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How toTrain Surgical
https://t.me/medicina_free
Subspecialists inSub-Saharan
Africa
JereyPunch
It is not enough to know what is good: you must be able to do it.
– George Bernard Shaw
Abbreviations
FMHACA Food, Medicine, and Healthcare
Administration and Control
Authority
LMICs low- and middle-income countries
NCDs non-communicable diseases
PFSA Pharmaceutical Fund and Supply
Agency
Introduction
Surgeons have traditionally volunteered their
time and expertise around the world by traveling
to low- and middle-income countries (LMICs) in
order to provide needed surgical care to desperate
patients. Many countries have edgling health
care systems. The traditional paradigm in many
successful ventures has involved highly trained
teams of surgeons and nurses that travel as missions for 2–4weeks to areas where patients are
unable to access needed specialized surgical services. Frequently other specialists including
J. Punch (*)
University of Michigan School of Medicine,
Ann Arbor, MI, USA
e-mail: jpunch@med.umich.edu
8
Anesthesiologists and Medical Specialists
accompany the team. Supplies and sometimes
devices are brought by the team from the home
country to the destination in order to accomplish
the complex missions that are planned. While
laudable, and clearly providing valuable lifesaving and life-enhancing therapies, as described
in the following chaps. 34–40 focused on charity
missions by Facing Africa. These surgical mission trips usually impart minimal, if any expertise on the local community. In fact, such efforts
can actually undermine local efforts to develop
such capacities since the locals cannot compete
with a free service, provided by a well-respected
organization. Finally, such efforts are not sustainable because inevitably funding dries up, interest
wanes after leadership retires from active operating, and disruptions like pandemics bring a halt
to the activity.
In the 1980s, Dr. Tim Johnson and colleagues
began the process of creating a training program
for desperately needed OB/GYN specialists in
Ghana [1]. This program was successful, in that
the specialists that it produced stayed in Ghana
and provided needed care. The program was also
sustainable, in that Ghana soon developed the
expertise to train more specialists without outside
help. Herein is described a similar effort to bring
© 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_8
87
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kidney transplant services to a public hospital in
Addis Ababa, Ethiopia. By training specialists in
their own country, it was hoped that specialists
would remain in their homeland to serve the local
need and to train future specialists.
Background– Ethiopia
Ethiopia is considered the birthplace of humanity, since Lucy, the oldest fossil of the human species was discovered there. Ethiopia is the second
most populous African country after Nigeria,
with a population in excess of 100 Million. It is
located in East Africa and is the largest landlocked country by population. The lack of a seaport increases the cost of most imports, since
duties must be paid to the port of entry. Ethiopia
is bordered by Somalia to the East, Kenya to the
South, Sudan and South Sudan to the West, and
Eritrea and Djibouti to the North. Recent estimates put the per capita income of Ethiopia at
$2400, less than 4% of that in the U.S.One of the
oldest continuously inhabited areas in the world,
Ethiopia is notable for having never been formally colonized, although Mussolini’s Italy
occupied the country for ve years from 1936 to
1941. After World War II Ethiopia was ruled by
emperor Haile Selassie from 1941 to 1974 before
being under communist rule until 1991. In 1991
the country had a revolution, ending communist
rule. A constitution was written and the current
Federal Democratic Republic of Ethiopia was
established. The Africa Union was founded in
Ethiopia in 2002. According to UNICEF Budget
Brief, the per capita spending on health care in
Ethiopia was approximately 8.8% in recent years.
Spending is slowly increasing toward the 15%
target set out in the Abuja Declaration by the
African Member States.
Ethiopia Declares theDesire
toOer Kidney Transplant Services
The Health Minister of Ethiopia from 2005 to
2012 was Tedros Adhanom Ghebreyes. In order
to meet the needs of the rapidly growing popula-
tion, Dr. Tedros, a physician and infectious disease expert, markedly increased the number of
doctors trained in Ethiopia by increasing the
number of medical schools in Ethiopia during his
tenure [2]. These efforts were successful because
Ethiopian medical school enrolls directly from
secondary school, can quickly get candidates,
and can then graduate new physicians in six
years. After they graduate, the newly minted doctors are required to spend about two-to-four years
practicing as primary care physicians as part of
national service before they can begin residency
training. While highly successful, the task of
bringing modern specialty care to Ethiopia was
more challenging. Nevertheless, with encouragement from the legislature and the Prime Minister,
Dr. Tedros made it a national goal to initiate kidney transplant services in order to provide for
patients with chronic renal failure in a humane,
and cost-effective way which has not been previously available in the whole country.
A physician from the University of Michigan,
Dr. Senait Fisseha had grown up in Ethiopia and
trained in Obstetrics and Gynecology as well as
Reproductive Endocrinology in the United States.
She connected with Dr. Tedros while visiting the
country and evaluating opportunities to improve
local health care. Through this effort, Dr. Senait
became engaged with the Ethiopian Ministry of
Health’s desire to improve capacity. She obtained
funding to expand capacities and was heavily
involved in establishing training programs in
many specialties at St Paul’s Hospital and
Millennium Medical School in Addis Ababa,
including OB/GYN, General Surgery, and
Pediatrics. These programs were developed using
the model that Dr. Johnson, her department chairman, had demonstrated to be successful in Ghana.
St Paul’s, a public hospital, was built in 1969
under the leadership of Emporer Haile Salessie.
The Millennium Medical School was established
in 2007, the Ethiopian millennium. At that time,
the 369 beds at St Paul’s provided indigent care to
the community in Addis Ababa, including more
than 700 outpatient visits per day. Since then,
capacity at the medical school complex has grown
dramatically and now includes more than 700
beds and more than 2000 outpatient visits per day.
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Dr. Senait approached the kidney transplant
program leadership at the University of Michigan
on behalf of the Health Ministry and invited the
author (JP) to visit the hospital. This rst visit
happened in March 2013. The hospital appeared
to be staffed by enthusiastic and skilled surgical
and medical clinicians. Both inpatient and outpatient facilities were co-located, along with modern surgical operating theaters where elective
operations happened six days a week and emergency operations happened 24hours a day. Basic
radiology and laboratory services were available.
During this visit, it was revealed that more than
100 Ethiopians were being followed by a local
Nephrologist after successful kidney transplants
performed in other countries. These patients
appeared to be doing as well as their counterparts
in Western Countries. There was also a new
15-bed hemodialysis unit, one of the few in Addis
Ababa, being formed at a private Korean (MCM)
hospital. JP and Senait met personally with the
Minister of Health at the time, Dr. Kessetebirhan
Admasu who expressed willingness to rmly
commit whatever resources were necessary to
successfully launch kidney transplant services at
St. Paul’s. It was made clear that University of
Michigan’s role would be collaborative and facilitative, with the goal of creating a kidney transplant center at St Paul’s that could function
without outside help. The goal from the outset
was sustainability. On the basis of the enthusiasm
observed, the strong and unwavering governmental support, and the observation that transplant
recipients can thrive in the Addis Ababa environs,
the plan to develop kidney transplantation services at St. Paul’s became a common goal.
Background– Renal Failure Care
inAddis Ababa in2013
Hemodialysis had existed in Ethiopia since
approximately 1980 [3]. When the team arrived
in Ethiopia, renal hemodialysis was only occurring in approximately 20 dialysis chairs located
in several private hospitals around Addis Ababa,
a city of over three million inhabitants. St. Paul’s
Hospital did not offer chronic hemodialysis care
due to the prohibitive cost. Patients paid out of
pocket for dialysis services at a cost of US$ 30-50
per run, largely because of the cost of purchasing
hemodialysis membranes. The high cost relative
to the average income of residents meant that
most patients were under-dialyzed, some profoundly so. Some could afford hemodialysis only
once per week. Statistics for survival were not
known at the time, but it appeared to be very
uncommon for a patient to live beyond a year.
More modern data still show dismal survival for
patients on renal replacement therapy [4].
Background– Is Kidney Transplant
Appropriate forLMIC?
The true incidence of renal failure in Ethiopia,
like in Sub-Saharan Africa as a whole, is not
known. However, estimates indicate that
12-23% of adults have chronic kidney disease
and are at risk of developing renal failure [5].
While traditional efforts at improving lifespan
in Africa have focused on infectious disease
and nutrition, more recently attention has
turned to non- communicable diseases (NCD).
The World Health Organization has been championing the growing importance of NCD in
LMIC for over ten years, pointing out that 71%
of deaths globally can be attributed to
NCD.Given that kidney failure can affect individuals in the prime of life, and that kidney
transplantation offers a life- extending treatment that allows individuals to resume productive lives, it appears to be an appropriate option.
In addition, kidney transplantation can be surprisingly cost-effective in low- resource settings, as demonstrated by the public-private
partnership at the Sindh Institute of Urology
and Transplantation in Pakistan [6]. Chronic
hemodialysis, on the other hand, is almost certainly cost-prohibitive in LMICs.
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Steps toInitiate aKidney
Transplantation Program
Program Planning andTeam
Selection
The team from St Paul’s was selected by St.
Paul’s leadership with guidance from the Health
Ministry. A kidney transplant committee was created, led by the Vice-Provost in charge of the
Medical School and St Paul’s hospital. The committee members included the St Paul’s
Nephrologist who was selected to lead the program, along with the chairs of Medicine and
Surgery, as well as representation from St Paul’s
Laboratory service, procurement service, and
from Radiology. Surgeons that would be training
to do kidney transplantation were selected by the
Medical School authorities, after an internal
application process. A nurse with experience
implementing new programs within the Ethiopian
Health system was assigned to the project, as was
a physician project manager who worked for the
Health Ministry. This last individual would prove
invaluable, since he was accustomed to working
with various governmental entities on projects.
He reported directly to the Ministry of Health’s
Chief of Staff.
The team of individuals from the U.S. was
selected by polling colleagues at the University
of Michigan Medical Center, for interest. Dr.
Alan Leichtman, a senior clinical transplant
nephrologist, agreed to do a site visit. Once the
program was underway, Dr. Leichtman enlisted
other interested transplant nephrologists from
around the country. In addition, one nephrologist
with U.S. training who worked abroad volunteered to participate. Two nurses with transplant
coordinator experience, one of whom also had
ICU experience, and an operating room nursing
supervisor in charge of the transplant service line
all volunteered to participate in planning and
organization. Two social workers with kidney
donor and recipient experience were also interested in being involved. Site visits were planned
by these teams. Dr. Senait was able to fund this
work initially. Travel and expenses were later
supported nancially by the Ethiopian Health
Ministry.
The team program planning began with the
creation of a list of items required for transplantation. This list was created by obtaining pick lists
for the operating room for donor nephrectomy
and kidney transplantation at the University of
Michigan. Other supplies that would be needed,
including immunosuppressants, prophylactic
anti-infectives, and reagents for needed lab tests,
were added to the list. The list was created in a
spreadsheet and each item was color-coded based
on priority. Red items were those deemed to be
absolutely required in order to initiate transplantation, such as vascular instruments, methylprednisone, and tacrolimus-level kits. Medium
priority items that should be available but would
not be absolutely required, such as loupes for the
surgeons were coded orange. Items that should
be planned for in the future, such as on site histocompatibility capability, were coded as yellow.
The transplant committee met in person at St
Paul’s approximately every two months over a
period of 30months planning the rst renal transplant operation. Additional items were added to
the list over time. The list itself was helpful to
keep the project organized and as a tangible goal
for the team and for the Ministry of Health to
fund. In addition, given how long it take for the
project to come to fruition, the items on the list
that were completed served as a reminder of what
progress had been made over time. This kept the
team engaged and enthusiastic. Experience with
the recent Covid-19 pandemic, and improvements in information technology infrastructure
have taught us that some of these meetings could
have been done virtually. However, meetings in
person helped the team to form personal bonds
and to get to know each other better which was of
great benet when the program nally started.
Establishment ofLegal Framework
It is critical that a legal framework for living
donation is in place to protect all of the participants, as well as to be able to demonstrate to
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observers that ethical measures are in place to
preclude exploitation of living donors. In addition, if possible, it is prudent to establish a legal
framework for deceased donation as well. A bill
pertaining to organ donation in Ethiopia was
passed by the legislature during the rst year of
planning. The Ministry of Health and the transplant committee were involved with reviewing
initial drafts and providing feedback. The
Ministry of Health also ofcially designated St
Paul’s as a transplant hospital and added a
requirement that candidate donor and recipient
pairs were to be presented to an independent
committee overseen by the Ministry of Health for
nal approval to proceed.
Establishment ofFormal Training
Protocols
At the outset of the program, team members were
invited to the U.S. in order to observe at the
University of Michigan, a busy transplant program. This included members of the transplant
committee, as well as the clinicians that would be
involved in patient care. This included three general surgeons, a urologist, a nephrologist, an
anesthesiologist, a CRNA, and a radiologist.
Obtaining visas was an initial obstacle that was
overcome with the help of the Health Ministry.
Professional leadership, including that of the
Vice-Provost of the Medical School, on these visits turned out to be extremely valuable. While
hospital policy and State laws prevented surgeons
from scrubbing on any cases, they were able to
witness more than a dozen transplant procedures
over their month-long observership. In addition,
they made rounds with the teams, shadowed clinicians in pre-transplant and post-transplant clinics, attended selection committee meetings and
conferences pertaining to Transplant and
Nephrology topics. In addition to the observership at the University of Michigan, the surgeons
and nephrologists visited a program in Egypt that
was lower volume, but where they could be permitted to have hands-on involvement. The surgeons were also invited to spend a month each at
Hospital do Rim in Sao Paulo, Brazil. This hospi-
tal is solely dedicated to kidney transplantation
and has the highest annual kidney transplant volume in the world at more than 750 transplants
annually. This attachment was extremely valuable to the surgeons because of the opportunity to
observe multi-disciplinary teams at work, and
because they were exposed to a broad array of
transplant complications due to the high volume
of transplants.
A training curriculum was developed along
with graduation criteria, modeled after the
requirements set forth for kidney transplantation
by the American Society of Transplant Surgeons.
The curriculum was approved by the Ministry of
Health, the University of Addis Ababa, and by the
Food, Medicine, and Healthcare Administration
and Control Authority (FMHACA) in Addis
Ababa.
“The Team, TheTeam, TheTeam”
The Famous University of Michigan Football
Coach Bo Schembechler was often quoted widely
that success is all about teamwork. Transplant is
very much a team sport. In addition to qualied
surgeons and nephrologists, it is critical that
nurses with the necessary skill to manage posttransplant and post-nephrectomy patients are
available. Social workers and psychiatrists are
also an integral part of the team that functions to
assist in the selection of recipients capable of
managing the rigorous post-transplant follow-up
and care that will be required and of donors to
assure their volunteerism and motivations, as
well as their predicted response to donation.
Team members made site visits to provide recommendations and developed professional relationships with their counterparts. These site visits
were extremely valuable and resulted in numerous additions to the list of items required. For
example, nursing noted that sinks, soap, and towels were not available in every patient room and
patient care area. Since kidney transplants would
be treated with immunosuppression, this was an
important observation. In addition, crash carts
were not available. These items were added to the
list. The operating room appeared well run and
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utilized safe practices for sterility, but it was
noted that additional storage space for consumable supplies would be required. It was strongly
advised that a basic electronic medical record be
instituted in order to keep track of important elements of the patients’ evaluations and for efcient post-transplant care and monitoring.
It was noted that laboratory services were not
available at night. The availability of 24h a day,
7days a week laboratory testing was added to the
list as a critical item. Other upgrades needed
included the ability to do exible cystoscopy to
remove ureteral stents. Given the lack of skilled
interventional radiologists, it was reasoned that
routinely utilizing stents would reduce the likelihood of difcult-to-manage ureteral complications. Radiology needed to be enhanced in order
to provide contrast-enhanced spiral CT scans for
donor screening and to provide doppler ultrasound exams of kidney grafts with calculation of
resistive indices.
A dialysis unit was needed to support the program. It was felt that to ensure optimal outcomes,
patients should be well dialyzed prior to transplantation. Only patients with approved donors
that were accepted as transplant candidates would
be able to have chronic dialysis at this facility to
conserve resources. The availability of acute dialysis was also deemed to be important in the case
of delayed graft function or severe acute kidney
injury in a post-transplant patient at a later point
in time.
Pharmacy services needed to be expanded. In
particular, there was insufcient storage space to
store the valuable immunosuppressant and antiinfective medications. A method of recording
inventory was also needed to avoid running out of
a critical drug.
Establishment ofaTransplant
Protocol
It was imperative for the team members to create
a written protocol for the selection of recipients
and donors, and for the care of patients following
transplantation and donation. This process began
with reviewing protocols in use in similar set-
tings. Unfortunately, given the paucity of kidney
transplantation in LMIC, few protocols in this
setting existed. Fortunately, colleagues in South
Africa were willing to share protocols and give
advice. For example, it was advised that given the
endemic nature of tuberculosis in the region, and
the risk this poses to immunosuppressed patients,
all recipients receive prophylaxis with isoniazid.
In addition, all patients would receive antihelminthic treatment to deworm prior to donation
and transplant. To avoid the risks of overimmunosuppression, it was decided to avoid
induction immunosuppression therapies that
result in lymphocyte depletion.
After consideration, the team elected to pursue low-risk transplant candidates. High BMI
patients, patients with known severe coronary
disease or depressed ejection fraction were
excluded. Because plasmapheresis would not be
an option in the case of antibody-mediated rejection, donor/recipient pairs with known donorspecic antibody, even if at modest titers, were
excluded. Cytomegalovirus and Pneumocystis
jirovici chemoprophylaxis were deemed to be
important.
Operatively, the initial plan was to proceed
with hand-assisted laparoscopic donor nephrectomy, since minimally invasive nephrectomy was
felt to be the state of the art. Fixed retractors were
planned for the recipient operation in order to
simulate the way the procedure was performed at
high-volume centers.
Creation ofaTransplant Center
The initial plan was to perform the donor nephrectomy and kidney transplant operations at St.
Paul’s hospital and care for them in a dedicated
ward. This was felt to be less than optimal given
the number of patients being treated for infection.
While patients with tuberculosis were housed in
a dedicated ward, the lack of ventilation in the
facility was concerning. During a visit to the
University of Michigan the Vice-Provost from St.
Paul’s toured the transplant ward and transplant
clinic. When he returned to Addis Ababa, he was
inspired to rent a facility very near the St Paul’s
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hospital and renovate it into a dedicated transplant
unit. This facility, formerly used by an Information
Technology rm and later as classrooms, was
located about 100 meters from the entrance to St
Paul’s and was on the same side of the street. This
would prove to be highly efcient. The facility
comprised the intensive care unit, the dialysis
unit, pharmacy, laboratory, ofces, and outpatient clinic area on the rst oor. The second oor
was dedicated to wards with private rooms for the
recipients and semi-private rooms for the donors,
an operating theater area with adjoining donor
and recipient operating rooms as well as storage
areas and lounges for physicians and nurses.
Physician and nursing staff could be easily shared
with St Paul’s because of the close proximity.
The main drawback of the dedicated transplant center arrangement was that patients had to
travel to St Paul’s for imaging studies other than
ultrasound. An unexpected benet was that those
individuals that worked at the dedicated transplant unit developed a sense of pride and
camaraderie.
Procurement– TheBiggest
Challenge
Procurement of needed supplies turned out to be
very difcult. Initially, it was estimated that six
months would be required for planning and collecting the needed instruments, supplies, and
equipment required for transplantation. This
turned out to be wildly optimistic. It took two and
a half years after the rst visit before the rst live
donor kidney transplant was possible. The longest process was obtaining needed supplies. The
system in Ethiopia for purchases by the government involves a mandatory bid process. If insufcient numbers of bids were received, the process
had to be repeated from the beginning. The
agency in charge of purchasing of health care
products is called PFSA, Pharmaceutical Fund
and Supply Agency; it appeared to be quite
bureaucratic. In several instances the bid process
resulted in the substitution of items that were not
truly interchangeable, prolonging the process.
For example, hand-held staplers were procured,
rather than endo-staplers.
Dress Rehearsal: Porcine
Transplants
The delays caused by the difculty with procuring supplies were frustrating, but the Ethiopian
surgeons had an idea. They had visited the laboratory at the University of Michigan where porcine transplants were being performed as part of
experiments. They suggested that porcine transplants would be a way to test the readiness of the
entire system for an attempt at human transplants
[6]. This proved to be an excellent idea. Five different porcine transplants were attempted. The
nal transplant was successful. A number of
important observations were made. At one point
the power went out. This was a relatively frequent occurrence in Addis Ababa, and operations
can usually proceed with back up batteries for
anesthesia monitors, manual bag ventilation, and
ambient light. However, during laparoscopy, one
cannot proceed at all without power. While the
medical complex at St Paul’s had a backup generator, it clearly was not up to the task. It was also
discovered that many of the very low-cost vascular instruments that had been procured were not
functional and needed to be replaced with highquality products that would actually grasp and
cut tissue. It was also discovered that parts for the
xed retractor had been purchased from multiple
suppliers. As a result, the ratchets and blades did
not t on the ring. The retractor was virtually
worthless until the correct pieces were obtained.
Transplants Begin– TheTeam
Learns by Doing
After two and a half years of planning, the rst
live donor kidney transplant in Ethiopia went off
without a hitch in November of 2015. Two more
transplants were performed in the following days.
All six patients did well. Over the next four years
more than twenty visits were made. At least one
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J. Punch
surgeon and one nephrologist were always part of
the visiting team. Social workers accompanied
the team every few visits. Initially, a nurse accompanied the team for every visit. A skilled nurse
was initially critically important to assist and
teach the St Paul’s nursing team with postoperative care since they were initially not adept at
many of the necessary skills needed to care for
the patients. Such skills as calculating and administering intravenous boluses and how to replace
urine output with IV uid were beyond their previous experience. In addition, the nursing culture
in existence did not encourage nurses to bring
problems such as falling urine output or hypertension outside of expected parameters to the
attention of the physician team. Over the course
of the next two years the nurse always accompanied the team whenever transplants would occur
and was always available at the bedside in the
ICU, which also functioned as a recovery room.
In addition to teaching at the bedside she gave
lectures on various topics relating to transplant
nursing and the use of medications. The St Paul’s
nursing team became competent at managing
these challenging patients and the visiting nurse
was no longer needed for bedside care.
Between three and ve live donor nephrectomy procedures and kidney transplants were
done on each visit. Typically the team left the
U.S.Saturday evening and arrived late Sunday or
early Monday. On Monday afternoon a team
meeting was held where each donor/recipient
pair was presented and the donor CT scan images
were reviewed. In addition, any post-transplant
patients from previous visits having complications or requiring readmission were discussed.
On Tuesday through Friday one nephrectomy
and one transplant was performed each day. As
the team got more efcient and the backlog of
patients waiting for transplant got larger, the
team decided to try to do two donors and two
transplants on a single day in order to do more
than 4 transplants in a week. This was doable, but
it stressed the four bed ICU capacity to its limit,
and the team discontinued this practice, returning
to a comfortable four transplants per week.
The rst 48 donor nephrectomy operations
were performed with hand-assisted laparoscopy.
Unfortunately, at this point some critically important supplies such as endostaplers and harmon
scalpel handpieces were depleted. The Ethiopia
surgeons suggested ank nephrectomy as an
alternative. They had witnessed this operative
technique at Hospital do Rim where ank
nephrectomy was the standard approach because
of the increased cost of laparoscopy. From that
point on, all donor operations were done through
ank incisions. The patients, almost invariably
thin, did remarkably well postoperatively.
After four years, the surgeons had done a sufcient number of nephrectomies and transplant
operations and mastered the knowledge necessary
to select appropriate candidates and manage them
through their operations and recovery to become
independent. A graduation ceremony was held and
they were each pronounced qualied kidney transplant surgeons. The visiting team also learned
much during the training process. For example,
narcotic analgesia is not used at St Paul’s for postoperative pain control. The patients did remarkably well with acetaminophen analgesia. There
was initial concern over how thin many of the
patients were. Many times the BMI was less than
15, despite excellent functional status and nutritional laboratory parameters that suggested the
patient was not malnourished. These patients did
very well, with no observed increased incidence of
infection or surgical complications. Initially, the
team was also concerned by the very high BUN on
some of the patients having pre-emptive kidney
transplantation. BUNs as high as 250 did not result
in any particular postoperative problem such as
disequilibrium or oozing that has been described
for very uremic patients that suddenly are provided with rapid solute clearance. Overall, the
clinical outcome at St. Paul’s would be considered
excellent at any transplant center in the world. The
program was halted in March of 2020 due to the
Covid-19 pandemic. However, the program
resumed in September 2022. Despite the hiatus,
the Ethiopian group was able to resume succeful
living donor kidney transplants, and the program
continues. The major ongoing difculty is obtaining consumeable supplies such as ureteral stentsm,
polypropyline sutures, and kits to monitor immunosuppression levels.
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Summary
The experience described in this chapter is a
model for sustainability of improved surgical
capacity in LMIC.It proves that complex surgical and medical care is possible in low-resource
settings. The key to success begins with a group
of highly motivated individuals willing to dedicate themselves to a goal that may take years to
reach. Equally important is the requirement for
committed and supportive leadership at the
institution and at the Health Ministry levels.
The end result has the potential to advance
health care in LMIC to a level of sophistication
previously only available in the wealthy
countries.
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index.php/EMJ/article/view/1533
How toDevelop aSustainable
https://t.me/medicina_free
Program forVolunteer Medical
Care inLow- andMiddle-Income
Countries
SidneyB.Eisig, RobertoFajardo,
andDavidHoman
Success is not the key to happiness. Happiness is the key to success. If you love what you
are doing, you will be successful.
– Albert Schweitzer
9
Abbreviations
CRNA certied registered nurse anesthetists
IRB Institutional Review Board
LMICs low- and middle-income countries
Introduction
Volunteer medical missions provide necessary
care to underserved populations in low and middle
income countries [1]. Our overarching goal is to
provide the same level of care in Neiva as we do in
our hospitals in the United States. Patients born
S. B. Eisig (*)
Columbia University College of Dental Medicine and
NewYork Presbyterian/Columbia University Irving
Medical Center and Morgan Stanley Children’s
Hospital of NewYork, New York, NY, USA
e-mail: sbe2002@cumc.columbia.edu
R. Fajardo
Clinically Applied Science Education (CASE),
University of the Incarnate Word, School of
Osteopathic Medicine, San Antonio, TX, USA
e-mail: rfajardo@uiwtx.edu
D. Hoffman
Division of Oral and Maxillofacial Surgery, Staten
Island University Hospital/Northwell Health System,
Staten Island, NY, USA
with a cleft lip and palate have a high burden of
care (Table 9.1). We endeavored to provide this
care from birth through young adulthood. In coordination with our hosts, we expanded our team to
include orthodontists, pediatric dentists, geneticists, and speech and language pathologists. Local
specialists were recruited and trained if necessary
to continue to provide care after we left. An ongoing IRB-approved genetics research project in collaboration with Dr. Wendy Chung of Columbia
University in NewYork and Dr. Henry Ostos of
Surcolombiana has resulted in two peer-reviewed
articles. Bone grafting of the alveolar cleft around
age seven and then midface advancement around
age sixteen is coordinated with local orthodontists.
Our bilingual speech pathologists from Teachers
College in NewYork provide speech camp for the
children and their families and continuing education for local/regional therapists, educational videos available on YouTube, and remote consultations
for their local counterparts via the internet.
This past year, we utilized 10 operating rooms
and provided surgical care for approximately 170
patients. Our areas of concentration have been
expanded; our team provides treatment for children with congenital hip dysplasia and club feet,
cleft lip and palate, microtia, burn scar contracture
releases, syndactyly, polydactyly, congenital and
© 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_9
97
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