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3 How toMaintain Ethical Standards ofGlobal Surgery Practice andPartnerships
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33
easily be reversed in East Africa. Depend heavily
on those working in context to guide in navigating clinical challenges– never assume.
Teams should ensure that training opportunities
for residents in the host community are not
usurped by visiting surgical trainees. They should
be given priority in patient care and in the ORs.
Promote reciprocity. “What is good for the goose
is good for the gander.” Exchange programs
should not be one-sided, with HIC trainees
getting opportunities to operate freely in LMIC
contexts and LMIC trainees less likely to visit the
HIC, and when they do manage to secure funding
for travel and subsistence, are restricted to handsoff shadowing or observerships, almost always
due to legal licensing demands and malpractice
demands in some countries. While medical emigration is an individual choice inuenced by
stick, stay, push, and pull factors, it is unethical to
promote brain drain from human resource- limited
environments through global surgical exchanges.
This needs to be corrected by an appropriate
increase in salaries in LMICs as compared to
those for staff in HICs.
Ethical Considerations inTransBorder Global Surgery Research
Academic global surgery focuses on teaching
and research in LMIC contexts, as over 1000
articles are produced per year from global surgery partnerships, and there are numerous ethical
landmines to consider [26]. However, it should
be noted that research by internist teams, not surgeons, is more frequently funded. Testing of any
drugs, vaccines, and evaluation of treatments by
internists must be done jointly with the local physicians. Be sure to appropriately involve and adequately credit LMIC surgical researchers [27].
Ethical clearance is best obtained from both the
local and the international collaborating institutions. Never assume you do not need ethical
approval for any study. It is best to ask and receive
a waiver from the responsible committee, without payment and without articial delays, than to
proceed without regard to local standards. Where
such a committee does not exist, helping in the
building local capacity for this function is essential to maintain ethical standards. Excessive
emphasis on “generalizability” and “transferability” to the detriment of work that is benecial to
the local community should be avoided as
research should primarily benet them. In addition, any populations that can be exploited for
nancial, or academic gain must be identied and
protected. Informed consent must be true
informed consent – in a familiar language, and
with a dynamic that does not coerce the uneducated, poor, or ill with no alternatives for treatment or withhold permission to stop or drop out
of a study at any point without any consequences,
other than not receiving the experimental intervention or control drug.
Surgical outcomes including complications
must be evaluated and documented. Surgical
problems (post-operative complications left to
the hosts’ care, ill feelings by both hosts and visitors, and lack of trust by both sides) should not be
left behind [12]. Clearly, this may lead to no
repeat invitation and/or no wish to return.
Ethics ofInvolvement ofPartners
inResearch
Generally speaking, human resources for health
and research are constrained in LMIC contexts.
Many surgical staff are over extended and busy in
their practice, and may not have the time, and
perhaps expertise to facilitate research projects.
As much of the surgical research concerns evaluation of surgical needs or outcome studies, rather
than testing of new equipment, or novel operations, collaboration is mandatory to execute the
study properly. The ethical dilemma of wanting
to “get things done” rather than wait for local
engagement or to complete the work by the HIC
partners and getting a rubber stamp by the lowincome setting partners is real. Grants often have
deadlines, and reporting requirements that focus
on getting the work done, over developing capacity in partners. The ethical approach is to aim to
grow local partners’ capacity for research rather
than externally sourcing human resources for the
project.
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B. T. Alayande et al.
Ethics ofAuthorship
The question of authorship often arises in global
surgery engagements, and ethical pitfalls exist on
both sides of the road. On one side, there are
guest and gift authorship– adding in a known and
inuential name in a paper for the sake of publicity and sprinkling of local authors to tick the
boxes to avoid taking the ak on twitter. On the
other side, excluding local contributors because
we determine that they do not meet authorship
criteria because they only “collected the data”
and did not have the expertise to do the analysis
is not rare [21]. The expertise of LMIC global
surgery contributors is key to global surgery
research, and they need to be genuinely included.
Hedt-Gauthier etal raised the issue of authorship
order, showing that most LMIC contributors are
“Stuck in the middle,” with rst and last author
positions predominantly lled by HIC authors,
especially when HIC contributors are from top
US institutions [28]. In some cases, LMIC
authors and partners have been circumvented
because results are slow, or approvals are difcult. If studies are designed and carried out by
local surgeons, as in many outcome studies, the
local investigator must be rst or last author and
the visitors that he/she recruits for statistical
analysis or to help interpret the results, who meet
authorship criteria should be appropriately
placed. Authorship order should be clearly and
equitably decided after a transparent discussion
among the team members, not by the initiator or
funds holder of the study.
Institutional Review Boards (IRB)
andPermissions forResearch
Those that have been involved in IRB applications
in some more bureaucratic LMIC contexts understand that it is easy to follow the path of least
resistance. Some ethics committees sit once a
month and have 3–6-months turnovers of applications. It is tempting to circumvent the intellectual
and emotional stress of delays and depend on a
HIC ethical clearance from a home academic
institution to do work in such contexts. This temptation should be refused, as it underscores a colonial approach and is questionable. Advance
planning and strong local partnerships can help to
mitigate this. Due process integrates you into con-
text and legally covers you to carry out research in
these contexts. Extortion should not be permitted
on the part of local partners in the form of exorbitant differential IRB payments for visitors. Time
to review should also not be cost-dependent.
Data Management andPublishing
The question of where to publish global surgery
research is primarily practical in terms of probability of acceptance and satisfactory dissemination of the information, but it can also be an ethical
one. Data obtained from LMICs resulting in publications that should benet LMIC surgeons are
often published in foreign “high impact” journals
inaccessible to them. Publishing these articles
behind paywalls (driven by the often-exorbitant
price of open access publishing) is another
dilemma that can be considered unethical, as the
knowledge taken from a context is not accessible
to those from whom the knowledge is obtained.
HIC researchers should be committed – to the
best of their abilities– to open access publishing.
Some major journals now have open access preprints, or on-line publications prior to appearance
in the journal. This may help local physicians
have access through libraries or their institutions.
Photography, Publicity, andSocial
Media
Thought has gone into the ethics around
photography in global surgery (for clinical
education, education, publication, advertising,
and marketing) more recently. Treating global
surgery like medical tourism with patient seles,
and unsolicited pictures with patients in difcult
circumstances to be used to score narcissistic
points on Instagram or Twitter is considered
unethical, unacceptable, and may be illegal [6,
29]. This becomes even worse when patients are
identiable in the pictures. Informed consent
must be considered while visiting in low-resource
contexts, as it does in their own countries, and the
ethics of privacy, condentiality, image storage,
image distribution, and social media use must be
respected. Equitable use of medical photography
involves standardization of the photographic
method, and environment. The intended uses of
the photographs and the potential risks and benets should be made clear to the patients. Storage
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of these images, masked to avoid identication,
must be condential, and dissemination appropriate to maintain patient’s privacy. One ethical
challenge of posting these pictures on social
media is that consent cannot be withdrawn once
published [29]. When specimens, intra-operative
images, and ndings are photographed without
the potential of identifying patients, discussion
with the local team should be conducted in regard
to acceptability of using such images on social
media or for teaching.
Box 3.3 Practices in Global Surgery that
Reect Poor Collaborations
Undermining of local surgical providers and
surgical systems
Neglecting the local team in patient selection
Neglecting the local team in the planning phase
Neglecting patient follow-up in the planning
and execution
Diversion of local resources
Lack of local capacity development/knowledge
exchange
Inadequate prior notice for site visits
Sub-standard surgical approaches
Disruption and cancellation of local scheduled
procedures
“Savior mentality” and paternalistic
attitudes/“global health arrogance”
Prescriptive, one-sided partnerships with
inequitable exchanges
Lack of program integration
Partnerships and programs not focused on local
needs
Gift and guest authorship (naming authors on
articles who have not contributed to research)
Unhelpful equipment donations
Non-reciprocity
Data collection and research malpractice
Ethical Considerations inTransBorder Global Surgery Partnerships
andCollaborations
Capacity building should be at the core of
collaborations. Partners should discourage
perpetual dependence on nancial or external
material aid in the partnership and encourage
production of needed materials that meet
standards within the country perhaps utilizing
governmental subsidies. Box 3.3 shows practices
that reect poor and unethical collaborations.
Conclusions
Focus on ethics in global surgery must begin with a
willingness to acknowledge the power dynamics in
the eld of global health irrespective of its idealistic roots. HIC institutions and individuals generate
income through their national grants and enhance
proles through international work. On the other
hand, some HIC surgeons provide services for free,
covering their own living expenses and salaries.
One-sided partnerships sometimes occur, with
trainees from the global north beneting disproportionately from exchanges, even though local trainees benet from training opportunities by HIC
specialists. Organizations and individuals return
from a short-term mission trip with pictures to market themselves and their work on social media to
raise funds for more missions, generally not supported by local hospitals or health authorities.
Vertical missions (dumping cash into programs,
outreaches, and intervention events) with narcissistic African poster-child photographs and touching
social media posts may make many local patients
receive sometime unattainable operations and
make donors and visiting healthcare workers feel
good. However, this is not enough to grow a sustainable health system if thought is not given to
long-term surgical systems strengthening, and
local government or private funding is not available
or dedicated to growth of healthcare facilities and
their maintenance. The misuse of funds by local
governments, issues of corruption that dictate distribution of national budgets, with minimal funding
for health and surgery contribute to the ethical
dilemma. All this is in a setting of poor, vulnerable
patients, and surgical providers struggling with an
under resourced, inadequate health system, who
are not well positioned by history, ability, or power
to determine agenda or benet sustainably from
these arrangements [30]. These are signicant contributors to an ethical quagmire.
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B. T. Alayande et al.
The focus of this chapter has been largely on
ethics pertinent to HIC visitors in a cross-border
location. It must be emphasized that hosts also
have an obligation to high ethical standards.
Concerns about payment (to the point of “price
gouging”), and sudden changes in costs demanded
from visitors for services they provide for free to
the hospital is unethical. Partners must be careful
that bribery and corruption do not inuence donations in cash or kind, even when it is perceived as
the norm for doing business in the context. It must
be said that several countries experience pervasive
corruption at many levels, particularly with medical purchases, licenses, patient selection for special care or for rehabilitation, and stafng of
Box 3.4 Recommendations
• Operate within an established ethical
framework, and do not just “trust your gut.”
• Listen to and work closely with the host
global surgery community and be led by a
true contextual expert.
• Study, study, study– The people, the
practice, and the power dynamics. Never
impose your constructs on host
communities.
• Recognize and mitigate your intrinsic
biases. Do not nd others from your context
and talk about how “slow, resource
deprived, untimely, inefcient or corrupt”
hosting systems are in such a way as to put
down those working hard to effect system
change within such systems.
• Acknowledge your position and privilege in
the new setting and think deeply about how
you t in the foreign context. Appropriately
hand over, or share your privilege, and do
not abuse it.
• Remember: This is also an opportunity to
learn, create friendships, and long-lasting
professional partnership.
• Though the tensions will perpetually exist in
low resource settings, always err on the side
of maintaining high standards of practice
over “just doing something.”
hospitals. This should not be encouraged even if it
would cost the loss of future projects in the context. An insistence on integrity should be considered as part of overall surgical and healthcare
systems strengthening. Host organizations should
adhere to contractual obligations and keep their
word, as ethical obligations are bilateral.
Visiting surgeons must listen carefully to local
surgical providers. Maintaining an HIC pose and
gaze in an LMIC is an ethical disadvantage [25].
Visiting surgeons optimize their ethical advantage by keenly listening to, and understanding,
the perspectives of their local partners (Box 3.4).
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How toDevelop Bidirectional
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Partnerships
RondiM.Kaumann andCarlE.Haisch
With rare exceptions, all of your most important achievements on this planet will come
from working with others– or in a word, partnership.
– Paul Farmer
4
Abbreviations
COSECSA College of Surgery of Central, East
and Southern Africa
HICs High-Income Country
LMIC Low- and Middle-Income Country
PAACS Pan-African Academy of Christian
Surgeons
VUMC Vanderbilt University Medical
Center
WACS West African College of Surgeons
Introduction
The concept of “bidirectional partnership” to
describe global surgical efforts involving stakeholders from high-income countries (HICs) and
R. M. Kauffmann (*)
Division of Oncologic and Endocrine Surgery,
General Surgery Residency, Vanderbilt University
Medical Center, Nashville, TN, USA
e-mail: rondi.kauffmann@vumc.org
C. E. Haisch
Surgery, Division of Surgical Immunology and
Transplantation, Surgical Education and Faculty
Development, Brody School of Medicine, East
Carolina University, Greenville, NC, USA
e-mail: haisch@ecu.edu
low-middle income countries (LMICs) is a commonly used buzzword. Increasing interest in
addressing global health disparities among medical students, surgical trainees and surgical faculty, identication of surgery as a key component
of public health, and the inclusion of access to
safe surgical care in the World Bank’s Disease
Priorities has led to a steep growth in the eld of
academic global surgery [1–3]. Many
Departments of Surgery and surgical residency
programs have responded by creating opportunities for clinical rotations, surgical education initiatives, and research projects in an LMIC [4].
While not all such partnerships are formal, many
rely on the “twinning” of an academic institution
in a HIC and an institution in an LMIC.Inherent
power imbalances in these partnerships can lead
to unequal benets, with emphasis placed on
advancing the careers of faculty and trainees
from the HIC over those in the LMIC.The imbalanced, unilateral nature of many global surgical
initiatives is far-reaching and includes failure to
include LMIC authors on publications, funding
streams that prioritize HIC initiatives over the
stated needs of the LMIC population, unequal
access to clinical trials in LMICs, HIC trainees
providing care that is outside their scope of practice while in an LMIC, and HIC trainees rotating
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_4
39
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R. M. Kaumann and C. E. Haisch
at LMIC sites without reciprocal opportunities
for LMIC trainees to rotate at HIC sites [5, 6].
Responsible engagement in global surgical partnership requires intentional work to minimize
inequity between the partners and active effort
over time to ensure that both parties benet from
the collaborative relationship. In this chapter, we
present two successful frameworks for bidirectional partnership– one at the level of a surgical
accreditation program and the other at an individual institutional level. These are not intended
to represent the only possible frameworks for
bidirectional partnerships, but to serve as examples of successful programs.
The Pan-African Academy
ofChristian Surgeons Experience
Both Vanderbilt University Medical Center
(VUMC) and the Pan-African Academy of
Christian Surgeons (PAACS) have a presence at
AIC Kijabe Hospital outside of Nairobi, Kenya.
In this section, we examine the history and interactions of PAACS with Kijabe Hospital. It is the
policy of PAACS that an individual hospital must
approach PAACS to establish a relationship. This
can be initiated by an individual clinician or
administrator at the hospital on behalf of the
institution and begins a process of close communication between hospital personnel and the
administration of PAACS to establish a surgical
training program at that hospital. The presence of
a formal residency training program benets both
the hospital and its patients, increasing the number of patients served and elevating the hospital’s
prestige in the region. PAACS provides oversight, accreditation, and nancial support.
PAACS ensures that the hospital meets specied
clinical standards in the operating room (both
surgical and anesthetic), laboratory support, surgical beds, and nursing staff, as well as educational standard including conference rooms,
medical library, internet, and access to an adequate number of cases to train residents. Most
hospitals also provide housing for residents and
their families. A team from PAACS visits the
hospital prior to acceptance to review the hospital
facilities, speaks with the administration, and
assists with making necessary changes to meet
standards. The number of residents that can be
trained at that location is determined and PAACS
partners with the hospital to provide funding for
resident salaries. This is a particularly important
component of attracting high-quality residents to
train at PAACS hospitals, as many training programs in the region do not provide salary support
for trainees. A memorandum of understanding
between PAACS and the hospital is signed and
reviewed regularly.
PAACS is a faith-based non-governmental
organization founded in 1996 by a group of missionary surgeons who desired to train African
nationals who would remain in Africa to address
the immense burden of surgical needs on the continent. It is nanced entirely by philanthropic
gifts. The administration and support staff in the
United States (U.S.) are paid and PAACS pays a
large percentage of the resident salaries while
they are in training. The faculty and program
directors are paid by their own mission organization and the hospitals are frequently administered
by a third organization. This structure calls for
open and careful communication among all parties involved [7].
The goal of PAACS is to train African nationals in mostly rural mission hospitals that are
equipped with at least three surgeons that are
board-certied by a recognized national or international organization who act as faculty and program directors. The curriculum is designed to
provide graded responsibility in which the residents train in the full breadth of general surgery
and the surgical sub-specialties with the aim of
equipping them to work in either a rural or metropolitan area within Africa. The curriculum is ve
years and covers general surgery, orthopedics,
urology, obstetrics/gynecology, neurosurgery,
and pediatric surgery. Prior to the COVID pandemic, up to 200 board-certied surgeons per
year volunteered their time and visited PAACS
sites to help train residents. Most of these surgeons were from the U.S. and represented a variety of surgical sub-specialties to increase the
breadth of expertise to which the PAACS residents were exposed. With the COVID pandemic
4 How toDevelop Bidirectional Partnerships
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41
and political unrest in some of the countries, this
number has decreased markedly.
Early in the development of PAACs, the leadership recognized the importance of an afliation
with a U.S.-based university to give PAACS academic credibility in the eyes of African
governments and African surgical societies. A
number of universities were considered, and
Loma Linda University agreed to evaluate hospitals and their training programs on a regular
basis. Upon satisfactory completion of the veyear program, a resident receives a certicate
from Loma Linda University in addition to the
PAACS certicate. Loma Linda University has
continued in this role and reviews programs every
ve years with an in-person visit. The team is
comprised of surgeons who have educational
expertise and experience in evaluating surgical
training programs. Based on the ndings, the
visitation team makes recommendations to
strengthen and improve each program. The recommendations are sent to both the central administration of PAACS and the hospital
administrator.
PAACS also has a relationship with the West
African College of Surgeons (WACS) and the
College of Surgery of Central, East and Southern
Africa (COSECSA). COSECSA has granted certication to most of the PAACS training sites
with WACS certifying a few. If a resident has
trained in the appropriately certied training site,
they may seek fellowship in the respective organization. Most of the residents have been certied
by COSECSA, rst at the Membership level and
then three years later at the Fellowship level.
PAACS has trained over 130 residents since its
founding, and all have stayed in Africa and are
working in over thirty African Countries. Thirteen
percent of the teaching faculty are African nationals who have been trained by PAACS.
In 2006, AIC Kijabe Hospital opened a pediatric unit called Bethany Kids. A Canadian boardcertied pediatric surgeon developed a pediatric
surgery rotation for general surgery residents
which could be from two to twelve months in
length. Most of the residents needed some exposure to pediatric surgery and this was deemed to
be the optimal place for this to be carried out. The
residents were exposed to the operative, perioperative, and outpatient management of children
with neurosurgical conditions such as spina
bida, hydrocephalus, anorectal anomalies,
Hirschsprung’s disease, hypospadias, plastic surgery, cleft lip and cleft palate, skin grafting, and
burn contractures. Subsequently, in 2007, Kijabe
started a formal two-year pediatric surgery fellowship, offered after the completion of a veyear general surgery residency training program.
This fellowship has continued to the present and
has trained twelve pediatric surgeons who are
practicing in eight African countries. These surgeons are practicing in rural settings, government
agencies, and urban centers.
In 2007, Kijabe hospital was also approved to
train PAACS residents. This approval was granted
by PAACS after the hospital requested to be a
training center for general surgery residents. The
hospital agreed with the Memorandum of
Understanding and easily met the criteria for
PAACS approval. Over the years PAACS has
learned that the minimum number of faculty in
general surgery needs to be three. Faculty members rotate out for furlough, vacation, illness, and
meeting attendance. Three full-time faculty
members are needed to fulll the training needs
of the residents. Programs not meeting this
requirement are placed on probation, with rereview six months later. Subsequent to PAACS
approval, COSECSA approved Kijabe Hospital
for training at the MCS level and then approval at
the FCS level, making it a fully accredited surgical training program. Since that time, Kijabe
Hospital has trained a number of general surgery
residents and has expanded to train pediatric surgeons and orthopedic surgeons. The program has
also started an anesthesia residency program to
train anesthesiologists.
The Vanderbilt-Kijabe, Kenya
Experience
In 2011, VUMC’s Department of Surgery established a formal partnership with AIC Kijabe
Hospital in Kijabe, Kenya. PAACS had established a general surgery residency training pro-
42
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R. M. Kaumann and C. E. Haisch
gram at Kijabe in 2007 and VUMC already had
an anesthesia faculty member living in Kijabe
who hosted anesthesia residents yearly. A surgical faculty member from VUMC with 15years of
experience living in West Africa began discussions with VUMC and Kijabe leadership regarding the possibility of establishing a formal global
surgery partnership between the two institutions.
Discussions began with leadership from VUMC
traveling to Kenya to meet with leaders of Kijabe
Hospital. The primary goals of those meetings
were to conduct a “needs assessment” to dene
priorities of the partnership as stated by Kijabe
leadership, set “ground rules” to ensure that the
presence of VUMC surgical residents would not
jeopardize the education and experience of
Kijabe’s surgical residents, specify expectations
of each party’s responsibilities in the partnership,
identify strategies to ensure benet to Kijabe’s
residents and faculty, and create the framework
for a longitudinal collaboration including anticipated deliverables and joint ownership of the
partnership [8].
The initial priority identied by leadership at
Kijabe was capacity-building through surgical
education initiatives. Because Kijabe already had
their own surgical residency training program,
VUMC residents were asked to be willing to
assume any role on the surgical team that was
needed at the time of the rotation in Kijabe.
During times when Kijabe’s residents were rotating elsewhere on the continent, on vacation, or
out of town for exams, VUMC residents would
be the senior resident on the service. When
Kijabe’s resident complement was complete,
VUMC residents would act in a junior resident
role and double-scrub cases. Not taking cases
from Kijabe’s residents was emphasized repeatedly during pre-travel orientation for VUMC
residents. In addition, grant and philanthropic
funding was secured to establish a center for surgical and anesthesia simulation training in
Kijabe. Finally, VUMC granted adjunct professor
status to faculty in Kijabe who were actively
involved in resident education in order to facilitate access to key resources such as the VUMC
digital biomedical library, Redcap, and statistical
support.
As the partnership has matured, re-assessment
of the needs of each partner has been conducted at
regular intervals, both formally and informally.
When a faculty member from Kijabe approached a
faculty member from VUMC about creating an
open-access digital surgical atlas for resourceconstrained settings, the two collaborated on the
project and VUMC hosted the atlas on their web
server [9]. After a VUMC resident returned from
Kijabe and mentioned that the senior residents in
Kijabe had expressed an interest in mock oral
board practice, the weekly joint Kijabe-Vanderbilt
mock oral board training sessions with VUMC
faculty and PGY 4 and PGY 5 residents from both
institutions via zoom was started. Upon notication that PAACS began requiring completion of a
research project by all residents prior to graduation, faculty members from both institutions partnered to create and direct the Kijabe- Vanderbilt
Research Methodology for Healthcare Providers
Course held weekly every spring via virtual conferencing. All projects (abstracts posters, manuscripts) from that course have their principal
investigator (PI) and rst/senior authors from
Kijabe, with any VUMC faculty and residents
listed in secondary authorship positions. As
Kijabe’s need for capacity building in surgical
research has increased, the focus of the partnership
has turned to expanding collaboration in that
aspect of global surgical care. Keeping in mind the
importance of ensuring equality in benet for both
partners, subsequent applications for grant funding have included a PI from both institutions,
funding for both institutions, and emphasis on the
research priorities identied by researchers in
Kijabe (Table 4.1).
4 How toDevelop Bidirectional Partnerships
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Table 4.1 Summary of key components of bidirectional partnership and how programs discussed in this article
addressed them
Prioritizing local
needs Clarity of roles Resources Capacity building Sustaining relationships
PAACS Hospital
approaches
PAACS to start
relationship
VanderbiltKijabe
Face-to-face needs
assessment prior to
creation of
memorandum of
understanding,
frequent
re-evaluation of
needs of trainees
and faculty in
Kijabe, VUMC
grants adjuvant
faculty status to
faculty in Kijabe,
publications all
with joint
authorship
PAACS provides
oversight,
authority to
enforce
standards,
accreditation.
Hospital
responsible for
adhering to
standards and
adjusting as
needed
VUMC to
prepare residents
prior to rotation
in Kijabe. Kijabe
to provide
housing and
assistance with
obtaining
temporary
licensure.
VUMC residents
to ensure that
they are not
taking cases
from Kijabe’s
residents.
Hospital
funds part of
resident
salaries,
provides
housing for
faculty and
residents.
PAACS
funds
remainder of
resident
salaries
VUMC to
fund all
expenses for
their
residents.
VUMC to
provide
access to
online
biomedical
resources for
adjunct
faculty in
Kijabe.
Accreditation of
surgical training
programs with
goal of retaining
surgeons within
Africa
Joint educational
programs, mock
oral programs,
research training
programs.
Advocacy to
create new
licensure
category in
Tennessee to
allow residents
from Kijabe to
rotate at VUMC.
Formal relationship
between PAACS,
WACS,
COSECSA.Loma
Linda to provide
in-person evaluation of
training programs and
conferring of
certicates to residency
graduates. Frequent
in-person visits by
PAACS personnel,
PAACS volunteer
surgeons assist with
training of PAACS
residents
Regular involvement
by VUMC faculty in
Kijabe’s research and
educational initiatives.
Frequent check-ins
regarding additional
areas of partnership to
ensure needs of both
parties are met.
In-person visits by
VUMC faculty.
43
Barriers toBidirectional
Partnership andaCall toAction
Focused efforts to address needs of the LMIC
partner, mentor LMIC faculty and trainees, and
ensure equity in benet for both partners
engaged in a global surgery collaboration minimizes the risk that global surgery programs
between HICs and LMICs are just the “bold
new face of neocolonialism” [10]. However, the
inequity of sending HIC trainees to LMICs
without reciprocity of LMIC trainees coming to
HICs should not be ignored [11]. Licensing
restrictions in the U.S. limit trainees from
abroad to observerships only in most cases. This
reality severely hampers efforts at true bidirectionality and must be addressed if global surgery is to move toward equity of benet for both
partners. Furthermore, these “equitable
exchanges in global health education” are vital
to “support international goals for health,
improve the long-term stability of global health
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