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Liu Y, Wang X, Fang J, Zhou W, Luo D. What are they considering when they face a fetus with birth defects? A qualitative study on ethical attitudes of health professionals in China. Glob Health Res Policy 2024; 9:27. [PMID: 39010156 PMCID: PMC11247724 DOI: 10.1186/s41256-024-00370-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 04/19/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Birth defects are the leading cause of mortality in newborn babies and children under five years old. In response, the Chinese government has implemented a three-tiered prevention strategy, which has brought ethical concerns about fetuses with birth defects. This study aims to explore the attitudes toward fetuses with birth defects among health professionals engaged in maternal and child health services. METHODS A qualitative study was conducted among 13 health professionals engaged in maternal and child health services in Hunan Province, China. The questions were designed to elicit the participants' work experience and attitudes toward fetuses with birth defects. The data were collected through in-depth semi-structured interviews, and NVivo 12 was used for data coding and analysis. A thematic analysis approach was employed following the SRQR checklist. RESULTS Five themes and 13 attributes were generated regarding health professionals' perspectives on fetuses with birth defects. The five themes included: (1) severity and curability of diseases (two attributes), (2) family relations (four attributes), (3) medical assessments (two attributes), (4) social situations (three attributes), (5) self-value orientations (three attributes). The findings showed that the majority of health professionals held the view that a fetus with a curable disease could be born, whereas a fetus with severe disability and teratogenesis should be terminated. Twelve out of the 13 health professionals believed that parents should be the decision-makers, while only one thought that the family should make a decision together. CONCLUSIONS Attitudes toward birth defects were influenced by various factors, indicating the complexity of real-world cases identified in this study. The findings highlight the dilemmas faced by both families and health professionals regarding birth defects. Adequate medical knowledge and support from society are crucial to inform decision-making among family members. Additionally, standardized norms and policies for birth defects are needed. Establishing an ethics committee for prenatal diagnosis is necessary to address current ethical issues in this field.
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Affiliation(s)
- Yanlin Liu
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, Hunan, China
- School of Health Sciences, College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland
| | - Xiaomin Wang
- Center for Clinical Pharmacology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
- Center of Medical Ethics, Central South University, Changsha, China
| | - Junqun Fang
- Hunan Provincial Hospital of Maternal and Child Health Care, Changsha, Hunan, China
| | - Wei Zhou
- Research Center for Public Health and Social Security, School of Public Administration, Hunan University, Changsha, China
| | - Dan Luo
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, Hunan, China.
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Chahine EM, Shah ND, Al Abyad OS, Vyas RM, Hamdan US. Emergency Response Protocols for Overseas Outreach Settings: Global Smile Foundation Strategy. Cleft Palate Craniofac J 2021; 59:1086-1091. [PMID: 34636659 DOI: 10.1177/10556656211049998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Non-governmental organizations (NGOs) aim to alleviate unmet global disease burden and promote collaboration between visiting and host countries. Well-executed emergency response protocols are foundational to providing safe and quality care in an unpredictable global setting. Global Smile Foundation (GSF) instituted a protocol in 2012 based on over three decades of cleft care experience. Here, we update this protocol and provide information on how to address special circumstances such as humanitarian crises and disease outbreaks. The GSF response protocol was developed in conjunction with surgeons, anesthesiologists, nurses, and administrators to ensure all team members are adequately prepared to respond to emergency situations in global outreach. This protocol provides information on pre-departure preparation, onsite setup, operative precautions, and post-departure debriefings. Emphasis is placed on a standardized, reproducible workflow that accounts for necessary site-specific adjustments. Strategies include emergency simulations, site-specific safety checklists, standardized operating room protocols, and well-defined individual responsibilities. The authors also provide anticipatory guidance in addressing unexpected circumstances, such as disease outbreak and natural disaster, during global outreach. In conclusion, a proactive and systematic approach to emergency response and prevention is vital to minimizing morbidity and mortality during surgical outreach initiatives. The GSF protocol represents a reproducible approach that other organizations can adopt and adapt to their unique needs.
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Affiliation(s)
| | - Nikhil D Shah
- 12244Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Raj M Vyas
- Department of Plastic Surgery, 8788University of California Irvine, Irvine, California, USA
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Jonkman LJ, Ndungu M, Connor SE, Sharma VB, Pattabiraman R, Zaver A, Castillo T, Meyer M. A qualitative assessment of diabetes care access and disease management in Central America. Res Social Adm Pharm 2020; 16:1542-1549. [PMID: 32958443 DOI: 10.1016/j.sapharm.2020.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/11/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Diabetes is a growing concern in low-and middle-income countries. Medical missions play a role in increasing access to care and medicines, but often ignore non-communicable disease prevention and advanced management. Increased knowledge of local community needs and resources can lead to the development and implementation of pharmacist-supported interventions to improve diabetes management in rural areas. OBJECTIVES The purpose of this study was to 1) understand the availability of monitoring for diabetes locally; and 2) describe knowledge and health beliefs regarding diabetes management for those with diabetes, and prevention among those at high risk of developing diabetes. METHODS This qualitative evaluation used semi-structured interviews with key informants in a community in rural Honduras. Participants included those with diabetes, those at-risk for developing diabetes, and community leaders. Data was analyzed using thematic content analysis through an iterative process of coding and theme development. RESULTS A total of 35 interviews were conducted with five resulting themes: 1) participants identified multiple barriers to diabetes management including access to monitoring, access to certain medications, and access to advanced levels of care; 2) participants acknowledge the relationship between lifestyle choices and diabetes control, but struggled with adherence to a healthy lifestyle; 3) participants identify that they have limited knowledge of diabetes pathophysiology, diabetes management, and strategies to prevent diabetes; 4) participants felt that opportunities existed within the community to support diabetes education and prevention, and 5) providers should integrate culture, societal norms, and religion in diabetes management. CONCLUSION This research identifies challenges and resulting opportunities for managing diabetes in rural Honduras. Health care providers including pharmacy personnel should consider strategies to engage communities around self-care and diabetes education. Further, strategies are needed to enhance access to resources and essential medicines for diabetes management. These themes can guide clinicians in supporting communities to enhance diabetes care.
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Affiliation(s)
- Lauren J Jonkman
- University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, USA.
| | - Martha Ndungu
- University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, USA.
| | - Sharon E Connor
- University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, USA
| | | | - Roshni Pattabiraman
- University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, USA
| | - Aarti Zaver
- University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, USA
| | - Tania Castillo
- Community Physician, Shoulder to Shoulder Pittsburgh, San José, San José del Negrito, Yoro, Honduras
| | - Mark Meyer
- University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Shadyside, 6023 Harvard Street, Pittsburgh, PA, 15206, USA
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Grant CL, Robinson T, Al Hinai A, Mack C, Guilfoyle R, Saleh A. Ethical considerations in global surgery: a scoping review. BMJ Glob Health 2020; 5:e002319. [PMID: 32399258 PMCID: PMC7204923 DOI: 10.1136/bmjgh-2020-002319] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/02/2020] [Accepted: 03/14/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction An unmet burden of surgical disease exists worldwide and is disproportionately shouldered by low-income and middle-income countries (LMICs). As the field of global surgery grows to meet this need, ethical considerations need to be addressed. Currently, there are no formal guidelines to help inform relevant stakeholders of the ethical challenges and considerations facing global surgical collaborations. The aim of this scoping review is to synthesise the existing literature on ethics in global surgery and identify gaps in the current knowledge. Methods A scoping review of relevant databases to identify the literature pertaining to ethics in global surgery was performed. Eligible articles addressed at least one ethical consideration in global surgery. A grounded theory approach to content analysis was used to identify themes in the included literature and guide the identification of gaps in existing literature. Results Four major ethical domains were identified in the literature: clinical care and delivery; education and exchange of trainees; research, monitoring and evaluation; and engagement in collaborations and partnerships. The majority of published literature related to issues of clinical care and delivery of the individual patient. Most of the published literature was published exclusively by authors in high-income countries (HICs) (80%), and the majority of articles were in the form of editorials or commentaries (69.1%). Only 12.7% of articles published were original research studies. Conclusion The literature on ethics in global surgery remains sparse, with most publications coming from HICs, and focusing on clinical care and short-term surgical missions. Given that LMICs are frequently the recipients of global surgical initiatives, the relative absence of literature from their perspective needs to be addressed. Furthermore, there is a need for more literature focusing on the ethics surrounding sustainable collaborations and partnerships.
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Affiliation(s)
| | - Tessa Robinson
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Alreem Al Hinai
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Cheryl Mack
- Department of Pediatrics, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
- Department of Anesthesiology and Pain Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Regan Guilfoyle
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Office of Global Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Abdullah Saleh
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Office of Global Surgery, University of Alberta, Edmonton, Alberta, Canada
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McDonald VS, Ignacio RC, Kuettel MA, Schlitzkus LL, Sullivan ME, Tadlock MD. Practical Bioethics for the Humanitarian Surgeon: The Development, Implementation and Assessment of an Ethics Curriculum for Residents Participating in Humanitarian Missions. JOURNAL OF SURGICAL EDUCATION 2020; 77:390-403. [PMID: 31889690 DOI: 10.1016/j.jsurg.2019.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/10/2019] [Accepted: 11/06/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Humanitarian surgeons face many ethical challenges. Despite increasing resident participation during humanitarian activities, minimal literature exists describing premission ethics training. METHODS A systematic literature review was conducted to identify publications on humanitarian surgery. A 3-tiered review was performed assessing for ethical conflicts and guidelines. A Humanitarian Ethics Curriculum (HEC) was developed based on these findings and administered to residents prior to a humanitarian mission. Postmission essays were assigned to describe an ethical dilemma they encountered. The HEC's value was evaluated by identifying the ACGME core competencies represented in the essays. RESULTS 49 eligible publications were identified. Several areas of consensus were found. Controversies identified included: trainee involvement, surgical innovation, and operating on patients with dismal prognosis. All residents stated that the HEC was vital. 61% of ethical dilemmas involved surgical patients. Core competencies emphasized included systems-based practice, patient care, professionalism, interpersonal/communication skills, and medical knowledge. CONCLUSIONS There is consensus regarding ethical principles that surgeons should follow during humanitarian activities. However, areas of controversy persist. Premission HEC should be administered to residents participating in humanitarian missions.
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Affiliation(s)
| | - Romeo C Ignacio
- Department of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, California; Department of Surgery, UCSD School of Medicine, San Diego, California
| | - Matthew A Kuettel
- Department of General Surgery, Naval Hospital Camp Pendleton, California
| | - Lisa L Schlitzkus
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Maura E Sullivan
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Matthew D Tadlock
- Department of General Surgery, Naval Medical Center San Diego, San Diego, California.
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Cheok S, Dong C, Lam WL, Gollogly J, Rajaratnam V. A model for surgical volunteerism: a qualitative study based in Cambodia. Trop Doct 2019; 50:53-57. [PMID: 31747858 DOI: 10.1177/0049475519884442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Medical volunteerism continues to attract many doctors from high-income nations to low- or middle-income countries (LMIC). In spite of the wealth of positive experiences of these volunteers documented in the literature, there is little evidence concerning the impact and effectiveness of their activity. We documented our model of five-year experience in the delivery of hand surgery in Cambodia, attempting a qualitative approach with attempts to understand the perceptions of local and volunteer surgeons. We conducted independent qualitative interviews with five visiting and 12 Cambodian surgeons who participated in our community-based and outcome-oriented hand surgery training programme between 2013 and 2015. Data were coded and analysed using a content analysis method and then individually grouped into categories; software was used to generate frequencies and quotations of codes. Our results highlighted factors contributing to the success of the medical volunteering programme, to its success, with suggestions for sustainability, motivation and commitment to such a programme. A clearly defined strategy by the volunteer group and a commitment to time and resources by both partners were found to be effective.
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Affiliation(s)
- Sabrina Cheok
- Medical Officer, Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
| | - Chaoyan Dong
- Senior Education Manager, Department of Medical Education Sengkang General Hospital, Singapore
| | - Wee Leon Lam
- Consultant, Department of Plastic Surgery, Royal Hospital for Sick Children,Edinburgh, UK
| | - Jim Gollogly
- Consultant, Kien Khleang National Rehabilitation Center, Phnom Penh, Cambodia
| | - Vaikunthan Rajaratnam
- Senior Consultant, Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
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Doobay-Persaud A, Evert J, DeCamp M, Evans CT, Jacobsen KH, Sheneman NE, Goldstein JL, Nelson BD. Extent, nature and consequences of performing outside scope of training in global health. Global Health 2019; 15:60. [PMID: 31675976 PMCID: PMC6823963 DOI: 10.1186/s12992-019-0506-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/11/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Globalization has made it possible for global health professionals and trainees to participate in short-term training and professional experiences in a variety of clinical- and non-clinical activities across borders. Consequently, greater numbers of healthcare professionals and trainees from high-income countries (HICs) are working or volunteering abroad and participating in short-term experiences in low- and middle-income countries (LMICs). How effective these activities are in advancing global health and in addressing the crisis of human resources for health remains controversial. What is known, however, is that during these short-term experiences in global health (STEGH), health professionals and those in training often face substantive ethical challenges. A common dilemma described is that of acting outside of one's scope of training. However, the frequency, nature, circumstances, and consequences of performing outside scope of training (POST) have not been well-explored or quantified. METHODS The authors conducted an online survey of HIC health professionals and trainees working or volunteering in LMICs about their experiences with POST, within the last 5 years. RESULTS A total of 223 survey responses were included in the final analysis. Half (49%) of respondents reported having been asked to perform outside their scope of training; of these, 61% reported POST. Trainees were nearly twice as likely as licensed professionals to report POST. Common reasons cited for POST were a mismatch of skills with host expectations, suboptimal supervision at host sites, inadequate preparation to decline POST, a perceived lack of alternative options and emergency situations. Many of the respondents who reported POST expressed moral distress that persisted over time. CONCLUSIONS Given that POST is ethically problematic and legally impermissible, the high rates of being asked, and deciding to do so, were notable. Based on these findings, the authors suggest that additional efforts are needed to reduce the incidence of POST during STEGH, including pre-departure training to navigate dilemmas concerning POST, clear communication regarding expectations, and greater attention to the moral distress experienced by those contending with POST.
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Affiliation(s)
- Ashti Doobay-Persaud
- Division of Hospital Medicine, Departments of Medicine and Medical Education, Feinberg School of Medicine, Northwestern University, 51 E Huron St, Chicago, IL, 60611, USA.
- Institute for Global Health, Feinberg School of Medicine, Northwestern University, 645 N Michigan Ave, Suite 1058, Chicago, IL, 60611, USA.
| | - Jessica Evert
- University of California San Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, USA
- Child Family Health International, 400 29th St, Suite 508, Oakland, CA, 94609, USA
| | - Matthew DeCamp
- Center for Bioethics and Humanities and Division of General Internal Medicine, University of Colorado, 13080 E. 19th Avenue, Aurora, Colorado, 80045-2571, USA
| | - Charlesnika T Evans
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 680 N Lake Shore Dr, Chicago, IL, 60611, USA
| | - Kathryn H Jacobsen
- Department of Global and Community Health, George Mason University, 4400 University Dr, Fairfax, VA, 22030, USA
| | - Natalie E Sheneman
- Institute for Global Health, Feinberg School of Medicine, Northwestern University, 645 N Michigan Ave, Suite 1058, Chicago, IL, 60611, USA
| | - Joshua L Goldstein
- Departments of Neurology, Pediatrics, and Medical Education, Feinberg School of Medicine, Northwestern University, 303 E Chicago Ave, Chicago, IL, 60611, USA
| | - Brett D Nelson
- Divisions of Global Health and Neonatology, Department of Pediatrics, Massachusetts General Hospital, 125 Nashua St, Boston, MA, 02114, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
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Stawicki SP, Nwomeh BC, Peck GL, Sifri ZC, Garg M, Sakran JV, Papadimos TJ, Anderson HL, Firstenberg MS, Gracias VH, Asensio JA. Training and accrediting international surgeons. Br J Surg 2019; 106:e27-e33. [DOI: 10.1002/bjs.11041] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/03/2018] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Formal international medical programmes (IMPs) represent an evolution away from traditional medical volunteerism, and are based on the foundation of bidirectional exchange of knowledge, experience and organizational expertise. The intent is to develop multidirectional collaborations and local capacity that is resilient in the face of limited resources. Training and accreditation of surgeons continues to be a challenge to IMPs, including the need for mutual recognition of competencies and professional certification.
Methods
MEDLINE, Embase and Google Scholar™ were searched using the following terms, alone and in combination: ‘credentialing’, ‘education’, ‘global surgery’, ‘international medicine’, ‘international surgery’ and ‘training’. Secondary references cited by original sources were also included. The authors, all members of the American College of Academic International Medicine group, agreed advice on training and accreditation of international surgeons.
Results and conclusion
The following are key elements of training and accrediting international surgeons: basic framework built upon a bidirectional approach; consideration of both high-income and low- and middle-income country perspectives; sourcing funding from current sources based on existing IMPs and networks of IMPs; emphasis on predetermined cultural competencies and a common set of core surgical skills; a decentralized global system for verification and mutual recognition of medical training and certification. The global medical system of the future will require the assurance of high standards for surgical education, training and accreditation.
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Affiliation(s)
- S P Stawicki
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - B C Nwomeh
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - G L Peck
- Department of Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Z C Sifri
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - M Garg
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - J V Sakran
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - T J Papadimos
- Department of Anesthesiology, College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio, USA
| | - H L Anderson
- Department of Surgery, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - M S Firstenberg
- Department of Cardiovascular and Thoracic Surgery, Medical Center of Aurora, Aurora, Colorado, USA
| | - V H Gracias
- Department of Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - J A Asensio
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Surgery, Creighton University Medical Center, Omaha, Nebraska, USA
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Abstract
BACKGROUND In countries with ample resources, no debate exists as to whether heart surgery should be provided. However, where funding is limited, what responsibility exists to care for children with congenital heart defects? If children have a "right" to surgical treatment, to whom is the "duty" to provide it assigned? These questions are subjected to ethical analysis. METHODS Examination is initially based on the four principles of medical ethics: autonomy, beneficence, non-maleficence, and justice. Consideration of beneficence and justice is expanded using a consequentialist approach. RESULTS Social structures, including governments, exist to foster the common good. Society, whether by means of government funding or otherwise, has the responsibility, according to the means available, to assure health care for all based on the principles of beneficence, non-maleficence, and justice. In wealthy countries, adequate resources exist to fund appropriate treatment; hence it should be provided to all based on distributive justice. In resource-limited countries, however, decisions regarding provision of care for expensive or complex health problems must be made with consideration for broader effects on the general public. Preliminary data from cost-effectiveness analysis indicate that many surgical interventions, including cardiac surgery, may be resource-efficient. Given that information, utilitarian ethical analysis supports dedication of resources to congenital heart surgery in many low-income countries. In the poorest countries, where access to drinking water and basic nutrition is problematic, it will often be more appropriate to focus on these issues first. CONCLUSION Ethical analysis supports dedication of resources to congenital heart surgery in all but the poorest countries.
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Arora G, Esmaili E, Pitt MB, Green A, Umphrey L, Butteris SM, St Clair NE, Batra M, O'Callahan C. Pediatricians and Global Health: Opportunities and Considerations for Meaningful Engagement. Pediatrics 2018; 142:peds.2017-2964. [PMID: 30054345 DOI: 10.1542/peds.2017-2964] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2018] [Indexed: 11/24/2022] Open
Abstract
Pediatric practitioners whose expertise is primarily focused on the care of children within health settings in the United States are increasingly engaged in global child health (GCH). The wide spectrum of this involvement may include incorporating short-term or longer-term GCH commitments in clinical care, teaching and training, mentoring, collaborative research, health policy, and advocacy into a pediatric career. We provide an overview of routes of engagement, identify resources, and describe important considerations for and challenges to better equipping US pediatric practitioners to participate in meaningful GCH experiences. This article is part of a series on GCH describing critical issues relevant to caring for children from an international perspective.
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Affiliation(s)
- Gitanjli Arora
- Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California;
| | - Emily Esmaili
- Department of Pediatrics, Lincoln Community Health Center, Durham, North Carolina.,Center for Health Policy and Inequalities Research and Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina
| | - Michael B Pitt
- Department of Pediatrics, University of Minnesota and University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | - Andrea Green
- Departments of Pediatrics and Pediatric Primary Care, University of Vermont Children's Hospital, Burlington, Vermont
| | - Lisa Umphrey
- Doctors Without Borders/Médecins Sans Frontiéres, Sydney, Australia
| | - Sabrina M Butteris
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nicole E St Clair
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Maneesh Batra
- Department of Pediatrics, University of Washington, Seattle, Washington; and
| | - Cliff O'Callahan
- Department of Pediatrics, Middlesex Hospital and University of Connecticut, Middletown, Connecticut
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Sceats LA, Morris AM, Narayan RR, Mezynski A, Woo RK, Yang GP. Lost in translation: Informed consent in the medical mission setting. Surgery 2018; 165:438-443. [PMID: 30061041 DOI: 10.1016/j.surg.2018.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/06/2018] [Accepted: 06/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Informed consent is a fundamental tenet of ethical care, but even under favorable conditions, patient comprehension of consent conversations may be limited. Little is known about providing informed consent in more uncertain situations such as medical missions. We sought to examine the informed consent process in the medical mission setting. METHODS We studied informed consent for adult patients undergoing inguinal herniorrhaphy during a medical mission to Guatemala using a convergent mixed-methods design. We audiotaped informed consents during preoperative visits and immediately conducted separate surveys to elicit comprehension of risks. Informed consent conversations and survey responses were translated and transcribed. We used descriptive statistics to examine informed consent content, including information provided by surgeon, the translation of information, and patient comprehension, and used thematic analysis to examine the consent process. RESULTS Thirteen adult patients (median age 53 years, 69% male) participated. Surgeons conveyed 4 standard risks in 10 out of 13 encounters (77%); all 4 risks were translated to patients in 10 out of 13 encounters (77%). No patient could recall all 4 risks. Qualitative themes regarding the informed consent process included limited physician language skills, verbal domination by physicians and interpreters, and mistranslation of risks. Patients relied on faith and prior or vicarious experiences to qualify surgical risks instead of consent conversations. Many patients restated surgical instructions when asked about risks. CONCLUSION Despite physicians' attempts to provide informed consent, medical mission patients did not comprehend surgical risks. Our data reveal a critical need to develop more effective methods for communicating surgical risks during medical missions.
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Affiliation(s)
- Lindsay A Sceats
- Stanford University School of Medicine, Department of Surgery, Stanford, CA
| | | | - Raja R Narayan
- Stanford University School of Medicine, Department of Surgery, Stanford, CA
| | - Ana Mezynski
- Stanford University, S-SPIRE Center, Palo Alto, CA; and
| | - Russell K Woo
- University of Hawaii, Department of Pediatric Surgery, Honolulu, HI
| | - George P Yang
- Stanford University School of Medicine, Department of Surgery, Stanford, CA;.
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12
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DeCamp M, Lehmann LS, Jaeel P, Horwitch C. Ethical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position Paper. Ann Intern Med 2018; 168:651-657. [PMID: 29582076 DOI: 10.7326/m17-3361] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This American College of Physicians position paper aims to inform ethical decision making surrounding participation in short-term global health clinical care experiences. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and should inform how institutions, organizations, and others structure short-term global health experiences. The primary goal of short-term global health clinical care experiences is to improve the health and well-being of the individuals and communities where they occur. In addition, potential benefits for participants in global health include increased awareness of global health issues, new medical knowledge, enhanced physical diagnosis skills when practicing in low-technology settings, improved language skills, enhanced cultural sensitivity, a greater capacity for clinical problem solving, and an improved sense of self-satisfaction or professional satisfaction. However, these activities involve several ethical challenges. Addressing these challenges is critical to protecting patient welfare in all geographic locales, promoting fair and equitable care globally, and maintaining trust in the profession. This paper describes 5 core positions that focus on ethics and the clinical care context and provides case scenarios to illustrate them.
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Affiliation(s)
| | - Lisa Soleymani Lehmann
- Veterans Health Administration, Washington, DC, and Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts (L.S.L.)
| | - Pooja Jaeel
- University of California, San Diego, La Jolla, California (P.J.)
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Oliphant JB. Short-Term Medical Missions Done Well: What Every Sponsoring Institution Should Understand. J Physician Assist Educ 2018; 29:58-61. [PMID: 29461457 DOI: 10.1097/jpa.0000000000000182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- John B Oliphant
- John Oliphant, PhD, PA-C, is an assistant professor in the Physician Assistant Program, College of Sciences and Technology, at Rochester Institute of Technology, Rochester, New York
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Meidl KA, Meidl JM, Meidl LR, Meidl EJ. Effects of Short–Term Medical Mission Trips to Chiapas, Mexico, on the Religiosity of the Missionaries. Linacre Q 2017; 84:115-129. [DOI: 10.1080/00243639.2016.1268800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
This study evaluates the effects that short-term, foreign, Catholic medical mission trips had on the religiosity of the United States-based participants. The subjects of this study participated in Catholic medical missions to Chiapas State, Mexico, in 2014 and 2015. Twenty-two of forty-two participants responded to a survey to assess for any changes in their religiosity and associated attitudes and behaviors. The results revealed that participation in the medical mission was associated with a significant increase in non-organizational religious activity, intrinsic religiosity, concern for health disparities and the burden of illness in the developing world, the promotion of further missions, the provision of service and/or monetary aid to the poor in the missionary's local community, and an increased likelihood to discuss the Christian faith in conversations with others. There was no statistically significant association with organizational religious activity or local participation in evangelization activities. Summary This article reports on the changes seen in the religious attitudes and charitable works performed following participation in a short-term medical mission. After serving on a mission trip to Mexico, we found that United States-based missionaries had an increase in their private religious activities, felt closer to God, were more likely to help the poor in their own neighborhoods, and were more likely to discuss their Christian faith than prior to the mission trip. We discuss possible reasons for these changes.
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Bauer I. More harm than good? The questionable ethics of medical volunteering and international student placements. TROPICAL DISEASES TRAVEL MEDICINE AND VACCINES 2017; 3:5. [PMID: 28883975 PMCID: PMC5531079 DOI: 10.1186/s40794-017-0048-y] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 02/24/2017] [Indexed: 03/14/2023]
Abstract
It has been argued that much of international medical volunteering is done for the wrong reasons, in that local people serve as a means to meet volunteers’ needs, or for the right reasons but ignorance and ill-preparedness harm the intended beneficiaries, often without volunteers’ grasp of the damage caused. The literature on ethical concerns in medical volunteering has grown tremendously over the last years highlighting the need for appropriate guidelines. These same concerns, however, and an appreciation of the reasons why current aid paradigms are flawed, can serve as indicators on how to change existing practices to ensure a better outcome for those who are in need of help. Such paradigm change envisages medical assistance in the spirit of solidarity, social justice, equality, and collegial collaboration.
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Affiliation(s)
- Irmgard Bauer
- Division of Tropical Health and Medicine, College of Healthcare Sciences, James Cook University, Townsville, Qld 4811 Australia
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Coors ME, Matthew TL, Matthew DB. Ethical precepts for medical volunteerism: including local voices and values to guide RHD surgery in Rwanda. JOURNAL OF MEDICAL ETHICS 2015; 41:814-819. [PMID: 26066361 DOI: 10.1136/medethics-2013-101694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 05/13/2015] [Indexed: 06/04/2023]
Abstract
At the invitation of the Rwandan Government, Team Heart, a team of American healthcare professionals, performs volunteer rheumatic heart disease (RHD) surgery in Rwanda every year, and confronts ethical concerns that call for cultural sensitivity. This article describes how five standard bioethical precepts are applied in practice in medical volunteerism related to RHD surgery in Rwanda. The content for the applied precepts stems from semiscripted, transcribed conversations with the authors, two Rwandan cardiologists, a Rwandan nurse and a Rwandan premedical student. The conversations revealed that the criteria for RHD surgical selection in Rwanda are analogous to the patient-selection process involving material scarcity in the USA. Rwandan notions of benefit and harm focus more attention on structural issues, such as shared benefit, national reputation and expansion of expertise, than traditional Western notions. Harm caused by inadequate patient follow-up remains a critical concern. Gender disparities regarding biological and social implications of surgical valve choices impact considerations of justice. Individual agency remains important, but not central to Rwandan concepts of justice, transparency and respect, particularly regarding women. The Rwandan understanding of standard bioethical precepts is substantively similar to the traditionally recognised interpretation with important contextual differences. The communal importance of improving the health of a small number of individuals may be underestimated in previous literature. Moreover, openness and the incorporation of Rwandan stakeholders in difficult ethical choices and long-term contributions to indigenous medical capacity appear to be valued by Rwandans. These descriptions of applied precepts are applicable to different medical missions in other emerging nations following a similar process of inclusion.
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Affiliation(s)
- Marilyn E Coors
- Department of Psychiatry and Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Thomas L Matthew
- Department of Surgery, Heart Center of the Rockies, Longmont, Colorado, USA
| | - Dayna B Matthew
- University of Colorado School of Law, Boulder, Colorado, USA
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Shrime MG, Sleemi A, Ravilla TD. Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training. World J Surg 2015; 39:10-20. [PMID: 24682278 PMCID: PMC4179995 DOI: 10.1007/s00268-014-2516-0] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE This study was designed to propose a classification scheme for platforms of surgical delivery in low- and middle-income countries (LMICs) and to review the literature documenting their effectiveness, cost-effectiveness, sustainability, and role in training. Approximately 28 % of the global burden of disease is surgical. In LMICs, much of this burden is borne by a rapidly growing international charitable sector, in fragmented platforms ranging from short-term trips to specialized hospitals. Systematic reviews of these platforms, across regions and across disease conditions, have not been performed. METHODS A systematic review of MEDLINE and EMBASE databases was performed from 1960 to 2013. Inclusion and exclusion criteria were defined a priori. Bibliographies of retrieved studies were searched by hand. Of the 8,854 publications retrieved, 104 were included. RESULTS Surgery by international charitable organizations is delivered under two, specialized hospitals and temporary platforms. Among the latter, short-term surgical missions were the most common and appeared beneficial when no other option was available. Compared to other platforms, however, worse results and a lack of cost-effectiveness curtailed their role. Self-contained temporary platforms that did not rely on local infrastructure showed promise, based on very few studies. Specialized hospitals provided effective treatment and appeared sustainable; cost-effectiveness evidence was limited. CONCLUSIONS Because the charitable sector delivers surgery in vastly divergent ways, systematic review of these platforms has been difficult. This paper provides a framework from which to study these platforms for surgery in LMICs. Given the available evidence, self-contained temporary platforms and specialized surgical centers appear to provide more effective and cost-effective care than short-term surgical mission trips, except when no other delivery platform exists.
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Affiliation(s)
- Mark G Shrime
- Harvard Interfaculty Initiative in Health Policy, 14 Story Street, 4th Floor, Cambridge, MA, 02138, USA,
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Abstract
Short-term medical service trips (MSTs) aim to address unmet health care needs of low- and middle-income countries. The lack of critically reviewed empirical evidence of activities and outcomes is a concern. Developing evidence-based recommendations for health care delivery requires systematic research review. I focused on MST publications with empirical results. Searches in May 2013 identified 67 studies published since 1993, only 6% of the published articles on the topic in the past 20 years. Nearly 80% reported on surgical trips. Although the MST field is growing, its medical literature lags behind, with nearly all of the scholarly publications lacking significant data collection. By incorporating data collection into service trips, groups can validate practices and provide information about areas needing improvement.
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Affiliation(s)
- Kevin J Sykes
- Kevin J. Sykes is with the Department of Health Policy and Management in the School of Medicine at the University of Kansas Medical Center, Kansas City
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Howe KL, Malomo AO, Bernstein MA. Ethical Challenges in International Surgical Education, for Visitors and Hosts. World Neurosurg 2013; 80:751-8. [DOI: 10.1016/j.wneu.2013.02.087] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 02/28/2013] [Indexed: 11/25/2022]
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Asgary R, Junck E. New trends of short-term humanitarian medical volunteerism: professional and ethical considerations. JOURNAL OF MEDICAL ETHICS 2013; 39:625-31. [PMID: 23236086 DOI: 10.1136/medethics-2011-100488] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Short-term humanitarian medical volunteerism has grown significantly among both clinicians and trainees over the past several years. Increasingly, both volunteers and their respective institutions have faced important challenges in regard to medical ethics and professional codes that should not be overlooked. We explore these potential concerns and their risk factors in three categories: ethical responsibilities in patient care, professional responsibility to communities and populations, and institutional responsibilities towards trainees. We discuss factors increasing the risk of harm to patients and communities, including inadequate preparation, the use of advanced technology and the translation of Western medicine, issues with clinical epidemiology and test utility, difficulties with the principles of justice and clinical justice, the lack of population-based medicine, sociopolitical effects of foreign aid, volunteer stress management, and need for sufficient trainee supervision. We review existing resources and offer suggestions for future skill-based training, organisational responsibilities, and ethical preparation.
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Affiliation(s)
- Ramin Asgary
- Department of Medicine, New York University School of Medicine, , New York, New York, USA
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DeCamp M, Rodriguez J, Hecht S, Barry M, Sugarman J. An ethics curriculum for short-term global health trainees. Global Health 2013; 9:5. [PMID: 23410089 PMCID: PMC3598721 DOI: 10.1186/1744-8603-9-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 02/05/2013] [Indexed: 11/10/2022] Open
Abstract
Background Interest in short-term global health training and service programs continues to grow, yet they can be associated with a variety of ethical issues for which trainees or others with limited global health experience may not be prepared to address. Therefore, there is a clear need for educational interventions concerning these ethical issues. Methods We developed and evaluated an introductory curriculum, “Ethical Challenges in Short-term Global Health Training.” The curriculum was developed through solicitation of actual ethical issues experienced by trainees and program leaders; content drafting; and external content review. It was then evaluated from November 1, 2011, through July 1, 2012, by analyzing web usage data and by conducting user surveys. The survey included basic demographic data; prior experience in global health and global health ethics; and assessment of cases within the curriculum. Results The ten case curriculum is freely available at http://ethicsandglobalhealth.org. An average of 238 unique visitors accessed the site each month (standard deviation, 19). Of users who had been abroad before for global health training or service, only 31% reported prior ethics training related to short-term work. Most users (62%) reported accessing the site via personal referral or their training program; however, a significant number (28%) reported finding the site via web search, and 8% discovered it via web links. Users represented different fields: medicine (46%), public health (15%), and nursing (11%) were most common. All cases in the curriculum were evaluated favorably. Conclusions The curriculum is meeting a critical need for an introduction to the ethical issues in short-term global health training. Future work will integrate this curriculum within more comprehensive curricula for global health and evaluate specific knowledge and behavioral effects, including at training sites abroad.
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Affiliation(s)
- Matthew DeCamp
- Johns Hopkins Berman Institute of Bioethics and Division of General Internal Medicine, 1809 Ashland Avenue, Baltimore, MD 21205, USA.
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Hunt MR, Schwartz L, Sinding C, Elit L. The Ethics of Engaged Presence: A Framework for Health Professionals in Humanitarian Assistance and Development Work. Dev World Bioeth 2012; 14:47-55. [DOI: 10.1111/dewb.12013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Effectiveness of international surgical program model to build local sustainability. PLASTIC SURGERY INTERNATIONAL 2012; 2012:185725. [PMID: 23150816 PMCID: PMC3485906 DOI: 10.1155/2012/185725] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 10/02/2012] [Indexed: 11/17/2022]
Abstract
Background. Humanitarian medical missions may be an effective way to temporarily overcome limitations and promote long-term solutions in the local health care system. Operation Smile, an international medical not-for-profit organization that provides surgery for patients with cleft lip and palate, not only provides surgery through short-term international missions but also focuses on developing local capacity. Methods. The history of Operation Smile was evaluated globally, and then on a local level in 3 countries: Colombia, Bolivia, and Ethiopia. Historical data was assessed by two-pronged success of (1) treating the surgical need presented by cleft patients and (2) advancing the local capacity to provide primary and ongoing care to patients. Results. The number of patients treated by Operation Smile has continually increased. Though it began by using only international teams to provide care, by 2012, this had shifted to 33% of patients being treated by international teams, while the other 67% received treatment from local models of care. The highest level of sustainability was achieved in Columbia, where two permanent centers have been established, followed by Bolivia and lastly Ethiopia. Conclusions. International missions have value because of the patients that receive surgery and the local sustainable models of care that they promote.
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Abstract
The purpose of this presentation is to describe an American plastic surgery resident's experience working for an academic year in a district-level general hospital in rural Kenya. The operative experience, educational value, and cultural adaptation over the custom-designed year are discussed. Furthermore, the logistics and ethics of picking a location, adjusting to the milieu, and treating patients are evaluated. The importance of a qualified, supportive, and perceptive mentor is emphasized. International volunteerism in plastic surgery beyond the more typical 1- or 2-week short-term trips can be extremely beneficial to a resident's experience, although long-term benefit to the served population should not be overestimated. A careful understanding of plastic surgery in relation to the global burden of disease highlights the fact that plastic surgery, although valuable, is limited in its role within international medical volunteerism. Not unexpectedly, obstetric, orthopedic, and general surgical skills are vital in the management of the most common surgical maladies.
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Langowski MK, Iltis AS. Global Health Needs and the Short-Term Medical Volunteer: Ethical Considerations. HEC Forum 2011; 23:71-8. [DOI: 10.1007/s10730-011-9158-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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