Globalization, Volunteerism, and Mission Surgery: How to Help Without Harming Mimis Cohen, MD, FACS and Seth Thaller, MD, DMDy


lobalization has been used widely during the last years to denote the process of international integration arising from interchanges of ideas, products, views, and cultural activities. The International Monetary Fund (IMF) in the year 2000 identified 4 basic aspects of globalization to include the following: trade and transactions, capital and investment movements, and migration and the dissemination of knowledge. Albrow and King1 defined globalization as: ‘‘. . ... Those processes by which people of the world are incorporated into a single world society. . ..’’ Thus, people are now closer together than ever before because of the great advances in travel, transportation, telecommunications, and the Internet. But what does globalization and volunteerism have to do with surgery and what further effect does globalization have and will have in volunteerism and mission plastic surgery? We must always understand and appreciate the reasons that stimulate individual surgeons to be involved with volunteer surgery. Each donates their personal time and funds in an effort to assist needy and underserved people in various parts of the globe. Driven purely by altruistic and humanitarian instincts, these first pioneers started travelling in remote and underprivileged areas for short periods of time to treat needy patients. They had a few instruments and medical equipment but possessed volumes of good will. Performing fewer reconstructive procedures in areas with minimal recourses was a great but rewarding challenge. There was, however, little backup available and scarce or no follow-up. The present model, despite its significant drawbacks, is still used by several surgeons. Demands are great, but national recourses in personnel, financial support, and infrastructure are limited, and major nongovernmental organizations (NGOs) and other organizations of care are not able to cover all of the world needs. One of the first pioneers was the late Tom Reese who along with Sir Archibald McIndoe and Sir A. Michael Wood founded the Flying Doctors of East Africa in 1957. They flew into the bush to set

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From the Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois at Chicago, Chicago, IL, and the yDivision of Plastic, Aesthetic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, FL. Received December 4, 2014. Accepted for publication December 13, 2014. Address correspondence and reprint requests to Mimis Cohen, Chicago, IL. E-mail: [email protected] There are no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001677


up clinics in rural areas of East Africa in an effort to enable advanced medical care ranging from vaccinations to operating on and treating local patients with congenital deformities and other conditions requiring extensive reconstructive surgeries. Initially, there was no plastic surgery expert in this vast area, thus an integral part of their mission from the onset was to provide extensive training and education to the local doctors, residents, and students to provide them the necessary knowledge and hands-on experience to ultimately manage and efficiently treat the local population. This organization evolved to African Medical & Research Foundation, and is presently considered to be Africa’s largest health development NGO. Dr Rees’ adventures in Africa are chronicled in his fascinating book, ‘‘Daktari: A Surgeon’s Adventures With Flying Doctors in Africa’’2; incredible stories by an incredible human being. Lessons learned from these initial experiences allowed us to further evaluate global needs, in a more detailed way. The result was improved and comprehensive care around the world to children and adults requiring our assistance. Need for better organization and coordination of mission trips become obvious. Several of the initial small teams guided by visionary surgeons evolved, with the assistance of philanthropy, to complex multinational organizations now able to provide superior care in partnerships with local physician, health facilities, and sometimes local governments. Several centers of excellence in various parts of the world were established. They promote safe and ethical reconstructive surgeries by well qualified individuals, with adequate follow-ups, quality improvement programs, and additional emphasis to education and research. We should always have in mind, when we start considering participation in a surgical mission, the Hippocratic teaching from the Oath: meaning: abstain from doing harm! This advice should always guide our steps. Concepts such as medical safari surgery should be condemned and never incorporated into any plans related to plastic surgery missions. Prerequisites for success include extensive planning, understanding the needs for the specific local population, appreciating available community recourses, personnel and support people, facilities and available equipment. Any medical equipment from instruments to sutures, anesthesia machines to monitors necessary to perform safe surgeries should be brought in, if not available locally. Screening of the prospective patients by qualified individuals should be considered mandatory. Malnourished patients with or without comorbidities should be carefully triaged before being included in the surgical schedule. Owing to the wide availability of Skype, Face Time, and other recourses, surgeons are now given the opportunity to ‘‘meet’’ their prospective patients ahead of time and plan accordingly. Cooperation with local physicians is extremely important, not only for the initial evaluation and selection of the most appropriate patients, but for follow-up as well as management of possible complications after the departure of the team. Surgeons need to beware of their capabilities and limitation. They should never use a mission to improve their surgical skills. Certainly, one

The Journal of Craniofacial Surgery

Volume 26, Number 4, June 2015

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

Volume 26, Number 4, June 2015

should not plan to perform procedures that he/she are not privileged in their own institution or perform experimental surgery that they could not accomplish in their own facility. In addition, while preparing for a mission, a surgeon should try to understand some social issue related to the mission; appreciate basic historical and cultural aspect of the area he/she is planning to visit. They must be humble and friendly, but also mindful and respectful of some of the local customs and religious beliefs. Because of the increased demand for participation in mission surgery, the American Society of Maxillofacial Surgeons introduced in 2007 refresher courses in cleft surgery. Our goal was to provide prospective volunteer surgeons, experienced otherwise, with knowledge necessary to manage patients with clefts. A great number of surgeons attended these courses and found the opportunity invaluable. Participation in surgical mission is also getting recognized to have a significant value in residents’ education. Based on these observations, the Accreditation Council for Graduate Medical Council and the plastic surgery RRC have approved inclusion of cases performed in missions, under supervision by qualified surgeons, in their plastic surgery operating log. This practice not only helps residents in improving the number of cases in some categories that they may have been deficient in some institutions, but, more importantly, instills in them the humanitarian principles and prepares them to become future leaders in the field. Based on previous experiences, surgeons started reconsidering the focus of mission surgery toward providing local institutions and physicians with means to develop independence and sustainability in health care. Several successful examples have been presented in the present literature. These studies clearly demonstrate that with appropriate planning, partnership with interested parties, and establishment of cleft centers, improved care can be delivered by the local physicians all-year round. This scenario provides not only surgical care, but all inclusive necessary care for cleft patients, including speech and orthodontic care. Obviously, more needs to be done in this direction, but early experience seems to demonstrate that this one of the models we will need to support and expand in the future.3 –5 The International community has extensively recognized the efforts of various volunteer organizations and individuals not only with financial support, but with many awards. Doctors without Borders/Me´decins Sans Frontie`res is a French-founded humanitarian-aid NGO that provides emergency medical care to millions of people caught in crises in some 70 countries around the world. They were awarded the Nobel Prize for Peace in 1999 ‘‘in recognition of the organization’s pioneering humanitarian work on several continents’’. It is also remarkable that 3 documentary films related to volunteer plastic surgical activities recently received Oscars by the Academy Awards. ‘‘A story of healing,’’ a film produced by Donna Dewey, followed a group of American plastic surgeons,


2015 Mutaz B. Habal, MD

Globalization, Volunteerism, and Mission Surgery

anesthesiologists, and nurses on a journey to An Giang, Vietnam, in January 1997.6 In this remote Mekong Delta province, the surgeons operated >100 children to correct various facial deformities, including cleft palates, cleft lips, and tumors. Their journey was organized by ReSurge International (Sunnvale, CA). In 2009, the documentary ‘‘Smile Pinki,’’ directed by Megan Mylan, received the Oscar of best short subject. The documentary presented the story of Pinki Sonkar, a 5-year-old girl living with a severe cleft lip in one of the poorest areas of India. She was ostracized because of her deformity and not allowed to attend school. Her poor parents could not afford the costs for the surgery. Through the Smile Train program, Pinki had her cleft lip repaired and was able to attend the Academy’s award ceremony along with her surgeon Dr S.K. Singh.7 Just 3 years later, in 2012, the Academy awarded the Oscar for documentary film to ‘‘Saving Face.’’ This is a documentary film directed by Sharmeen Obaid Chinoy and Daniel Junge dealing with acid attacks on women in Pakistan. The film followed the Londonbased Pakistani plastic surgeon Dr. Mohammad Jawad as he traveled to Pakistan to perform reconstructive procedures on survivors of acid violence. The Pakistani’s parliament decision to pass a bill on acid violence and proceed with conviction of one of the perpetrators was also included in this powerful documentary.8 ‘‘The reward for a good did is that you did it.’’ This quote by the Roman stoic philosopher Lucius Annaeus Seneca, in one of his letters to Luculious, sums up why we participate in these volunteer surgical missions: Not only do we share in improving our global community and reducing human suffering, but also enhancing our own souls. It is our strong belief that plastic surgeons will continue to take a leading role in this field by providing direct care and innovative strategies to sustain new programs.

REFERENCES 1. Albrow M, King E. Globalization, Knowledge and Society. London, UK: Sage Press; 1990:8 2. Rees TD. Daktari: A Surgeon’s Adventures with the Flying Doctors of East Africa. Santa Fe, NM: Sunstone Press; 2004 3. Goh RCW, Wang R, Chen PKT, et al. Strategies for achieving long-term effective outcome in cleft missions: The Noordhoff Craniofacial Foundation and Chang Gung Memorial Hospital. J Craniof Surg 2009;20 (suppl 2):1657–1660 4. Magee WP Jr. Evolution of a sustainable surgical delivery model. J Craniof Surg 2010;21:1321–1326 5. Aliu O, Chung KC. Discussion: the clinical and economic impact of a sustained program in global plastic surgery: valuing cleft care in resource-poor settings. PRS 2012;130:95e–97e 6. A story of healing. http://www.youtube.com/watch?v=uI1qRODHpwc 7. Smile Pinki. Available at: http://www.vimeo.com/6172785 8. Saving Faces. Available at: http://www.hbo.com/documentaries/savingface


Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Globalization, Volunteerism, and Mission Surgery: How to Help Without Harming.

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