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M. A. Hardy et al.

riers, simple housing, usually without airconditioning and sometimes no fan in the hot climates, but usually with an electric heater in cold climates. It is critical to keep an open mind and remember that as guests, the visitors ought to act graciously and not be a burden to the host hospitals and their staff.

Goals and objectives must be continually reevaluated according to the situation. There may be a smaller number of operations than expected if there is a shortage of supplies or personnel. It is judicious to bring gloves, masks, caps, scrub suits, coats, and some sutures if one can, regardless of the role that one may play. No matter what the difculties with accreditation may be, it is important to realize at the outset that the role of an observer, rather than as a responsible physician, may be more appropriate and equally valuable for a resident or a student.

Where one wants to go is partially dictated by language abilities, cultural interests, degree of hardship one wishes to tolerate, and most importantly, the surgical or medical experience and the degree of collaboration and/or supervision that is available. The tendency to group LMICs together is misleading and the term “underserved areas” may be more appropriate. Various countries have vastly different economic proles, health systems, and opportunities for service. Because of such striking differences among hospitals, especially those in major urban areas as compared to the district hospitals in the rural areas, rst-hand accounts from previous volunteers are very helpful in choosing a site for the rotation. The host facility can provide the student/resident/attending with details on the regional safety and the epidemiology of diseases in the region, and may provide details on specialized medical skills and knowledge that is required. Others who have foreign contacts can also provide helpful information. It may be a chairman, a colleague, a senior resident, or someone that one meets at a convention. Having a close acquaintance in the host country can provide comfort and safety to the visitor. Organizations such as Surgeons OverSeas (SOS) [22], Operation Giving Back of the American College of Surgeons [23], and Global Pediatric Surgery Network [24] have facility

databases that include pertinent information about each hospital or facility, such as case mix, volume, available supervision, and travel information. Information sharing with residents from other institutions who have had experience in the desired area should also be used.

The duration of a surgical rotation in an underserved region must provide enough time to gain benet from the visit and to be tolerated, if needed, by the volunteer’s partner. In addition, permissions are required from the Host Institution, visitor’s PD, and from the Director of Institutional Graduate Medical Education (GME) ofce. Adequacy of funding will also inuence the length of the rotation. The longer the rotation, the greater the possible medical contribution to the host, and the greater the educational and cultural benet to the volunteer. The longer rotations lead to more lasting and more effective relationships with the hospital personnel and administration. They also permit greater continuity of patient care. Repeat rotations to the same hospital are encouraged throughout the visitor’s lifetime.

Implementation of formal PDT programs can be hindered by inadequate time for preparation and occasionally by lack of dedication to PDT by non-global health educators [19]. In nonacademic training environments, where individuals themselves are primarily responsible for their own training, it may be difcult to replicate the programs of large academic institutions. In the absence of a formal PTD program, there are many resources that can assist in the preparation of volunteers for their global health experiences. For instance, the United States State Department website (www.travel.state.gov) contains infor- mation regarding potential safety concerns in the host country. Similarly, the Centers for Disease Control and Prevention website (www.cdc.gov) provides recommendations regarding vaccinations and antimicrobial prophylaxis. The Consortium of Universities for Global Health also offers an open-source “Global Health Competencies Toolkit”, which can serve as a reference for developing one’s own pre-departure curricula (https://www.cugh.org/online- tools/

competencies- toolkit/). There are also a number

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of medical societies that provide resources to help prepare for global health experiences. These include the following: 1) Society for Education in Anesthesia (www.seahq.org); 2) American Society of Anesthesiologists (https://www.asahq.

org/charity); Canadian Anesthesiologists”

Society International Education Foundation (https://casief.ca/); American College of Surgeons (https://www.facs.org/ogb); Lancet Commission on Global Surgery (https://www.

lancetglobalsurgery.org/); World Health

Organization (https://www.who.int/teams/inte-

grated-health-services/patient-safety/research/ safe-surgery); United States State Department

website (www.travel.state.gov); Centers for Disease Control and Prevention website (www.

cdc.gov); The Consortium of Universities for

Global Health also offers an open source “Global Health Competencies Toolkit” (https://www.

cugh.org/onlinetools/competencies-toolkit/).

Consultation and approval of the rotation by one’s family, professional partners, department chairman and division chief, program director or medical student advisor are essential. The host facility almost always requires written conrmation of medical qualications from the visitor’s hospital or institution. There are many other requirements, depending on the site, regarding licensing and permits in some cases, travel arrangements, and establishment of contacts at the host institution to devise a specic plan for

hot seasons should follow cultural and medical indications for some clothes (e.g., long pants and long-sleeved shirts to decrease mosquito bites and to follow cultural mores, especially for women, while thick-soled shoes may be needed where snakes are found). Other items include personal medical equipment, some of which may be left behind, such as a portable Doppler, camping forehead battery-powered light to be used when the electricity and the generator fail, and any other items that are needed and may be left behind such as gloves, caps, medical coats for personal use, and vascular grafts, meshes, or even a donated portable ultrasound machine, if possible. Some of these items may be subject to import fees if declared as donations (the hospital may help to bypass the customs fees). They may be brought in as personal items and then “forgotten” at departure. A detailed list of necessary items to bring is available on the Surgeons OverSeas (SOS) website (http://www.surgeonsoverseas.

org) under the “Resources” section. After con-

sulting with your hosts, bring only OR equipment that has been requested or that is absolutely needed to perform specialized operations by the visiting faculty. Customs regulations are generally very strict, and advice should be sought from host institution before importing any major medical equipment, or even minor supplies. They have experience in facilitating entry of imported

equipment at the lowest cost possible. the rotation. The required documents usually need to be obtained at least 6months in advance to permit appropriate processing at both the host’s and visitor’s sites. Funding which may be possible through medical schools, home hospitals or institutions, or local surgical societies and various foundations, also requires adequate advanced time for applications. Without funding, it may be necessary for the volunteers to take either unpaid leave or use their vacation times. Malpractice insurance coverage is essential and should be carried by the individual through their sponsoring institution.

To determine which items to bring along is part of the preparation. These include personal items appropriate for the climate and seasonal conditions. Appropriate clothes for rainy, cold, or

tions, ight arrangements, living, and travel arrangements as soon as rotation plans are solidied. Some countries may require work visas and registry as a doctor which may be a prolonged process. Flight arrangements to remote locations may also require careful planning in both directions, depending on seasons. Attention to clean food and potable water (even if it has to be boiled) is critical to one’s health. Living quarters, whether provided by the host hospital or a hotel, need to be protected from mosquitoes (netting and other antimalarial precautions). Windows and shutters, and a working fan in tropical climates or heater or radiator in cold climates (as in the high mountains) may be necessary. Select a comfortable season (e.g., avoid monsoons or winter in the

To be a smart traveler arrange visas, vaccina-

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M. A. Hardy et al.

Himalayas). Places that are unstable or war zones are not suitable for visiting rotations. At times of local climate disasters such as aftermath of an earthquake or a tsunami, communicate with local experts on whether volunteers are needed and what precautions should be taken before offering one’s services. It is wise to notify your embassy or consulate of your arrival in the country and of your location in cases of emergency (check the respective embassy’s website). Provide information about local contact who has some degree of responsibility for you. It is highly recommended to keep a list of important local addresses and telephone numbers and to be familiar with a reliable evacuation route to safety, such as the embassy or consulate. Safety for oneself must remain the top priority.

Take care of your own health. It is wise to have a full medical examination with a chest X-ray, EKG, full laboratory workup, including tests and up-to-date vaccinations for major viral infections and for TB.This can serve as a baseline for any problems that may be discovered during or after the rotation. One’s health is of concern not only to the volunteer but also to his colleagues, both local and visiting. Doctor’s records, X-rays, EKGs, and latest laboratory data should accompany the visitor and be available for comparison if need arises. Tentative plans for evacuation to more modern or home hospital (with appropriate travel insurance) should be available if a major emergency arises that requires transfer to the nearest specialty hospital. Simple medications, such as oral rehydration solutions and anti- diarrhea medications, can reduce downtime should the volunteer fall ill. Anti-allergy medications and antibiotics, including epinephrine and steroids, should also be brought. Be aware that any pre-existing medical conditions might worsen in a different climate and with a different diet.

one is a senior surgeon or a junior medical student. The chain of command usually begins with the CEO of the hospital, but special requests may occasionally require approval of the regional or national Ministry of Health. If this rule is not followed not only may new projects or initiatives be stopped, but the initiator may be asked to leave the institution and not return. There are really no legal or public appeals where such decisions may be reversed. Independent initiatives by visiting faculty or by residents, without the consent by the administrative host hospital, are not only frowned upon but may lead to disciplinary actions. The role of partially trained personnel, such as surgical residents and medical students on surgical rotations or elective trips, is variable and frequently initially ill-dened. This may lead to misunderstandings which must be avoided as much as possible and corrected promptly when they occur.

Work within the local system(s) and protocols since it is important to maintain the local chain of command into which the visitors must t and adjust themselves. This includes absolute discretion regarding the use of social media to express experiences with the patients or with the hospital, as well as criticisms of the staff, ORs, procedures, or protocols. Most improvements and corrections can be achieved if presented in collaboration with the local practitioners and approved by the senior administrators. Any press releases about innovations must be initiated by the local administrators and NOT by the visitors. Long-term changes or innovations are not likely to succeed unless they were developed and introduced in collaboration with the local staff and, most importantly, approved and introduced by the local administrators, frequently with the recommendation of the Minister of Health or his/ her deputies.

The Visitor’s Role at theHost Facility

Interaction with Administration is critical for everyone’s satisfaction. It is important to adhere to the local chain of command and not try to take shortcuts to achieve goals regardless of whether

Availability ofSupervision

Assurance that adequate clinical supervision is available is a frequent issue regarding operative

procedures performed by residents. Visiting residents should have an accredited local or visiting

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surgical attending within short walking distance to the operating room where the senior resident may be operating alone (junior residents should rarely be permitted to operate alone and only on appropriate cases for their level of training). It is prudent that the attending surgeon (either visiting or host) be present in the operating room for the critical parts of any major operation (both decision and technical aspects). In 2011, the American Board of Surgery (ABS) and the Residency Review Committee for Surgery (RRC-S) of the Accreditation Council on Graduate Medical Education (ACGME) approved international elective experiences for credit toward graduation requirements, under strict guidelines [25] https://

www- sciencedirect- com.ezproxy.cul.columbia. edu/science/article/pii/S0039606012000980?via %3Dihub- bib11). RRC-S has determined a set

of eligibility criteria to ensure that surgical residents benet maximally from an international rotation’s education potential. Although the idea of performing at a more complex level than they have been trained may seem to the residents to be very attractive, it raises serious ethical and legal issues and must be discouraged if adequate clinical supervision is not available. The popular concept that “some surgery, however inexpert, is better than none” is erroneous. To perform the surgical procedures correctly the rst time and avoid a higher rate of iatrogenic morbidity and/or mortality is most important in LMICs, as it is everywhere. It is important not to place an unnecessary burden on an already stressed resourcepoor health care system. To avoid and/or prevent any harm to patients it has now become a requirement from the RRC to have a faculty member on site during the international rotation before it can be approved [25]. It is best for both patients and resident/students that the supervisors be ofcially accredited as trained surgeons (by American, European, British, or African surgical boards), or may even be local experienced surgical practitioners. Prior to choosing a rotation, it is essential rst to determine the type of hospital, the expected surgery to be encountered, the volume of surgery, and most importantly, to identify the level and quality of surgical and medical supervision that is available.

Remember that local training programs take priority. It must be clearly understood that local

trainees have priority, if qualied, to perform elective and emergency surgical procedures under supervision of visiting or local faculty. The visiting trainee’s learning opportunities should never supersede that of the local trainees. Collaborators on research project should include local staff and they should be included in designing and executing the project. Eventually, they should be included as co-authors on submitted manuscripts.

Record Keeping

Maintain a surgical case log (end of each day) despite the fact that in most instances the resident will NOT get credit for the rotation from the RRC-S unless all the conditions are fullled by the resident’s program prior to the rotation (especially continuous supervision by Board certied surgeons (ABS, RCS, WACS) and many other conditions). Keeping a log is important for your own personal use and for teaching purposes, as well as recruitment of faculty and residents in the future. With the recently approved guidelines for implementation of international rotations by the ABS and RRC-S [26], the accreditation process will be evolving and developing in the coming years. At present, it is important to determine the status of the RRC-S regulations in regard to the visitor’s institution and host institution, as well as the degree of accreditation of the supervising faculty. International rotation for residents and faculty should serve to broaden their clinical knowledge and improve their skills to make diagnoses with hands, eyes, and brain, at least as well, or perhaps even better and faster, than with the radiographic equipment and laboratory tests which may likely be unavailable. To maintain a diary of cases and experiences serves not only as a specic reminder of the rotations for many years, but may serve as a basis for reports, articles, and as teaching tools for future trainees. The diary should also include photographs for which consent has been obtained, so that they can be used ethically and legally in future

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M. A. Hardy et al.

publications. In keeping diaries and records of the visit, it is imperative to avoid any public discussion on social media of any details of the medical aspects of the hospital or its staff and administration. Regardless of whether the comments may be positive or negative, they may be misinterpreted by the readers with serious negative consequences for the visitor and discontinuation of future rotations. Communication with others regarding the rotation must be respectful and restricted only to facts with avoidance of speculations, personal opinions about staff, or criticisms.

Consider opportunities for using/establishing

blogs or mass e-mail. This has to be done with

great care and adherence to patient rights to privacy. Commentaries about staff or institutions, other than attering, are not welcome by the host institutions and countries. Adverse comments may lead to dissolution of relations, as has happened previously. It is wisest to avoid any professional communications with colleagues via blogs or mass e-mails.

Activities after your return. The main goal is to encourage others to volunteer or elect similar experiences and service to the underserved. This may take the form of lectures to staff, informal discussions with colleagues, and formation of clubs or groups to encourage this type of volunteerism. Efforts should be directed to raise funds, collect professional books, and obtain surgical instruments and monitoring equipment that may be surplus or no longer needed from the hospitals and then ship it to your previous host, if it is needed and requested. One should try to maintain contacts with colleagues at host institution after thanking them appropriately soon after return to home institution. All joint publications should include a member of host staff as a co-author.

Continue communication with hosts after your experience. This is easily accomplished by e-mail

or telephone. It should be maintained at scientic meetings and at any available social interactions. If at all possible nancially, it is very desirable to invite the host staff members for a rotation at your hospital, even as an observer, if accreditation rules forbid anything else for medico-legal reasons. Continuous contact with the staff of the

host institution will facilitate future rotations of residents, students, and faculty to the same institution.

Provide a written summary to your sponsor(s). This record is important when archived condentially as a source of detailed information for future volunteers. This summary should comment about the staff, type of patients, available resources, living conditions, cultural environment, obstacles encountered, and other pertinent observations. These details need to remain condential in the Residency Program Director’s (PD) ofce and be available only on a “need to know” basis. Such material may be very useful for a future volunteer as he/she chooses a site for a rotation [25].

Volunteer as an advisor to residents and students who wish to follow. This may be accom-

plished via PD or Dean of Students if a distinct Global Surgery Program is not yet established. If a distinct Program exists, its leader and its members may be the best source of information for future candidates. We have highlighted a list of suggestions that are by no means complete, and are meant to be only a practical guide to a safe and productive experience. Adequate preparation for an international surgical rotation is vital to its success, its benets to the participants, to the host institution, and to the development of meaningful and fruitful exchanges among surgeons from different backgrounds. Such exchanges will benet patients in both the visitors’ and hosts’ nations.

Impact ofGlobal Health Experiences

Volunteer-Trainee Perspective

Many studies have evaluated the impact of these experiences on volunteers and trainees and their respective host institutions. Some have reported benets of these experiences, such as improved medical knowledge and clinical skills, exposure to a wider spectrum and stages of illnesses, increased awareness of social determinants of health, and improved understanding of cultural competencies and health care disparities.

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Table 2.2 Risks and benets of global health experiences

Medical Volunteer Perspective Host Institution Perspective Benets Risks Benets Risks

• Medical knowledge.

• Communication skills.

• Learn about provision of health care in low-resource settings.

• Increased cultural awareness.

• Provide motivation to practice in underserved communities (for trainees).

Personal satisfaction.

• Exposure to health and safety dangers.

• “Culture shock”/ homesickness

• Exposure to ethical dilemmas.

• Exposure to poor clinical outcomes.

• Inability to communicate with practitioners and patients.

• Establishment of bidirectional learning opportunities.

• Collaboration in academic pursuits.

• Access to resources (i.e., funding and medical supplies.

• Access to health care services, otherwise unavailable.

• Lack of mutual benet.

• Lack of sustainability of interventions.

• Inadequate follow-up.

• Increased burden of work in an already overburdened system.

• Trainees practicing above level of training.

• Cultural insensitivity.

• Perceived devaluation of host institution/ country practitioners.

Occasionally these experiences have long-term impacts on the practice of volunteers after their return home [3, 9–11]. Additionally, in some cases, these experiences have motivated health care personnel to pursue careers which focus on LMICs [10]. However, PDT can put participants at risk (Table2.2). Lack of knowledge regarding emergency contacts, necessary vaccinations, or prophylactic medications can put volunteers’ personal health and safety at risk [12]. There are also numerous anecdotes of culturally incompetent volunteers encountering ethical dilemmas that result in inappropriate or damaging interactions with the host hospital staff, patient-doctor relationships, poorer patient outcomes, and unpleasant experiences [12, 14]. Again, while much of this literature concerns trainees embarking on short-term projects, most of the issues and problems are just as relevant to the seasoned practitioner as he/she heads off to an unfamiliar environment.

For surgical or anesthesia missions, the types of “preparation”, described in detail above, can be classied as “clinical” and “personal”. The “clinical” preparation involves ensuring that the appropriate equipment and surgical, nursing, and anesthesia skills and personnel are adequate at the host institution. It is also critical to ensure that the other necessary resources are available (water, light, oxygen, medications, ORs, and tables) to avoid major limitations. The “personal” preparation should include familiarity with the culture (and potentially the geography) of the foreign site

and how these may affect the visitor’s behavior or safety. The visitor must also have full understanding of the scope and limitations of the mission. Attention to appropriate personal medical matters (e.g., vaccines, malaria prevention, antidiarrhea medication, post-exposure HIV prophylaxis strategy, and other necessary medications) and to desirable or required documents (health insurance, proper travel documents, licenses, etc.) is also crucial to success. When the mission is sponsored by a large international agency many of these issues are settled during formal orientation sessions or informational documents and e-mails, including checklists. For those traveling alone or with smaller organizations, these issues require careful thought and early individual attention.

Host Institution Perspective

The impact of the visitors’ experiences on the local host institutions is variable and depends on the individual or group mission (e.g., direct care, teaching, joining a locally established team, or various combinations of these functions) as well as on the preparation and resultant performance and behaviors of the individuals involved. Inadequately prepared volunteers may (usually inadvertently) devalue local providers’ performance (sometimes, only as a perception), alter continuity of services, promote a post-colonial narrative, and manage patients inappropriately

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M. A. Hardy et al.

due to lack of cultural competence [3, 8–10]. Such inappropriate interactions can overtax the host institution’s infrastructure and may put patients at an increased risk for adverse outcomes [16] (Table2.2). In the best case scenario, global health rotations and visits can lead to prolonged academic collaboration, the establishment of bidirectional educational opportunities, longterm sustainable partnerships, and improvement in patient care and local resources [15].

In summary, as has been learned in the assessment of clinical adverse events, debrieng following a visit is also both important and very useful. Post-trip reection allows for individuals to gain a better understanding of themselves and their experiences [2, 27, 28]. It may of course provide feedback for institutions and organizations in their planning of future missions [21]. Reection may also permit analysis of previously encountered distressing situations and outcomes which will lead to avoidance of future discouragement. The entire team, including members of the host institution, should participate in an analysis of the impact of a global health experience [18]. This bidirectional feedback can help improve partnerships between the visiting and host institutions and ensure that the relationships benet both the hosts and the volunteers.

As the number of global health opportunities for volunteers, medical trainees, and clinicians continues to increase, it is important to develop more standardized PDT programs and following the visitors’ return, implement more rigorous evaluations and debriengs to avoid repetition of problems and errors. Better-prepared volunteers and health care workers will be less likely to put themselves and members of the community they are serving at risk. Most importantly, they are more likely to provide appropriate services for the patients they will care for and improve the experience and long-term outcomes for themselves and the programs that they serve.

References

1. Birnberg JM, Lypson M, Anderson RA, Theodosis C, Kim J, Olopade OI, Arora VM. Incoming resident interest in global health: occasional travel

versus a future career abroad? J Grad Med Educ. 2011;3:400–3.

2. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Merisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SL, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.

3. Hau DK, Smart LR, DiPace JI, Peck RN. Global health training among U.S. residency specialties: a systematic literature review. Med Educ Online. 2017;22:1270020.

4. Kaeppler C, Holmberg P, Tam RP, Porada K, Stryker SD, Conway K, Schubert C, Medical Student Global Health Study Group. The impact of global health opportunities on residency selection. BMC Med Educ. 2021;21:384.

5. Chetta MD, Shakir A, Paek LS, Lee GK.Evaluating resident perspectives on international humanitarian missions. J Craniofac Surg. 2018;29:279–85.

6. Melby MK, Loh LC, Evert J, Prater C, Lin H, Khan OA. Beyond medical “missions” to impact-driven short-term experiences in Global Health (STEGHs): ethical principles to optimize community benet and learner experience. Acad Med. 2016;91:633–8.

7. Vu MT, Johnson TR, Francois R, Simms-Cendan J.Sustained impact of short-term international medical mission trips: resident perspectives. Med Teach. 2014;36:1057–63.

8. Henry JA, Groen RS, Price RR, Nwomeh BC, Kingham TP, Hardy MA, Kushner AL.The benets of international rotations to resource-limited sttings for U.S. surgery residents. Surgery. 2013;4:445–54.

9. Bessette J, Camden C.Pre-departure training for student Global Health experiences: a scoping review. Physiother Can. 2017;69:343–50.

10. Kaur G, Tabaie S, Brar J, Tangel V, Pryor KO.Global health education in United States anesthesiology residency programs: a survey of resident opportunities and program director attitudes. BMC Med Educ. 2017;17:215.

11. Prin M, Phelps J. International elective opportunities in United States anesthesia residency programs. J Educ Perioper Med. 2017;19:E613.

12. Imperato PJ, Bruno DM, Sweeney MM.Ensuring the health, safety and preparedness of U.S.Medical students participating in global health electives overseas. J Community Health. 2016;41:442–50.

13. Kung TH. Host physician perspectives to improve pre-departure training for global health electives. Med Educ. 2018;52:3–5.

14. Peluso MJ, Kallem S, Elansary M, Rabin TL.Ethical dilemmas during international clinical rotations in global health settings: ndings from a training and debrieng program. Med Teach. 2018;40: 53–61.

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15. St Clair NE, Pitt MB, Bakeera-Kitaka S, McCall N, Lukolyo H, Arnold LD, Audcent T, Batra M, Chan K, Jacquet GA, Schutze GE, Butteris S, Global Health Task Force of the American Board of Pediatrics. Global health: preparation for working in resourcelimited settings. Pediatrics. 2017;140

16. Ouma BD, Dimaras H.Views from the Global South: exploring how student volunteers from the Global North can achieve sustainable impact in global health. Glob Health. 2013;9:32.

17. Anderson KC, Slatnik MA, Pereira I, Cheung E, Xu K, Brewer TF.Are we there yet? Preparing Canadian medical students for global health electives. Acad Med. 2012;87:206–9.

18. Herbst de Cortina S, Arora G, Wells T, Hoffman RM.Evaluation of a structured predeparture orientation at the David Geffen School of Medicine’s Global Health education programs. Am J Trop Med Hyg. 2016;94:563–7.

19. Anderson K, N. Bocking, Slatnik M, Pattani M, Breton J, Scaciragic L, Dhillon S.Preparing medical students for electives in low-resource settings: a template for national guidelines for pre-departure training. 2008.

20. Crump JA, Sugarman J, Working Group on Ethics Guidelines for Global Health Training. Ethics and best

practice guidelines for training experiences in global health. Am J Trop Med Hyg. 2010;83:1178–82.

21. Purkey E, Hollaar G.Developing consensus for postgraduate global health electives: denitions, predeparture training and post-return debrieng. BMC Med Educ. 2016;16:159.

22. Surgeons OverSeas (SOS) web site; 2022. http://

www.humanitariansurgery.org/

23. Operating Giving Back web site; 2022. http://www.

operationgivingback.facs.org/

24. Global Pediatric Surgery Network web site; 2011.

http://globalpediatricsurgery.org/

25. Residency Review Committee website. Criteria for approved international rotations; 2022. http://www.

acgme.org/acWebsite/navPages/nav_440.asp

26. Mitchell KB, Tarpley MJ, Casey KM.Elective global surgery rotations for residentgs: a call for cooperation and consortium. World J Surg. 2011;35:2617–24.

27. Abedini NC, Gruppen LD, Kolars JC, Kumagai AK. Understanding the effects of short-term international service-learning trips on medical students. Acad Med. 2012;87:820–8.

28. Chang BA, Karin E, Davidson ZA, Ripp J, Soriano RP.Impact of a short-term domestic service-learning program on medical student education. Ann Glob Health. 2019:85.

How toMaintain Ethical Standards

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ofGlobal Surgery Practice andPartnerships

BarnabasT.Alayande, RobertR.Riviello, andAbebeBekele

The single story creates stereotypes, and the problem with stereotypes is not that they are untrue, but that they are incomplete. They make one story become the only story.

– Chimamanda Adichie

Abbreviations

HIC High-Income Country IRB Institutional Review Board LMIC Low- and Middle-Income Country

Introduction

Global surgery is an area of study, research, practice, and advocacy that seeks to improve health outcomes and achieve health equity for all people who require surgical care, with a special emphasis on underserved populations and populations in crisis [1]. The Lancet Commission on Global Surgery estimated that 5 billion people

lack access to affordable, available, adequate surgical care when needed. It is agreed that this burden tilts signicantly towards low- and middle- income countries (LMICs), where over 148 million additional surgeries are needed annually to meet the global surgical need [2]. This special emphasis on underserved populations and LMICs, along with the often-colonial mindset that is associated with high-income surgical providers intervening in these contexts, many times raises a multifaceted ethical challenge. This challenge is compounded by the vulnerability of the sick and injured within an already vulnerable low-income system. Most interventions brought from a high-income country (HIC) setting comes with an intrinsic

B. T. Alayande (*) Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA e-mail: balayande@ughe.org

R. R. Riviello Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA

Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA

Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA e-mail: riviello@post.harvard.edu

A. Bekele Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda

School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia e-mail: abekele@ughe.org

https://t.me/medicina_free

B. T. Alayande et al.

power dynamic-skin color, resource, educational advantage, exposure, institutional prestige, political power, passport and visa privilege, knowledge gradient, and money.

Ethics refers to the branch of moral philosophy concerned with the “manner people should act in a knowledge context, based on what they know, ought to know, and should know and do.” It is a “value-laden judgment about actions, the rules guiding the actions, and the appropriate choices of reasonable steps to take in a context” [3]. Surgical ethics have been dened as the application of ethics to situations specic to surgical practice, considering the peculiarity that surgery literally causes harm before healing, and that it is intrinsically characterized by intense accountability [4]. Four domains have been identied in the ethics of global surgery– ethics of clinical care, research, education, and collaborations [5]. Most ethical considerations in literature are, however, skewed toward ethics of clinical practice during short-term missions, and up to 80% of this literature is from HICs, specically academic institutions in the United States, Canada, and the UK [5]. This raises ethical questions within the development of ethics for LMIC engagement, as the recipients of most global surgery engagements are not at the table to contribute to this important subject matter. Partnerships are key to effectively engaging the problems of surgical burden, insufcient manpower, inadequate surgical infrastructure, frail surgical systems, and inadequate surgical nancing. While local surgical champions provide the context, often, they do not have adequate resources to address the very real problems they are steeped in. Ethical considerations of partnerships are therefore extremely important to global surgery ethics.

Colonialism refers to the policy or practice of acquiring full or partial political control over another country, occupying it with settlers and exploiting it economically. Arguably, frank colonialism is fading, and giving way to more subtle control of country systems without open conquest, or unabashed exploitation. Neocolonialism is associated with unfair exchange, resource exploitation and extraction, a “strings-

attached” model of funding, one-sided partnerships, non-contextual interventions, and gifting of results without capacity building among other issues. This neo-colonialism might be perceived by some as more acceptable than colonialism, but still represents the same principles, with more covert practices [6]. The fact that LMIC collaborators do not speak up or comment on these issues might reect power imbalances, post-colonial cultures, host country cultures and norms, respect to guest or the elders, perceptions of respect, fear of funding loss, lack of trust and deep engagement, or even that surgical visitors to these contexts are simply not listening. It is also not uncommon for surgical visitors to have backings of hospital and ministry leaders that intimidates local surgeons. The decolonizing global health movement (inclusive of global surgery) was born in an attempt to counter these norms, and has gained traction in the past few years, catalyzed by the COVID pandemic [7].

Decolonizing is an essential part of the journey to equity, but we must be careful to move beyond attempting to dismantle structures to constructively building partnerships focused on inclusive access to surgical care and education based on quality and on diversity. As we learn from the colonial past, our greatest focus should be on equity for the future. If decolonization is not an ending of partnerships, then we must unlearn, learn, and relearn global surgical relationships. This chapter is focused on identifying the common ethical challenges experienced in global surgery surrounding the domains of clinical delivery of health care, of education in global surgery, and also of trainee exchange, surgical research, and collaborations and partnerships [5]. We describe frameworks for ethical and equitable partnerships which intend to help readers reect on the ethics of their current work. We also aim to bring HIC partners to terms with pervasive structural racism and suggest how to mitigate the likelihood of permitting these systems to work in global surgery. Finally, we hope that readers will learn how to initiate difcult discussions (constructively confront), ask forgiveness (humble vulnerability), and change practice (sensitive accompaniment) as they seek to be ethical in

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