Global surgery has as one of its foundations the interacting of diverse cultures and contexts with the goal of improving care for destitute sick and injured patients. Thus, it is inherent to the nature of the field that patients and providers will move across contextual settings, or at least encounter other individuals or systems previously foreign to themselves. How individuals respond to new experiences and stressors is critical to the outcome for both parties. Narrative inquiry, a qualitative research methodology developed in the early 20th century, recognizes that story telling is ubiquitous in the human experience. Utilizing the near universality of narrative, the methodology entails active interrogation and listening by the researcher of the participants. The structured analysis of the stories told can then bring insights into the complexity of relational experiences that make up people’s lives. Insofar as partnership-based collaborations start with building relationships, narrative inquiry holds promise as a field of research that could greatly improve the quality of work that global surgery produces in the future.

Partnerships, be they South-South or North-South, bilateral or multilateral, are a critical mechanism for the delivery of global surgical care, education and research. Understanding the partnerships themselves poses several challenges. There is a need to identify methods to report on and study the success and failure of these collaborations with the goal to create best practice guidelines for partnership implementation. In this domain, we may be best advised to take our cues from business and policy schools. At these higher education institutions, structured, facilitated discussions based on teaching cases of programs, projects, and leadership allow students and professors to analyze the complexity of organizations and their management. Case writers effectively act as investigative reporters, interviewing a broad range of actors relevant to the program narrative in question. Combining aspects of finance, economics, management, leadership, policy and politics, teaching cases are written from the perspective of a protagonist decision-maker. When the cases are taught in the classroom setting, students are engaged in active discussion, based on the data presented in the case (this may be budgetary information, process measures, or quotes from stakeholders), to identify lessons learned and principles elucidated in management and leadership. While this mode of inquiry is relatively new to surgery as a field, it lends itself well to the complex nature of the multi-institutional context of much of global surgery. As such, we expect that there will be increasing partnership with schools of business and management to expand the role of such teaching cases in our scholarship.

Chapter 3 of this textbook has laid out an ethical framework for clinical and scholarly collaborations in global surgery. Thus here we wish to express only a few important points that we believe deserve special emphasis.

First, a comment is warranted regarding the words in the title of this chapter – appropriate, applicable, and global. Webster’s Dictionary defines appropriate as “right or suited for some purpose or situation.” When asking ourselves if a research methodology, or a clinical intervention for that matter, is appropriate for a setting where there is poverty, we must first ask who gets to define what is right or suited for the situation. The term appropriate seems to have entered our global surgery lexicon from the global public health discourse of the 1990s with the term ‘appropriate technology’. Unfortunately, this term tends to tacitly imply ‘appropriate for poor people,’ but not for others. We would argue, from a perspective of global health equity, that the term appropriate should refer to the researchers in question – that we comport ourselves ethically in the pursuit of scientific inquiry. And we also argue that determining who defines right and suited is complex, but ultimately this must be based on the good of the poor patients and their caregivers in the setting of poverty.

The word applicable is another term that can be hijacked by conscious or unconscious paternalism. Investigators in global surgery, as in many other fields of global health, certainly face great challenges because the human resources and infrastructure for research are few and weak in settings of poverty. Thus, it must be understood that to perform rigorous research in these settings will necessarily require much greater effort and patience than in settings of developed research capacity. We thus prefer to describe certain methodologies as more challenging to implement rather than not applicable.

We believe that global surgery researchers are ethically obligated to strengthen the local clinical and research enterprises of the settings in which they work. In view of this obligation, a number of additional points should be kept in mind: