The World Health Organization (WHO) has dened health to be “a state of com­plete physical, mental, and social well-being, and not merely the absence of disease or inrmity” since the advent of the organization in 1948 [1]. This denition pushed health beyond the binary of solely sick versus well and enshrined the idea that health is a state which can be promoted. This opened the door for global health advocates to work to improve the health of people around the world and across dened country borders.

Despite global health being a large eld that encompasses many domains, sur­gery has not always been considered a primary element [3]. As the eld has tradi­tionally been dened by specic populations (i.e., mothers, children, etc.) and diagnoses (i.e., HIV), surgery is a hard entity to fund, as it intersects all patient populations and includes a variety of disease pathologies. There has been a more recent push to dene global surgery and include it within the umbrella of global health [4]. This includes supporters of the addition such as Jim Kim, the 12th President of the World Bank, who has stated that “surgery is an indivisible, indis­pensable part of health care and of progress toward universal health coverage” [5]. The addition of surgery within the eld is especially important since common surgical procedures are cost-effective and comparable to other widely accepted global health interventions (i.e., antiretroviral therapy) when performed in LMICs [6].

There is a large burden of surgical disease worldwide and a disproportionate allocation of resources currently. Three-fourths of all surgeries take place in the wealthiest third of the world [7]. As a result, there are two billion people who do not have access to surgical care [8]. This is all due to differing levels of resource avail­ability and capacity. For example, HICs have 10 times as many operating rooms [8] and 11 times as many trained surgeons [9] per person as LMICs.

Conversely, the burden of disability-adjusted life-years from surgical conditions is concentrated within LMICs [10]. Approximately 94% of complex congenital anomalies that require surgical intervention occur in LMICs [11]. When specically examining genitourinary conditions, they are incredibly common [12]. They are ve to ten times more likely than cleft lip and/or palate and are the third most common non-chromosomal anomaly behind congenital heart and limb defects. While rare compared to other genitourinary anomalies, bladder exstrophy epispadias complex (BE) occurs in 1in 50,000 live births [13]. As such, it can account for a signicant number of cases, especially in places with higher birthrates. It is a common trend within LMICs to have higher birth rates than HICs, and this can contribute to an increased burden of disease [14]. Global surgery endeavors to treat conditions like BE and should not be viewed as too costly [6] or complex because the burden of disease within these countries is signicant. Outside of cost, from a moral stand­point, there is an obligation that exists to provide the highest level of care possible for these children and their families.

care to monitor their long-term outcomes, including continence, renal function, fer­tility, and sexual function. All of this is complicated in the LMIC setting, where access to care and medical specialties is limited.

2. Resources: Programs should not hinder existing infrastructure, and obtained

4. Capacity building: Training should be applicable to the LMIC setting in which

Successful global surgery collaborations employ the above strategies and put an emphasis on capacity building. An example of a robust global surgery collabora­tion, irrespective of disease of interest, is the International Bladder Exstrophy Consortium (IBEC) based in Ahmedabad, Gujarat, India. The program began in 2009 when surgeons from two academic research centers in the United States joined with the Department of Pediatric Surgery at the Civil Hospital and BJ Medical College in Ahmedabad, Gujarat, India, to form a multi-institutional col­laboration. Since then, the partnership has grown to include the Children’s Hospital of Philadelphia, Cincinnati Children’s Hospital, Seattle Children’s Hospital, sur­geons from the Hospital for Sick Children in Toronto, Canada, and a pediatric anesthesiologist specialized in pediatric pain management. The Civil Hospital, a government-nanced public hospital offering free medical care to a primary catch­ment area of 60 million people, serves as the host institution. The collaboration includes at least one annual visit from the same team of surgeons, during which new patients are evaluated and care plans are made, while all previous patients are recalled for long-term follow-up. Patients undergo yearly urodynamic evaluation, cystogram, ultrasound, DMSA scan, and bloodwork. The collaboration also evolved toward a more holistic approach to care, including mental health screen­ings, educational sessions with family members, and community-building activi­ties for the entire cohort.

The IBEC is an example of successfully putting the criteria outlined by the ASAWG into practice in order to exact long-term benets for patients. The follow­ing sections will outline the unique benets of the collaboration and how they have been implemented according to the ASAWG principles.

Cultural sensitivity is of primary importance for the collaboration, so local partners lead all patient interactions, and all visiting partners are educated on cultural sensi­tivity prior to attending the collaboration.