethically appropriate way to produce the greatest result.

Venue-Related Issues

Surgery vs. Primary Care

Would resources spent on outreach surgery not be better spent on conditions with a heavier global health burden, such as HIV/AIDS or diarrheal disease?

This issue reflects the medical ethics of resource allocation in situations in which multiple needs exist. Resource allocation toward surgical diseases has lagged behind primary care for several years where efforts have focused on conditions with a significant global health burden. Highly visible targets have included malnutrition, diarrheal illness, and sanitation (32). Notably, these targets also require less infrastructure than that needed for surgical diseases such as operating room teams,

equipment, blood banking, surgical supplies, and postoperative care. How then do we justify money and time being spent on a low-impact field such as neurosurgery, for example, as compared with conditions affecting millions? In fact, given that basic sanitation is unavailable for a large part of the world, how then do we justify not putting our financial and other resources to water sanitation instead? Recent data are beginning to address this issue through studies evaluating the burden of surgical disease and cost according to years of healthy life lost when these go untreated. Surveys have shown that surgical disease is 1 of the top 15 causes of disability worldwide and accounts for 15% of disability adjusted life years (DALYs) across the globe 6, 16. Moreover, Tollefson et al. provided data on comparative costs of care per (DALY) averted in Sierra Leone with surgical intervention being $32.78US/DALY vs. $5 to $7US/DALY and $300 to $500US/DALY for vaccines and antiretroviral therapy, respectively (23). So although there will be costs attached to provision of surgical services, treatment of surgical disease is not only necessary, but also affordable, and therefore an attainable goal for resource-poor countries.

Location

A colleague in location “A” asks you to come and teach at their center. What about location “B, C, or D”, places that also would benefit from assistance?

This is an issue of resource allocation and fairness. What is the decision-making process underlying the selection of a host country that will receive direct benefit from a given surgical educational mission? Beyond a valuable medical exchange, these missions also typically provide donated resources, educational materials, and exposure to new skills that together can lead to regional inequity when distributed unfairly. How then do we determine where to allocate these human and fiscal resources? Although no specific data exist on selection method, anecdotal evidence suggests location of elective surgical missions has been facilitated by ease of access, such as safe travel, available infrastructure, a common language, and networking between organizations, mutual acquaintances, or friends. To approach the decision from the ethical principle of justice as fairness, it would seem reasonable to perform a needs assessment and have a transparently visible list of networks or institutions that are targeted over a specific timeline. Although sociopolitical contexts will undoubtedly influence annual decisions, a solution might be for visiting surgeons/donor institutions to keep a 10-year plan that enables selection to vary based on regional stability, influx of new resources, or increased need. In this way, people can feel ethically satisfied that all reasonable places will be considered. Importantly, we must all be globally accountable. Human and fiscal resources are valuable and finite and merit being shared as broadly as possible, avoiding duplication of efforts. Without a centralized repository of past and ongoing surgical missions, accountability has rested primarily with the hosts—including a duty to share incoming resources within their local networks and facilitate capacity building. Responsibility for ensuring fair resource allocation must be shared, however, between visitors and hosts alike. In this way, it is promising to see online access to surgical and obstetrical education initiatives (5) and records of surgical equipment donations or subsidized costs made available by the World Federation of Neurosurgical Societies

(29). Finally, this is clearly a shared process in which visiting teams must ensure that they only go where they are wanted and/or needed, and as such, the hosts have expressed a desire for engagement in surgical education.

Sustainability

A surgical technique has been taught in a resource-limited country, but there have been no surgeries independently performed in your absence. How do you ensure that your teaching mission will have long-term utility?

Sustainability has become a critical focus in global health development, and in international surgery specifically. A key issue that arises is the question of whether a new service, technique, and/or skill can be sustained after departure of the visiting team. Skill translation is only one aspect of sustainability; success also depends on addressing supplementary issues with new procedures such as technology-based needs (e.g., imaging or surgical drills), surgical supplies (e.g., surgical hardware), system capability, and institutional commitment. With respect to the latter, it is key that the host country/institution has a clinical environment embracing new procedures and skills from visiting colleagues. The ethical issue of nonmaleficence arises when we ignore a critical evaluation of our plan and instead, albeit unintentionally, embark on surgeries that leave patients incompletely treated and hosts incompletely trained, and ultimately produce a greater societal burden. Planning for sustainability, however, is possible and might include a feasibility assessment that determines how well a given technique can be implemented in resource-limited settings where electricity, supplies, and blood banks are unpredictable. The simplest procedures are likely the best—less invasive, less hardware, less operating and recovery time. Similarly, sustainability in surgical education might reflect a plan that includes skill enhancement in the domains of nursing, administration, and management practices to build broad-based capacity. Notably, Operation Smile has demonstrated that the effectiveness of surgical educational missions on creating local sustainability and capacity building based on a 20-year historical data review showing the number of patients treated by international surgical teams has decreased from 100% initially to the current 33% worldwide (15).

Misrepresentation

A patient is told you are the visiting surgeon who is an expert in aneurysm surgery, when in fact you have been a tumor specialist for the past 25 years.

This concept addresses “primum non nocere” or “first, do no harm” (nonmaleficence), and truth-telling. Misrepresentation similarly occurs in the situation in which visiting staff are asked to perform surgery on special patients who have been promised that the foreign surgeon will do the entire surgery, or when they are informed that critical equipment is unavailable, when in fact hosts may simply be uncomfortable/unfamiliar with its use (e.g., an operating microscope). Preventing these situations is key and can be facilitated when the visiting and host surgeons set the conditions of the teaching mission clearly in advance of arrival. This issue underscores the importance of

preparation in planning surgical education missions, including case selection. When possible, visiting surgeons and hosts should have a prearrival discussion regarding case selection to properly plan and to avoid misrepresentation, accidental or otherwise. In some situations, however, visiting teams arrive and may not have been part of case selection, or it has been altered due to logistical or financial constraints (e.g., geographic barrier, cost of procedure). In these cases, visiting staff must know their limitations, have an appreciation for the limits of the health care system faced by the hosts, and be prepared to negotiate case selection and execution in a culturally sensitive but ethically sound manner.

Informed Consent

You are the visiting staff surgeon planning to teach a new operative procedure, but do not speak the native language and are concerned that the patient does not understand.

This issue addresses the ethical principle of patient autonomy. The process of obtaining consent for surgical procedures is based on an informed decision process. Patients should be told the benefits and risks of performing a surgery as well as those associated with no intervention—all of this is based on expectations of what a reasonable person would want to know. This process is challenging enough at home, but what about when an itinerant surgeon is visiting a foreign health care system? What does he or she do when this may not be the standard in a developing country? Alternatively, we must consider whether language and cultural barriers such as medical paternalism or family hierarchies negatively affect the process of informed consent, or simply respect cultural norms. Clearly, one can envision a scenario in which a new procedure is being described to patients in a region where it has not yet been performed by their own surgeons. Resolving this situation requires protecting patient autonomy while empowering the host surgeons, as full engagement will be a key feature of any sustainable teaching effort. Open communication between host and visiting colleagues should facilitate discussions that outline everyone's expectations for the duration of the mission, including appropriately posed questions regarding cultural practices for obtaining informed consent.

Unfair Expectations

You are a brain surgeon teaching awake craniotomy, but your hosts ask for you to operate on a complex spinal tumor without a microscope, a procedure you would not perform at home.

Expectations can be unfair on both sides. This venue-related issue, however, refers to expectations placed upon the visitor performing in conditions less optimal that what he or she is used to (e.g., inadequate microscope, etc.) or performing surgeries for which he or she no longer feels qualified. Often, the visiting specialist is seen as an outright authority on a subject, as opposed to a colleague with whom clinical problems can be discussed in a shared manner. In this setting, we must balance the idea of doing good with the ethical principle of nonmaleficence. Some have suggested an argument can be

made for being satisfied that patients who would otherwise go untreated are at least given a chance, despite an increased risk of a suboptimal operation that would not occur at home. Until case series and adverse events data support this argument, surgical missions should at minimum work within the limits of the host country's ability, such as ensuring that the infection rate is no worse than what is routinely tolerated and the error rate is similar. A critical first step has recently been published in the British Medical Journal, outlining sources of adverse hospital events in 8 low- and middle-income countries in Africa and the Middle East (28). Importantly they note that approximately 75% of adverse events were related to therapeutic, diagnostic, and operative error, and suggest these could likely be ameliorated by implementing the top 3 suggested strategies of protocols, education, and communication. International surgical education can easily incorporate these strategies within missions if made a priority on both sides, for example, helping implement systems for improvement such as the WHO surgical checklist, site marking, and making a general concerted effort to improve patient safety.

“Operating Room Circus”

A throng of surgeons, students, nurses, and reporters swarm the operating room where a new procedure is being performed.

For those who have participated in surgical missions to developing countries, the term above likely brings memories of 20-person-plus crowds gathering in the operating room to observe and record the new technique. Frequently included are television crews with little to no sterile gowning, students holding cameras and phones above the operative field, and significant movement of traffic in and out of the operating room. Invariably, the visiting (and host) team finds itself concerned about sterility, patient confidentiality, and informed consent for the presence of unnecessary personnel. Although this would unlikely be tolerated back home, how often do visitors or hosts actually monitor the situation and request that numbers be limited? Clearly this scenario poses several added surgical risks that should be mitigated, such as infection, privacy, and medical error. In this situation, several ethical principles are being compromised, including nonmaleficence, beneficence, patient autonomy, and respect for persons. As such, it is our duty to address the “operating room circus” through prevention and a willingness to discuss concerns openly. Here again, the concept of setting expectations and fostering open communication while teams interact is a critical aspect of successfully addressing this significant issue.

Misapplication of Teachings

You have returned to a country where you taught a new procedure, but realize the host surgeons have applied it to cases you would not consider appropriate back home.

This issue addresses the ethical principle of nonmaleficence and surgical innovation. Bringing a new technique for implementation in a developing country means skills will be left behind for host surgeons to apply as they deem appropriate. In some cases, the visiting surgeon will never know the outcome of his or her mission. In others, the visiting

surgeon does know, and although there was no intent to create harm, patients in a resource-poor setting are now receiving potentially unsafe operations as a consequence of skills taught during a surgical teaching mission. What is the ethical duty for the visiting surgeon who was responsible for teaching a new skill in a developing country, when host staff are an autonomous group of capable and well-intended surgeons? This issue importantly highlights the argument for visitors and hosts to maintain regular contact and encourages an outcomes/evaluation system to enable patient tracking, surgical progress, and bidirectional feedback for host and visiting surgeons alike. Furthermore, a strategy that uses continuing medical education sessions may be key to reinforcing technical principles and patient selection, and to facilitating increased capacity building at a local level. Finally, we must be aware that surgical innovation can be discovered through improvisation in restrictive settings and therefore must consider whether a new or better alternative has been discovered (20). Ultimately, this scenario is a risk inherent to international surgical education that should be anticipated, and preparation should be used as an opportunity for host and visiting surgeons to critically appraise the literature regarding practice management and alternatives as part of a continuing medical education process.

Determining End Points

You have left country A after the fourth surgical mission and realize the local surgeons have mastered the skills set out with the original educational mission, but you have been asked to return nonetheless.

This issue refers to several ethical principles, including truth-telling and justice as fairness. Determining whether or not to signal completion of a project can be difficult, particularly when there are no concrete end-goals. In the case of international surgical education missions, additional goals will always exist, whether they are in the form of lectures, collaborative research projects, material goods, or ongoing skills development such as self-management and capacity building. Friendships and camaraderie will have likely formed, making it difficult to end ongoing missions. An end point may need to occur, however, in order to preserve justice in distributing scarce resources to other settings where needs exist. How should this be determined? In one scenario, hosts could indicate the mission is complete when it is time, which may be difficult as a result of financial or institutional pressure (regarding the influx of funds, resources, and distinction that typically accompany surgical missions). Alternatively, the visiting team may be compelled to end a working relationship when they feel educational saturation has been achieved or when the social or intellectual climate becomes unfavorable. Although the latter is uncommon, both can happen and are challenging ethical dilemmas requiring the visiting surgeon to weigh his or her own value system in the context of achievable goals, ensuring that sufficient attempts have been made to adapt or modify the mission to accommodate the host setting, and being truthful once a decision is reached. When it is time, a crucial element of global accountability is not only recognizing when to move on, but also the value of leaving a positive “legacy” amidst those who have been there before you and for those who will arrive long after you are gone (4).

Visitor-Related Issues

Team Selection

You are a surgeon going to a developing country to teach a procedure. Who do you need to take as part of the team and how do you select them?

This issue reflects the ethical dilemma of team selection for an educational surgical mission in a resource-limited country, and again relates to resource allocation. To date, very few groups have described the rationale for which types of health care professionals to include. For instance, is there an absolute need to take anesthetists, operating room nurses, and/or residents? Reports are emerging indicating the benefits of surgical education for residents in a resource-limited setting (13). In some cases, however, a more critical team member might be a logistician and biomedical engineer, particularly in regions where geographic access and equipment conditions are likely to be challenging. All of these can play a key role in driving sustainability and capacity. Additionally, we must acknowledge the duty to select a culturally sensitive team that can promote good cultural exchange with collateral benefits such as resident interaction and nurses training nurses. In this way, ongoing development can be made possible through lasting collaborations and knowledge translation that occurs both inside and outside the operating room. Finally, an added dilemma is the selection of individuals when many may express interest. Depending on the ethical framework, one may selectively choose people with field experience and good cultural rapport who are invaluable, but will fail to develop the next generation without proper inclusion of new recruits. Although team selection is inherently specific to the needs of a given mission, it is critical to acknowledge the existence of ethical dilemmas faced during this process and take steps to address them. Above all, team members must want to participate for appropriate (i.e., “the right”) reasons, be able to work well as part of a team, and be open to new interactions that may require adaptive behavior in unfamiliar settings (27).

The “White Knight”

The visiting surgeon goes to country X, does a few complex cases that the local surgeons do not feel comfortable performing independently, and then goes home.

An egregious example of unsustainable teaching is when the head of the team falls into the “white knight” syndrome. In this case, the surgeon performs a few difficult cases and then leaves. Herein the ethical principle of beneficence is being ignored when we fail to do what is best for the host medical system and staff—to facilitate sustainability through surgical teaching missions. Instead, the “white knight” syndrome reinforces paternalism through the idea that visiting staff can do anything. It is supported by the host request for more complex cases to be tackled in the presence of this “greatness”, a situation that can feed into the cycle of venue-related mispresentation and unfair expectations. The hosts ideally foster this process because of a genuine wish to learn, but it also can be driven by secondary gain such as institutional reputations and retention of patient-generated income. The visiting staff may then return home from such a mission enjoying a boost to the ego, without having effected knowledge translation, and/or reinforcing the

skills gap between the home and host situation. Avoiding these situations when on teaching missions will help promote sustainable new techniques and promote the development of more self-sufficient clinical environments in the developing country. Finally, avoiding this scenario ultimately provides all patients in the host country access to new techniques performed in the hands of a capable surgeon, regardless of country of origin.

Unmet Needs at Home

You have patients at home who must wait an additional month for surgery while you are teaching and operating on faraway patients.

This is the ethical principle of justice and the subject of resource allocation. Surgeons are a scarce resource, and there should be a just allocation of their time and expertise between patients at home and those in other regions. Unmet needs at home can refer to patients forced to wait for surgical consultation as well as those waiting for intervention. In Canada, the socioeconomic context is such that taxpayers have contributed heavily to the health care system, with the expectation that they are a priority. Although this is reasonable, physicians and surgeons have also sworn a Hippocratic oath that should not, in theory, have a geographic boundary. Is it possible then, to foster an ethical framework where health care access and provision are equal across the globe, when the reality is that funding schemes are disparate and unfairly established between continents? For some individuals, surgical teaching missions are vehicles to address inequity and a means to share the riches of a prospering developed world. Imperative to the work being undertaken is sufficient reflection to be aware of one's motivations and aspirations in the context of medical justice.

Role of Sponsors/Who Should Pay

A large land development company has donated a Chair to fund your surgical missions—do you have an obligation to go to countries where they have business interests?

This scenario relates to the ethical principles of truthfulness, transparency, and freedom. Funding for any surgical mission requires investment of financial capital, be it personal, public, or private. University engagement in global health is gaining momentum, with significant policy suggestions being put forth into sustaining these advances (17). How much should be allocated is currently being debated—a suggestion might be to apply the United Nations Millennium Development Goals funding target of 0.7% of the gross national product from high-income countries (24), where surgery department budgets similarly allocate 0.7% toward global health projects. Although funds have started to flow via institutional support such as twinning projects, corporate donations and sponsors are frequently relied upon. No scenario is without ethical concerns. Although twinning is a good way to establish centers of excellence with long-term sustainability, host funding may actually reflect revenue for the donor institution with corresponding unfair expectations for the visiting surgeon and/or local patients that must be addressed.

Alternatively, well-intentioned corporate philanthropic goals can be undermined by business policy when boards become involved in decision-making surrounding a surgical mission. Despite these issues, private sector donations are becoming a critical source of funding for many resource-limited social systems, particularly one such as health care that is under severe strain. We must therefore resolve the role of donations in this era of social responsibility in which companies, institutions, and wealthy individuals are looking to provide global health aid through critical evaluation and perhaps even public debate (21). Notably, we should be concerned with “who” the donor is, and whether they are an “ethical” choice. Examples of this concept would be corporate donations from tobacco or alcohol companies where some may consider it “blood money” [e.g., lung cancer studies (9) and cigarette companies (22)] or ongoing pharmaceutical sponsorship in regions where behavior has been questionable in the past (e.g., drug patent legislation or clinical trials). Although criticisms and potential conflicts of interest will persist, public debate must ultimately promote and support the growth of exceptional private and public sector efforts, from those who have demonstrated lasting and positive global health commitments over the past decade (e.g., Bill and Melinda Gates) to the newly explosive development of social innovation (e.g., mobile technology health tools) (14).

Expired Equipment

As a visiting surgeon, you want to bring expired hardware, outdated cautery, and an older microscope that would be unacceptable and/or questionable for use at home.

Surgical missions face questions similar to those posed regarding the ethics of expired medications—strongly discouraged by the United States Food and Drug Administration (25) and WHO (30)—highlighting the ethical principle of nonmaleficence, despite good intentions. Concerns over surgical supplies and equipment, however, need to be considered separately. Although hardware and equipment are marketed with expiration dates, it is critical to consider the basis on which these dates are selected. For example, are dates selected based on engineering principles and material degradation, and if so, are they updated according to new materials or revised for storage humidity/temperatures that differ between continents? In Canada, manufacturers are mandated to determine expiration based upon the component with the shortest projected useful life (10), although the literature is scant on how these component projections are made. Moreover, expiration dates may not be followed in host countries for a variety of complex sociopolitical reasons. As such, decisions regarding expired or outdated equipment might be better left to the host team. Although some expiration dates may be less significant than others, there is clearly an ethical dilemma when regulations set for patient safety are ignored—providing a rationale not only for understanding criteria used to determine expiry dates, but also highlighting the need to follow up outcomes in centers where this equipment is used. Similarly, ethical dilemmas arise when high-tech equipment is donated without the means to ensure that repairs are possible, contributing to the phenomenon of abandoned equipment. Encouragingly, progress is being made as institutions begin to formalize the process of surplus equipment donations, implementation, and education, with one notable example being

the Global Health Placement of Life-Changing Usable Surplus jointly administered by Duke University Health System and the Duke Global Health Institute (7).

Taxing of Local Resources

The visiting surgical team is taken to dinner, chauffeured about, has items purchased for them, and day-to-day needs taken care of by the host team, although the visiting team's self-sufficiency has been clearly communicated in advance.

These issues relate to the ethical principle of beneficence, whereby a self-sufficient visiting team should not displace valuable host resources. In many cases, host staff in developing countries are paying the above expenses out-of-pocket, and although perhaps unsolicited, they may feel obliged to deliver niceties that consume their time, human resources, and money. Given that many surgical teaching missions have received adequate funding to cover all costs, accepting gifts and excursions undermine the philanthropic intent of the donors. Although many visiting surgeons may in fact resist these gestures, there is a need to be sensitive to cultures in which rejecting such expressions of gratitude is extremely offensive—in many situations hosts are simply expressing thankfulness as they would to local guests, something considered an “ethical imperative” within their culture. Moreover, these acts of generosity may also be about honor given the imbalance of means, equipment, and experience between the visitors and hosts. As such, each scenario will have to be approached with respect and flexibility. Finally, until such time that international agreement exists on this topic, it is noteworthy that important cultural and academic exchanges occur during these times, and are a distinct form of capacity building that will foster future endeavors.

Situational Sensitivity

As the visiting surgeon you become impatient with the progress of implementing the newly taught technique.

This is the ethical principle of respect for persons. Regardless of where surgical teaching takes place, or with whom, mutual respect is critical. In the operating room in particular, visiting surgeons will provide more sustainable skills through positive feedback and patiently supporting host surgeons while they learn the technique. Situational insensitivities occur in scenarios where a visiting surgeon demands that his or her way must be followed without modification or question, or where they expect several additional surgeries like the ones taught to be performed the week after a visiting team's departure. Setting expectations is an appropriate element of surgical education, but must be discussed between the teams as part of a mutually respectful process. Situational insensitivities can also arise when the visiting surgeon believes they must correct all aspects of the host system, when in fact they are inadequately informed about the host cultural norms. A greater challenge for the visiting team, however, can be resisting the instinctual urge to offer to pay for urgent life saving imaging in resource-poor settings when faced with the dire reality of delivering health care in these environments. This is also a time for situational sensitivity, whereby we must accept the

limits of the system. For these examples, one can easily see where ethical issues arise when different cultures work together in an intimate but typically authoritative environment where host staff surgeons are rarely in a “trainee” role, or where a visiting surgeon must sit idly knowing that lives might be saved if they intervened. Situational sensitivity not only requires being aware of tone, manner, and body language, but also requires acceptance of the limitations of a system in which the visiting team finds themselves working and adaptation to cultural norms. On many profound levels, the visiting team has as much to learn from the hosts as the other way around.

Doing Second Best

As the visiting surgeon, you are asked to scrub in and remove a complicated lesion without a microscope, which would be considered below the standard of care back home.

This scenario involves the ethical principle of nonmaleficence. In some surgical environments, tools are poorly maintained or unavailable (19). In others, there is a need for technology-based tools such as operating microscopes, without which surgery carries an added risk that would not be acceptable in the developed world. Lack of consistent electrical power without a reliable generator also creates risk that would be intolerable back home, and yet the visiting surgeon may find him or herself working under these conditions. Additionally, visiting surgeons may find themselves involved with cases for which follow-up treatment such as radiation therapy is unavailable, making the role of surgery futile. In these scenarios, a visiting surgeon may have to reconcile the principle of nonmaleficence in a setting where no alternative treatment exists. Alternatively, the issue of doing second best can arise when the visiting surgeon operates on pathologies for which his or her experience is significantly lacking—a situation that would be inexcusable back home. Finally, an ethical dilemma arises when missions bring essential equipment such as laparoscopes or electrical brain stimulators to teach a procedure, only to then transport them back home because they are too costly to leave behind. Here, second best can be avoided by ensuring that sustainable solutions are part of the teaching mission.

Personal Gain

You go to developing countries as a visiting surgeon and you find that you enjoy the travel, meeting people, the “feel-good” atmosphere, and the ego-boost.

Finally, we must acknowledge the ethical dilemma of personal gain. Regardless of the educational mission, nothing is 100% altruistic. Each mission will likely contain travel, adventure, novelty, exceptional cases, and cultural exchange, which greatly benefit the visitor (3). However, we must acknowledge the primary drivers of the projects by asking whether we are serving the greatest need with full host engagement and likelihood of sustainability, or whether personal gains are driving location, team selection, and cases performed. Is there a small part that enjoys the “white knight” effect and/or escapism, and elevation of one's profile at one's home hospital or university? Here again, brutal

self-reflective honesty is required to heighten our ethical awareness. It is ethically acceptable for visiting surgeons to enjoy themselves, as long as that is not the prime driver for the missions. As current and future generations of surgical residents with interest in global health develop, training might include self-reflective practice and open discussion forums to promote self-awareness and ethical practice in these unique settings.

A Suggestion

The burden of surgical disease is worldwide, but is significantly undertreated in low-income countries where resources are scarce (26). According to basic ethical principles, to ignore the suffering of the individual is devaluing, thus we are morally obliged to act when possible to do so within reason (1). So how can we address some of the ethical dilemmas in international surgical education?

Perhaps an “ethical checklist” can be used as a paradigm for planning, executing, and providing ongoing support for international surgical education missions. Here we offer a format similar to the WHO surgical checklist with Before Mission/During Mission/After Mission categories in the hopes that it may at least provide a framework for approaching the design of an international surgical mission (Table 2).

While still in its infancy, the enthusiasm and support for international surgery and education is encouraging (8). Momentum is being harnessed by engagement of key players such as the WHO, corporate sponsors, academia, and health care providers worldwide. Presumably this is a reflection that people across the globe are aware of the need for health equity and are keen to find creative solutions. Capacity building is a positive collateral benefit of surgical missions whereby entire health delivery systems can be improved [e.g., neurosurgery in Uganda (11)]. Continuing to support fellowship-training programs for surgeons from resource-limited settings in high-income countries provides a means to develop creative and sustainable solutions as they interact with colleagues and medical systems different from their own. International surgical education will continue to evolve as people look to share experience with colleagues elsewhere. As such, there will continue to be new ethical dilemmas to be faced; therefore, learning to invest upfront in open and candid ethical discussions will undoubtedly be valuable in shaping the framework by which we advance international surgery in the context of universal health for all.

Acknowledgements

The authors thank the Greg Wilkins-Barrick Chair in International Surgery, University Health Network, Toronto, Canada, for its generous support.

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