Ram Roth, Elizabeth A.M. Frost, Clifford Gevirtz and Carrie L.H. Atcheson (eds.)The Role of Anesthesiology in Global Health10.1007/978-3-319-09423-6_2

2. The Evolution of Surgical Humanitarian Missions

Ofer Merin¹

(1)

Shaare Zedek Medical Center, 3235, Jerusalem, 9103102, Israel

Ofer Merin

Email: merin@szmc.org.il

Keywords

Surgical missionsDisastersForeign medical teamsInternational aid agencies

Abbreviations

FMTs

Foreign medical teams

NGOs

Nongovernmental organizations

Introduction

International aid agencies have traditionally focused on infectious diseases in resource-limited settings. Global health initiatives, however, are now increasingly addressing surgical conditions as well. A growing awareness of the heavy burden of surgically treatable diseases and conditions has led to extensive involvement of both public and public resources in surgical international humanitarian missions, which perform and teach surgery in order to improve healthcare worldwide [1, 2]. These services can be in the form of a preplanned mission to an underserved region, or an acute response in the aftermath of a major disaster or humanitarian crisis. The latter is provided by medical and surgical units, collectively referred to as “foreign medical teams” (FMTs). A “global burden of surgical disease working group” was established in 2008, and it arrived at a strategy consensus of how to measure the burden of surgical conditions and the unmet needs for surgical care [3].

Every year thousands of physicians and nurses travel to developing countries, with stays ranging from days to years. The increased ease of world travel and transport and the heightened interest in international matters have led to greater numbers of healthcare providers involved in these humanitarian efforts. Humanitarian assistance can be in the form of a single individual, a group, part of a nongovernmental organization (NGO), a government agency, or under the auspices of a United Nations (UN) Organization, such as the World Health Organization (WHO).

This chapter will briefly describe the history of surgical missions, update the current situation and identify the main global players, and then focus on the main challenges and dilemmas faced by these missions. The benefits will be balanced against any potential harm resulting from their deployment. Some of those challenges will be described in greater detail than others. Just as little guidance exists on how to measure the benefits of outreach trips, even less is known about what harm they might cause or how to deal with that harm. This chapter will conclude with a vision for the future.

History

Before World War II (WWII), two institutions dominated international health development: The Pasteur Institutions (functioning mainly in the Far and Middle East and Africa) and the Rockefeller Institute (functioning mainly throughout Latin America). Their efforts were largely directed to the control or eradication of major infectious scourges, such as malaria, typhoid, plague, and other tropical and sanitation-based public health problems. Basch characterized international health after WWII as having evolved through four distinct stages [4]:

1945–1950: Period of general international stability with intergovernmental cooperation for reconstruction.

1950–1970: Development of various UN agencies largely around a medical model focused on eradication of diseases.

1970–1980: UN agencies’ development of a series of “agendas,” such as primary health care, community empowerment, and women’s issues.

1980–1990: The World Bank, the International Monetary Fund (IMF), and various NGOs focusing more on underlying health and societal system-level issues as obstacles to optimum health.

The publication of the Global Burden of Disease Report in 1996 [5] has increased the awareness of the impact of chronic diseases and injuries on the overall health burden, leading to recognition by international development agencies that more attention must be directed toward them. Remarkably little attention was drawn to surgical missions throughout this entire period.

The Present

Global health policy in the developing world traditionally emphasized primary prevention and categorical vertical programs aimed at communicable disease, maternal health, perinatal and child health, and nutritional deficiencies. Such categorical health initiatives have achieved considerable success in developing countries [6]. They emphasize healthcare delivery at the primary care level, and provide preventative measures, health promotion activities, and essential primary care services. Their premise is that “an ounce of prevention is worth a pound of cure.” It makes sense to focus on communicable and infectious diseases, since about 25 % of deaths in developing countries are secondary to those diseases compared to only 3–4 % in developed countries. It became evident over the last decade, however, that global epidemiologic and demographic shifts have been changing the burden of disease in all societies. Developing countries are now facing a dramatic increase in noncommunicable diseases, including injuries and chronic illnesses [7]. This change is gradually producing a parallel shift in the focus of healthcare provision in terms of individual patients vs. cohorts/populations. Today, surgeons and anesthesiologists are becoming involved in humanitarian efforts to a much greater extent than ever before.

Although there is an increasing awareness of the importance of unmet needs for surgical care worldwide, it is still estimated that up to one-half of the world’s population lacks access to basic surgical needs [8]. The burden of surgical care is potentially enormous. It was estimated that 2–3 billion people (approximately one-third to one-half of the world’s population) have no access to basic surgical care [9, 10]. Despite this clear imbalance around the world, surgery is still “the neglected stepchild of global health” as noted by Farmer and Kim [11]. There are probably many reasons for this, one of which is that international health was dominated for decades by those concerned with communicable diseases, from smallpox to AIDS. Another reason is that surgery is much more complex and more expensive to deliver than vaccinations [11].

The international projects that aimed to fill the gaps in surgical needs may be classified into three types: clinical, relief projects, and developmental projects.

Clinical: These are preplanned delegations that deal mainly with chronic conditions and diseases, often targeted to a specific disease. Humanitarian missions to underserved areas throughout the world aim to relieve specific surgical conditions. Examples include plastic surgical procedures [12, 13], pediatric cardiology surgery [13, 14], ophthalmology (mainly cataract surgery) [15, 16], pediatric neurosurgery [17], and combined specialties, such as otorhinolaryngologists and plastic surgeons who repair facial deformities [18], among others.

Relief: These include surgical teams that respond to needs that result from natural disasters or wars (see Chap. 11). They are “acute” missions, organized within a short time frame, and frequently deal with many uncertainties. Their aim is to alleviate a time-limited crisis. These include foreign medical teams (FMTs) that respond in the aftermath of sudden impact disasters, either to substitute or complement the local medical system. They have three distinct purposes [19]:

Early emergency care. This period lasts up to 48 h following the onset of an event.

Follow-up care for trauma cases, emergencies, and routine health care (from day 3 to day 15). During this phase, the local health services are progressively overwhelmed by the need for secondary or maintenance care for the trauma victims. The primary roles of the FMTs are to temporary fill the gaps in emergency medical assistance resulting either from a large number of casualties or the inability of the local health services to respond to the usual emergencies.

Act as a temporary facility to substitute for damaged local facilities during the rehabilitation phase until a permanent solution (reconstructive phase) is available. This phase usually starts from the second month and can last up to several years.

Developmental: These are organized for a long-term framework and their aim is to create or augment local capacity to address the burden of surgical disorders. There is an increasing understanding that short-term medical missions cannot substitute for a continuing investment in the local health infrastructure and staff training that will allow low- and middle-class countries to develop their own long-term surgical capacity [20]. Training programs, when carefully considered and implemented, can be mutually beneficial and provide a sustainable and lasting solution to the unmet health needs of the developing world. The outcome of such a training program should be reasonably self-sufficient local surgeons who are able to cope with most of the surgical problems in district hospitals in the developing world.

Major Players in Humanitarian Assistance

The total number of humanitarian aid workers around the world was 210,800, as calculated in 2008 by the Active Learning Network for Accountability and Performance in Humanitarian Actions (ALNAP), a network of agencies working in the humanitarian system [21]. The last decade has witnessed increasing involvement in the provision of humanitarian aid: it is estimated that the humanitarian fieldworker population has been increasing by approximately 6 % per year [21]. Those workers include medical students, residents, senior and retired surgeons who were involved in short-term missions and physicians/nurses who devoted longer periods (months/years) in order to treat the needy and train local health providers.

The involvement of medical students in this system has been increasing. For example, 22 % of US medical students had completed an international educational experience in 2004 [22], and 47 % of accredited MD-granting medical schools had established initiatives, centers, institutions, or offices of global health by 2008 [23]. All of the plastic surgery residents who participated in such missions reported that this experience had an important impact upon their life and career [13]. Two-thirds of responders to an American College of Surgeons (ACS) survey asked to be placed on a mailing list of surgeons interested in volunteerism [24]. Similar responses were received to a questionnaire of the American Association of Thoracic Surgeons [25].

The major participants in humanitarian assistance typically fit into one of the five following categories [26]:

United Nations (UN) organizations and other international organizations. Included are the UN High Commissioner for Refugees (UNHCR), the WHO, and the International Committee of the Red Cross (ICRC). These organizations typically provide the oversight, coordination, and funding for NGOs and program implementers.

Governmental organizations. Various industrialized countries maintain funding agencies dedicated to relief and development. Examples include the US agency for International Development and the relief and disaster branch, the United Kingdom’s Department for International Development, The European Commission Humanitarian Aid Office, the Canadian, Danish, and Australian Agencies for International Development, and many more. These governmental agencies set priorities for funding and provide financial support for implementing partners through grants and contracts.

NGOs and private voluntary organizations. The World Bank defines NGOs as being private, independent organizations that initiate activities to relieve suffering, promote the interests of the poor, provide basic social services, and/or undertake community development [27]. These organizations are the primary implementers of relief assistance. Today, there are over 40,000 actively engaged NGOs [28]. They can be large or small, local or international, religious or secular, and have a wide range of expertise. In some countries, like Haiti, NGOs account for over 70 % of the total healthcare delivery. The need for external governments not to be seen as directly intervening in another sovereign territory is one cause for the NGO’s expansion. Government-funded NGOs generally work from a position of neutrality and impartiality and are therefore regarded as being free of political influence. Their ability to gain easier cross-border access and attract less attention and scrutiny than governmental agencies has motivated major funding from governmental donors and spurred their global growth. This increased funding has promoted the growth of some well-known established international agencies, such as the Medecins Sans Frontiers (MSF: Doctors without Borders). The MSF received the 1999 Nobel Peace Prize in recognition of its members’ continuing efforts to provide medical care in acute crises, as well as raising international awareness of potential humanitarian disasters. Other large organizations include the International Rescue Committee, CARE International, Catholic Relief Services, and World Vision.

Private industry, consulting firms, and academic organizations. There has been a significant growth in the participation of for-profit organizations and consulting firms in humanitarian aid and post-disaster reconstruction. Similarly, greater numbers of academicians in the various fields of medicine, public health, human rights, epidemiology, and social services have been providing assistance. Universities, such as Johns Hopkins, Harvard, Tufts, Columbia, and others, have academic programs in various aspects of humanitarian aid. The American College of Surgeons (ACS) has also become involved in volunteer activities by establishing the volunteer initiative, Operation Giving Back (OGB) [29].

The military. Various military branches are involved in important humanitarian aid in the form of security, communications, and logistic operations, as well as the provision of medical assistance, food, shelter, and public health around the globe. The Office for the Communication of Humanitarian Affairs developed a set of guidelines for the use of military assets in non-conflict relief operations known as the “Oslo guidelines” [30].

Challenges

A foreign team is parachuting into a foreign environment. Medical care in underserved and under-resourced areas is provided in a difficult environment for a foreign medical team. Primary care is often not available in many of these areas, and therefore many medical conditions are underdiagnosed and undertreated. Surgeons on overseas missions will wrestle with challenges that are a far cry from their usual clinical practice, sometimes to the point of appearing surreal.

Surgeons on humanitarian missions are inarguably engaged in a noble cause, but good intentions alone cannot ensure success. The principle of non-malfeasance, often defined as the obligation to “do no harm,” must be rigidly upheld under all conditions. Many medical initiatives automatically focus on what and how to provide appropriate medical/surgical care. Equally imperative, however, is what not to offer. One has to be aware of the risk in conducting a mission that provides temporary, short-term solutions but fails to take in the entire picture.

It is impossible to establish clear-cut guidelines before embarking upon humanitarian missions in foreign countries, but it is important to take appropriate precautions when planning and executing such missions. The line between an exemplary voluntary humanitarian effort of altruistic health providers that has an important positive impact and a mission criticized and labeled as “neocolonialism,” “surgical safari,” “medical tourism,” and “short-term overseas work in poor countries by clinical people from rich countries” [31] is sometimes not clear enough. Not infrequently, and despite the best of intentions, mistakes are made in attempts to help others. Groups must be aware of and avoid, as much as possible, “the seven sins of humanitarian medicine” [32] and the potential pitfalls [33, 34].

The following Ten Commandments are proposed to describe some of the unique challenges in planning and executing surgical humanitarian missions. They are based on accounts in the literature as well as on personal insights after responding to disaster areas around the globe:

Careful selection of cases and of the most appropriate anesthesia. One important surgical challenge in these short-term missions is to perform the right procedure. It is a common temptation to perform complex surgery when indicated. However, once the short-term mission leaves, the local physicians will have to deal with any complications from surgeries which they themselves cannot perform, or do not have the knowledge or expertise to properly treat. It is sometimes better to do a simpler procedure within the abilities of a given local system. Better to leave with hope than with desperation. When choosing the proper procedure the best interest of the patient, the hospital, and the local physicians should clearly prevail. According to Welling et al., “One good rule is to offer the types of procedures that are minimally invasive, relieve immediate discomfort, and require little follow-up care, especially for missions that are short term” [32]. Complications may be inevitable, but when they affect an impoverished patient in a developing country who was treated by a volunteer physician, the situation can be politically as well as emotionally charged [35].

Choosing the most appropriate anesthetic technique is another challenge. It should be tailored to the kind of care, monitoring, and skills that will be available postoperatively. It is sometimes better to choose a different approach from what one might usually employ (our preference is to use regional/local anesthesia, instead of general anesthesia, if at all possible).

Follow-up. Short-term missions provide clinical/surgical care for patients who may never be seen again by the foreign team. Continuum of care which is a basic and essential part of surgical treatment is lacking. The local community sometimes criticizes this failure to provide follow-up care. One example was the accusation of Operation Smile volunteers by local surgeons of “dumping” their complications once their mission was over. The organization refuted this charge [35], but one should bear in mind that this can be a sensitive issue. When it is not possible to provide long-term follow-up care, it is recommended that chronic care medications and elective surgery be avoided.

Cultural competence. This item refers to the ability of healthcare providers to deliver effective services to racially, ethnically, and culturally diverse patient populations. A culturally competent physician is aware of different cultural beliefs or concepts of illness and health and has the skills to explore how and whether these beliefs are relevant to a specific individual [36]. There are several models available that emphasize the important concepts of cross-cultural communication process. One such example is the RESPECT model, developed by the Boston University Residency Training Program in Internal Medicine, Diversity Curriculum Taskforce [37]. The RESPECT model stands for: Respect, Explanatory model, Sociocultural context, Power, Empathy, Concerns and fears, Therapeutic alliance/trust. Personnel involved in such work should understand and respect the local culture and be aware of the local customs. How we dress, how we act, what we drink, and other behaviors will define us to our hosts. Miscommunication and misunderstanding may lead to potential harm. Therefore, one should establish an effective method of communication and become familiar with cultural norms before departure. Awareness of a given culture’s beliefs and practices is important because it fosters an environment of trust and mutual respect, which may translate to better compliance and greater effectiveness of medical treatment [38].

Informed consent. The principle of informed consent is aimed at the legality of health assistance and reflects the concept of autonomy and of decisional auto-determination of the patient. Operating even in a disaster scenario does not allow another individual to decide for a conscious and coherent patient. The same rules apply as they do within the United States. The World Medical Association (WMA) 1994 statement on medical ethics in the event of disasters states there may not be enough time for informed consent to be a realistic possibility in a disaster response situation [39]. This may also apply when responding to disasters in one’s own country, but we believe that a different approach should be taken when one arrives to a foreign country as a relief delegation. Our team, which has vast experience in response to natural disasters, is very strict about this issue. We never operate or perform an invasive procedure on a patient without his/her consent (or consent of a surrogate) after a clear explanation by a local interpreter. It should be borne in mind that cultural and religious differences may exist, and that relief workers are at risk of delivering culturally inappropriate services.

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