A recent article on NPR’s Goats and Soda blog took a critical look at traditional short-term, “fly-in” medical missions that are common throughout the developing world. I found this piece very interesting, and after spending seven years with CURE International in our hospital in Niger, West Africa, a lot of what was said resonated with me. Of course for many people, these short-term medical missions are a great opportunity to help others who are in real need and to demonstrate their compassion in a tangible way. However, there are legitimate concerns raised in this article that need to be considered, especially when surgery is involved.
Flying a surgeon in for a week-long surgical camp may seem like a very efficient use of their time and can be very beneficial to the patients, especially if the surgeon is a specialist. The visiting surgeon may have a particular surgical skill-set that is just not available in the country they are visiting. However, many factors go into achieving a successful surgical outcome, and if ignored, the visitor could cause more harm than good. It is easy to get excited about doing 100 surgeries in a week, but there are questions to address to ensure that this is done safely. For example, what about the post-surgical follow-up? Surgeons perform operations relatively quickly, but healing takes time—when a surgeon leaves after a week of surgery, how confident is she that her patients will have access to nurses trained for wound care? Will the nurses have the materials they need? What about post-surgical complications? What if the patient requires another procedure, but all the surgeons are gone?
More issues arise regarding the operation of a surgical camp. Patient turnover often becomes a concern, and the surgical schedule can become overbooked. Certainly, coordinators do this out of a desire to maximize the impact of the visiting surgeons and to help as many patients as possible. Unfortunately, this can easily lead to practices considered unsafe and unacceptable in the hospitals where the visiting surgeons usually serve. In a surgical camp setting, sometimes an attitude of expediency can develop, and substandard conditions are explained away by saying, “Well, this is better than nothing.” Aside from the fact that this is an inherently arrogant and culturally insensitive sentiment, it is also not always true. While many patients do benefit from this type of fly-in medical mission, there are plenty of patients who end up worse off than they were before.
While CURE International does host short-term surgical teams, the context is very different than what I’ve described. We are attentive to the issues raised above, and many visiting surgeons have commented on this. They enjoy visiting our hospitals because, for the most part, they are aware of these issues and are glad to work in a facility that is well maintained, well staffed, and well equipped. Their perception is not accidental—CURE International was founded on the principle of establishing and maintaining a long-term, sustainable presence, and therefore it is the antithesis of the short-term, fly-in mission.
The idea of building a sustainable presence in the developing world began with CURE International’s founders, Scott and Sally Harrison. They were not satisfied with the traditional medical missions model (including the fly-in surgical mission), so they started building hospitals, not only to provide surgery to the patients but also to provide training to local surgeons and healthcare workers. The idea was simple; instead of just performing operations, they would invest in the local healthcare system through training and capacity building. There are many great examples of this from around our network:
- The first hospital that CURE opened was in Kijabe, Kenya, in partnership with the Africa Inland Church. The hospital opened in 1998 and was African’s first orthopedic pediatric teaching hospital for children with disabilities. The orthopedic surgical training program, certified by the College of Surgeons of East, Central, and Southern Africa (COSECSA), is considered one of the pre-eminent orthopedic surgical residency programs in East Africa and hosts residents from Kenya and from across Africa. CURE Kenya’s Medical Director, Dr. Joseph Theuri, has worked at the hospital in Kijabe for more than 20 years and has trained and mentored many orthopedic surgeons through the residency program. The CURE hospital in Kenya has produced so many talented orthopedic surgeons that they have even sent some of them to our hospital in Niger to fill in on multiple occasions.
- In 2002 CURE International opened a hospital in Blantyre, Malawi, and Dr. Jim Harrison came from the UK to help get the hospital up and running. When he arrived, the hospital building was still under construction. Dr. Harrison spent his time at the government teaching hospital, networking with healthcare workers from hospitals and clinics around the country and also training clinical officers and healthcare providers. After the hospital opened, Dr. Harrison continued to volunteer at the government hospital for over a decade, coming in once a week (plus nights and weekends on call). He also helped develop the training program at the CURE hospital which has equipped surgeons, clinical officers, and nurses from Malawi and around Africa.
- The CURE hospital in Ethiopia also has a great residency program, which is accredited through COSECSA and has helped train many Ethiopian surgeons. CURE’s hospital in Zambia also runs a COSECSA residency program and maintains a close working relationship with the national hospital. The CURE hospital in Niger works with the Medical School at the National University hospital to rotate surgical students and students of anesthesia through the hospital as a part of their training.
There are many more examples as well, and this approach, with such a strong emphasis on training, is essential because it is sustainable in a way that short-term, fly-in missions can never be. There is also another aspect to consider: when provided with training and allowed to operate, local surgeons often develop unique expertise based on their experience and have something to teach even the experts who visit. Knowledge accrues based on the sheer numbers—in the developing world, there are many more patients per surgeon than in the developed world, and as a result, surgeons in the developing world have more experience dealing with certain conditions. Although prevalence rates are similar across the globe for some of the congenital pathologies like cleft lip and clubfoot, there are many more patients suffering from these conditions in the developing world. There are many reasons for this, but a big one is the lack of qualified surgeons. A surgeon who specializes in cleft lip/cleft palate repairs in the United States may only perform 30-40 cases a year, whereas a surgeon in the developing world may do that many in a month.
There are also conditions that US- or European-based surgeons do not see but which are frequent in the countries where we serve, such as neglected clubfoot and other congenital orthopedic conditions. Many experienced and well-trained visiting orthopedic surgeons are puzzled by cases that are routine in our hospitals, only because they have never seen anything like them in their regular practice. This highlights another important point—when visiting surgeons do come, they should be willing to teach what they know and help pass along their training, but they should also be willing to learn.
Our CURE hospital in Uganda draws surgeons from around the world who are eager to learn from our doctors. The hospital, which opened in 2000, specializes in neurosurgery with a particular emphasis on hydrocephalus and spina bifida. It was at this hospital that Dr. Benjamin Warf developed the revolutionary ETV/CPC technique for hydrocephalus treatment (Dr. Warf was later awarded the MacArthur Foundation “Genius Grant” for his work in Uganda.) In addition to being another COSECSA training site, this hospital also hosts the CURE Hydrocephalus and Spina Bifida program, which focuses on training surgeons and equipping them to treat these conditions. To date, the program has trained 32 fellows from 19 different countries in the developing world, as well as 10+ from the United States and Europe. It is not often that you have surgeons coming from around the world to learn from their colleagues in Africa, but that is what is happening at the CURE hospital in Uganda.
In any case, I believe that there is still a place for the short-term surgical trip, as long as it is done with a spirit of humility and a desire to aid in the development of the local surgeons and the local healthcare system as a whole. In Niger, we had some great experiences with visiting surgeons who were leaders in their field. They were very intentional about imparting wisdom and training our team, and they were just as intentional about learning from our team. These visitors were also committed to remaining engaged with us even after their departure, both for the follow up of their patients, and for the training of our staff. Based on these wonderful experiences (as well as on other, less wonderful experiences), we developed a simple calculus when considering potential visitors: you can come if a) you can do something our team cannot do, and b) you are committed to teaching and training our team.
If, on the other hand, your goal is to come and do as many surgeries as possible with little regard for our local clinical staff and no regard for patient follow-up, we are most likely going to decline your offer to help. Our patients and our staff do not need someone to parachute in and save the day. They need someone willing to invest in the local capacity to provide healing a sustainable way, and through our network of hospitals, we have a great platform to facilitate that.
Overall, it is good and healthy to have this conversation on the efficiency of fly-in medical missions. We should all take time to reflect on how we do the work before us, looking at the consequences of our actions, intended or otherwise. In any case, the mission of CURE International has not changed since the first hospital in Kenya was built—our mission is to proclaim the kingdom of God and to heal the sick. In the context of this discussion, the way we do that is by building up the local capacity of the healthcare system in the countries we serve and extending the reach and impact of our work. Strategically, this is the smart thing to do, but it also the right thing to do.