SPECIAL EDITORIAL
Shared Education and Shared Innovation in the Global Health Setting Arturo J. Rios Diaz, MD and E.J. Caterson, MD, PhD
N
‘‘
ecessity is the mother of invention’’ is a proverb with roots attributed to Plato. Indeed, this has held true particularly in the world of medicine where lowresource settings have driven and motivated innovations that have transcended. For instance, in 1984, a second year surgical resident in the poorest area of Bogota, Colombia was assisting a complex laparotomy case. The abdominal infection was impeding the closure, so he suggested temporarily closing the open abdomen by suturing a 3-L urologic irrigation bag to the edges of the wound until the abdomen could be formally closed at a later time. The technique was successful and it is known today as the ‘‘Bogota Bag.’’1 Now jump to rural India, where in 2013 surgeons validated the use of a low-density polyethylene mosquito net for hernia repair.2 Finally, in the 1950s, when a Polish surgical resident training in an industrial town in Kurgan, Serbia constructed the first fracture external fixator from gaskets cut from old tanks and wires, that were actually bicycle spokes drilled through the bone.3 Each of these different accomplishments share the common threads of taking an existing need and innovating to solve a clinical problem. Low resource settings are often similar in terms of having a large backlog of existing clinical need. Therefore, it should be no surprize that this ‘‘need’’ fuels the desire to help patients and that it will continue to drive what has been termed reverse innovation. This process is defined as the spreading of an inexpensive and successful innovation from a resource-constrained country to an industrialized nation.3 This concept is common in the global health literature when authors describe transferrable lessons from lowincome countries’ insights to wealthier nations.4 In agreement with Cotton et al,3 the term reverse is patronizing, implying that the natural flow of ideas is unidirectional (from high- to low-income countries), and diminishing the significance of these accomplishments. The authors believe that the flow of knowledge and innovation between nations has always been bidirectional. Therefore, the word shared should be used in place of reverse, making the terms shared innovation and shared education more accurate reflections of this mutual process.
Throughout history the spread of knowledge across the world has been a slow process; however, with increase in global access to the Internet the process has and can further be expedited. To illustrate this, let us briefly look at some historical landmarks of nasal reconstruction and how long it took to get to the United States. Rhinoplasty is said to have been practiced from as early as 3000 to 2500 BC in Egypt.5 The next known Rhinoplasty registry in the literature is from the ancient Indian compendium of medicine Sushruta Samhita (500 BC).6 It is not until the 15th Century that it is spread to Italy, when Branca de’Branca introduced a method to use forehead and cheek flaps for facial reconstruction.7 His son modified this technique by using the arm as the primary donor site and delaying the initial transfer of the graft, what is known as the Italian method.7 This technique was later improved and described in detail by Gasparo Tagliacozzi in 1597.7 In 1794, an English surgeon who was working in India witnessed a forehead flap for nasal reconstruction; he sent a letter describing the operation to the Gentleman’s Magazine of London that was published that year.7 Dr Carpue, who was also a British surgeon, read this edition and was so intrigued in the procedure that he practiced it on cadavers for 20 years, publishing the cases and gaining recognition.7 Finally, it was not until late 1830s when Dr JM Warren in Boston, Massachusetts performed the first nasal reconstruction in the United States.7 It took literally hundreds of years to break the geographical, cultural, and religious barriers allowing the transfer of knowledge from Africa to Asia, then to Europe, and finally to America. These obstacles no longer need to be a problem with the Internet. The only barrier that a physician from a low resource setting with Internet access may encounter is the access to a paid-journal-article, which could cost him 2 days of salary.4 Herein, lays the importance of open access for the dissemination of global health literature.4 The United States produces almost as much research in citable documents as its closest 5 competitor nations combined (Fig. 1). The United States represents 4.4% of world’s population9 and yet it
What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA. Received April 2, 2015. Accepted for publication April 2, 2015. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001862
The Journal of Craniofacial Surgery
FIGURE 1. Citable medical research output (articles, reviews, and conference papers) of the most productive nations between 1996 and 2013. X axis represents years; Y, publications. (Data from the SCImago Lab8).
Volume 26, Number 4, June 2015
1009
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Rios Diaz and Caterson
The Journal of Craniofacial Surgery
TABLE 1. Accreditation Council for Graduate Medical Education (ACGME) Minimum Operative Requirements for Head and Neck Congenital Defects Head and Neck Congenital Defects Primary cleft lip repair Primary cleft palate repair Secondary cleft lip or palate repair Cleft lip nasal deformity repair Craniomaxillofacial reconstruction Vascular malformation (laser) Other head and neck congenital defects procedures Total
No. Cases 7 7 7 50
Data taken from the ACGME.11 Minimum cases required are not specified by the ACGME.
generates close to half of the research output listed in PubMed.10 Based on these facts, United States health professionals may be quick to overlook low-income nations’ ability to provide opportunities to surgical professionals, trainees, and residency programs from high-income countries. In fact, the global health community has started to acknowledge the potential to build mutual surgical capacity through international partnerships.4 Many plastic surgery residents and staff participate on international medical missions to perform cleft surgery. In most cases, these itinerant surgeons travel to locations with overwhelming surgical needs permitting relationships that can be formalized into training programs. American and European plastic surgery residency programs have developed short-term rotations, which provide virtually unlimited access to cleft cases for both established surgical professionals and resident trainees. These ‘‘International’’ rotations can be especially important if one takes into consideration the minimum operative requirements set by the Accreditation Council for Graduate Medical Education (ACGME) for cleft (Table 1). In these bidirectional educational missions, it is often the local surgeon and the itinerant surgeon who are both the trainer and/or the educator depending upon the circumstance. On the contrary, albeit few in number, there are also well-established plastic surgery traveling fellowships promoted by surgical societies, which allow foreign residents/surgeons to come to the United States or Europe to gain experience and knowledge. This activity, although limited, is irrefutable evidence that the dynamic of surgical education is truly bidirectional.
1010
Volume 26, Number 4, June 2015
With health expenditure representing 18% of the United States’ gross domestic product (the highest in the world),9 it can be said that healthcare is a major priority in our economy. As result of this investment, we have a well-trained work force with potential excess capacity. Providers have started to realize that this presents opportunity for healthcare delivery in low-income countries to enrich both medical education and to serve the global community. As healthcare professionals, it is our duty to use our skill sets to contribute to both local and global health initiatives. We must never underestimate the educational potential of other regions, and we must continue fostering true international partnerships for the common benefit.
REFERENCES 1. Borraez OA. Manejo del Abdomen Se´ptico. Utilizacio´n del Polivinilo. Avances en Cirugı´a e Infeccio´n. (Presentations of the XV Congress). Bogota´: Editorial Me´dica (Panamericana) Internacional, Colombia; 1989. 2. Tongaonkar RRB, Mehta VK, Singh NS, et al. Preliminary multicentric trial of cheap indigenous mosquito-net cloth for tension-free hernia repair. Indian J Surg 2003;65:89–95 3. Cotton M, Henry JA, Hasek L. Value innovation: an important aspect of global surgical care. Global Health 2014;10:1 4. Binagwaho A, Nutt CT, Mutabazi V, et al. Shared learning in an interconnected world: innovations to advance global health equity. Global Health 2013;9:37 5. Shiffman MA, Di Giuseppe A. Cosmetic Surgery: Art and Techniques Heidelberg, New York: Springer; 2013 6. Saraf S, Parihar R. Sushruta: the first plastic surgeon in 600 B.C. Int J Plast Surg 2007;4:2 7. Belinfante LS. History of rhinoplasty. Oral Maxillofac Surg Clin North Am 2012;24:1–9 8. SCImago. SJR – SCImago Journal & Country Rank. Available at: http:// www.scimagojr.com/countryrank.php. Accessed March 30, 2015 9. The World Bank. United States – Data. 2013; Available at: http:// data.worldbank.org/country/united-states. Accessed March 30, 2015 10. U.S. National Library of Medicine. MEDLINE1 Citation Counts by Year of Publication (as of mid – November 2014). Available at: http:// www.nlm.nih.gov/bsd/medline_cit_counts_yr_pub.html. Accessed March 30, 2015 11. Accreditation Council for Graduate Medical Education. Operative Minimums Effective July 1, 2014. Review Committee for Plastic Surgery. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/ Operative_Minimums_effective_07012014.pdf. Accessed March 30, 2015
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Shared Education and Shared Innovation in the Global Health Setting Arturo J. Rios Diaz, MD and E.J. Caterson, MD, PhD
N
‘‘
ecessity is the mother of invention’’ is a proverb with roots attributed to Plato. Indeed, this has held true particularly in the world of medicine where lowresource settings have driven and motivated innovations that have transcended. For instance, in 1984, a second year surgical resident in the poorest area of Bogota, Colombia was assisting a complex laparotomy case. The abdominal infection was impeding the closure, so he suggested temporarily closing the open abdomen by suturing a 3-L urologic irrigation bag to the edges of the wound until the abdomen could be formally closed at a later time. The technique was successful and it is known today as the ‘‘Bogota Bag.’’1 Now jump to rural India, where in 2013 surgeons validated the use of a low-density polyethylene mosquito net for hernia repair.2 Finally, in the 1950s, when a Polish surgical resident training in an industrial town in Kurgan, Serbia constructed the first fracture external fixator from gaskets cut from old tanks and wires, that were actually bicycle spokes drilled through the bone.3 Each of these different accomplishments share the common threads of taking an existing need and innovating to solve a clinical problem. Low resource settings are often similar in terms of having a large backlog of existing clinical need. Therefore, it should be no surprize that this ‘‘need’’ fuels the desire to help patients and that it will continue to drive what has been termed reverse innovation. This process is defined as the spreading of an inexpensive and successful innovation from a resource-constrained country to an industrialized nation.3 This concept is common in the global health literature when authors describe transferrable lessons from lowincome countries’ insights to wealthier nations.4 In agreement with Cotton et al,3 the term reverse is patronizing, implying that the natural flow of ideas is unidirectional (from high- to low-income countries), and diminishing the significance of these accomplishments. The authors believe that the flow of knowledge and innovation between nations has always been bidirectional. Therefore, the word shared should be used in place of reverse, making the terms shared innovation and shared education more accurate reflections of this mutual process.
Throughout history the spread of knowledge across the world has been a slow process; however, with increase in global access to the Internet the process has and can further be expedited. To illustrate this, let us briefly look at some historical landmarks of nasal reconstruction and how long it took to get to the United States. Rhinoplasty is said to have been practiced from as early as 3000 to 2500 BC in Egypt.5 The next known Rhinoplasty registry in the literature is from the ancient Indian compendium of medicine Sushruta Samhita (500 BC).6 It is not until the 15th Century that it is spread to Italy, when Branca de’Branca introduced a method to use forehead and cheek flaps for facial reconstruction.7 His son modified this technique by using the arm as the primary donor site and delaying the initial transfer of the graft, what is known as the Italian method.7 This technique was later improved and described in detail by Gasparo Tagliacozzi in 1597.7 In 1794, an English surgeon who was working in India witnessed a forehead flap for nasal reconstruction; he sent a letter describing the operation to the Gentleman’s Magazine of London that was published that year.7 Dr Carpue, who was also a British surgeon, read this edition and was so intrigued in the procedure that he practiced it on cadavers for 20 years, publishing the cases and gaining recognition.7 Finally, it was not until late 1830s when Dr JM Warren in Boston, Massachusetts performed the first nasal reconstruction in the United States.7 It took literally hundreds of years to break the geographical, cultural, and religious barriers allowing the transfer of knowledge from Africa to Asia, then to Europe, and finally to America. These obstacles no longer need to be a problem with the Internet. The only barrier that a physician from a low resource setting with Internet access may encounter is the access to a paid-journal-article, which could cost him 2 days of salary.4 Herein, lays the importance of open access for the dissemination of global health literature.4 The United States produces almost as much research in citable documents as its closest 5 competitor nations combined (Fig. 1). The United States represents 4.4% of world’s population9 and yet it
What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA. Received April 2, 2015. Accepted for publication April 2, 2015. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001862
The Journal of Craniofacial Surgery
FIGURE 1. Citable medical research output (articles, reviews, and conference papers) of the most productive nations between 1996 and 2013. X axis represents years; Y, publications. (Data from the SCImago Lab8).
Volume 26, Number 4, June 2015
1009
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Rios Diaz and Caterson
The Journal of Craniofacial Surgery
TABLE 1. Accreditation Council for Graduate Medical Education (ACGME) Minimum Operative Requirements for Head and Neck Congenital Defects Head and Neck Congenital Defects Primary cleft lip repair Primary cleft palate repair Secondary cleft lip or palate repair Cleft lip nasal deformity repair Craniomaxillofacial reconstruction Vascular malformation (laser) Other head and neck congenital defects procedures Total
No. Cases 7 7 7 50
Data taken from the ACGME.11 Minimum cases required are not specified by the ACGME.
generates close to half of the research output listed in PubMed.10 Based on these facts, United States health professionals may be quick to overlook low-income nations’ ability to provide opportunities to surgical professionals, trainees, and residency programs from high-income countries. In fact, the global health community has started to acknowledge the potential to build mutual surgical capacity through international partnerships.4 Many plastic surgery residents and staff participate on international medical missions to perform cleft surgery. In most cases, these itinerant surgeons travel to locations with overwhelming surgical needs permitting relationships that can be formalized into training programs. American and European plastic surgery residency programs have developed short-term rotations, which provide virtually unlimited access to cleft cases for both established surgical professionals and resident trainees. These ‘‘International’’ rotations can be especially important if one takes into consideration the minimum operative requirements set by the Accreditation Council for Graduate Medical Education (ACGME) for cleft (Table 1). In these bidirectional educational missions, it is often the local surgeon and the itinerant surgeon who are both the trainer and/or the educator depending upon the circumstance. On the contrary, albeit few in number, there are also well-established plastic surgery traveling fellowships promoted by surgical societies, which allow foreign residents/surgeons to come to the United States or Europe to gain experience and knowledge. This activity, although limited, is irrefutable evidence that the dynamic of surgical education is truly bidirectional.
1010
Volume 26, Number 4, June 2015
With health expenditure representing 18% of the United States’ gross domestic product (the highest in the world),9 it can be said that healthcare is a major priority in our economy. As result of this investment, we have a well-trained work force with potential excess capacity. Providers have started to realize that this presents opportunity for healthcare delivery in low-income countries to enrich both medical education and to serve the global community. As healthcare professionals, it is our duty to use our skill sets to contribute to both local and global health initiatives. We must never underestimate the educational potential of other regions, and we must continue fostering true international partnerships for the common benefit.
REFERENCES 1. Borraez OA. Manejo del Abdomen Se´ptico. Utilizacio´n del Polivinilo. Avances en Cirugı´a e Infeccio´n. (Presentations of the XV Congress). Bogota´: Editorial Me´dica (Panamericana) Internacional, Colombia; 1989. 2. Tongaonkar RRB, Mehta VK, Singh NS, et al. Preliminary multicentric trial of cheap indigenous mosquito-net cloth for tension-free hernia repair. Indian J Surg 2003;65:89–95 3. Cotton M, Henry JA, Hasek L. Value innovation: an important aspect of global surgical care. Global Health 2014;10:1 4. Binagwaho A, Nutt CT, Mutabazi V, et al. Shared learning in an interconnected world: innovations to advance global health equity. Global Health 2013;9:37 5. Shiffman MA, Di Giuseppe A. Cosmetic Surgery: Art and Techniques Heidelberg, New York: Springer; 2013 6. Saraf S, Parihar R. Sushruta: the first plastic surgeon in 600 B.C. Int J Plast Surg 2007;4:2 7. Belinfante LS. History of rhinoplasty. Oral Maxillofac Surg Clin North Am 2012;24:1–9 8. SCImago. SJR – SCImago Journal & Country Rank. Available at: http:// www.scimagojr.com/countryrank.php. Accessed March 30, 2015 9. The World Bank. United States – Data. 2013; Available at: http:// data.worldbank.org/country/united-states. Accessed March 30, 2015 10. U.S. National Library of Medicine. MEDLINE1 Citation Counts by Year of Publication (as of mid – November 2014). Available at: http:// www.nlm.nih.gov/bsd/medline_cit_counts_yr_pub.html. Accessed March 30, 2015 11. Accreditation Council for Graduate Medical Education. Operative Minimums Effective July 1, 2014. Review Committee for Plastic Surgery. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/ Operative_Minimums_effective_07012014.pdf. Accessed March 30, 2015
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
