Health Volunteers Overseas meets global health care needs, addresses educational challenges

Introduction

On November 14, 1995, an event changed a young man’s life which, in turn, changed mine. I was the volunteer orthopedic surgeon in St. Lucia when a 26-year-old man twisted his neck carrying a sack of plantains and was carried in by his coworkers. As I write this introduction, I’m looking at the actual X-rays showing his C4-5 dislocation. We used sandbags filled with dirt from the parking lot and a cranial tong and rope to eventually reduce the dislocation. An old edition of Campbell’s was all I had. In desperation, I called a spine surgeon at the University of Vermont (or was it Virginia?). He advised that I proceed with surgical stabilization. I performed my only posterior cervical fusion before pressing the case with the hospital administrators for this young man’s transfer to the more wealthy side of the island where there were two ventilators. The patient made it to the ventilator; my wife and I eventually made it back home. No doubt my patient’s life was changed more significantly than ours, but our lives were changed.

I am now serving my second term on the board of Orthopaedics Overseas with diverse, but like-minded individuals. I have asked a few of them to share their often challenging but uniquely rewarding experiences. I am delighted to present this Orthopedics Today Round Table discussion to celebrate the 25th anniversary of Health Volunteers Overseas, which was founded by Orthopaedics Overseas.

— Dean K. Matsuda, MD
Moderator

Round Table Participants Moderator Dean K. Matsuda, MD Director, Hip Arthroscopy Southern California Permanente Medical Group Kaiser West Los Angeles Medical Center Los Angeles, California R. Richard Coughlin, MD, MSc UCSF Medical Center San Francisco, California Rebecca S. Yu, MD Northern California Permanente Medical Group Kaiser Oakland Medical Center Oakland, California Richard C. Fisher, MD University of Colorado School of Medicine Denver, Colorado

Dean K. Matsuda, MD: What is the relationship between Orthopaedics Overseas and Health Volunteers Overseas and why is the Health Volunteers Overseas’ 25th anniversary so significant?

Richard C. Fisher, MD: Orthopaedics Overseas was formed as a continuation of the activities of the Orthopaedic Letters Club. The Letters Club was formed in 1959 by a group of orthopedists in search of ways to donate orthopedic expertise and teaching to needy countries. They worked eventually under the auspice of CARE-Medico, and my first trip overseas was to Bangladesh with this group.

When CARE decided it would devote its energy to more basic needs, such as food, safe water and primary health care, it eliminated the orthopedic program. Wishing to continue with the initial vision of the Letters Club, they decided in 1984 to incorporate Orthopaedic Overseas. It was soon realized by returning volunteers that the need in developing countries was much greater than just orthopedics, so the decision was made to expand the scope of activities.

In August 1986, Health Volunteers Overseas was incorporated with orthopedics as the founding division and an orthopedist, Jim Cobey, MD, as the first chair of the board. Nancy Kelly became the executive secretary and has admirably led Health Volunteers Overseas through its 25-year history.

In that same year, the anesthesia division was established with an initial program in Ethiopia. The oral surgery division followed, and later the divisions of dentistry, nurse anesthesia and physical therapy. Today, 25 years since its founding, Health Volunteers Overseas has 14 divisions plus three special projects at work in 24 countries involving more than 500 individual volunteer visits per year. It is indeed a special time to pause and look ahead.

After the 2001 Gujarat India Earthquake, Coughlin (center) provides assistance in a relief tent. Image: Coughlin RR

Certainly the need for educated health care professionals remains an unsolved global issue. As countries develop, their needs slowly change in the direction of more complex problems and an expectation of more sophisticated treatments. Health Volunteers Overseas is addressing the educational changes within all divisions, but equipment and facility needs remain a perplexing economic issue. The major challenge for Orthopaedics Overseas is to appropriately address the rapid increase in the global burden of trauma.

With the increase in the number of divisions, some individual sites now have multiple programs. Coordinating program activities increases the effectiveness of all the programs. Hopefully, this trend will continue.

Matsuda: Can you summarize the areas of greatest health service need from a global perspective?

R. Richard Coughlin, MD, MSc: There has been an increasing awareness of the enormous and ever-growing impact of musculoskeletal conditions and injuries throughout the world, especially in developing or resource-poor countries that are already struggling with infectious diseases, such as tuberculosis, malaria and HIV. There is also increased awareness of inadequate infrastructures for clean water and sanitation. Measuring health impact by disability adjusted life years (DALYs), the Global Burden of Disease Study determined that by 2020, injuries and road traffic casualties will rank third after heart disease and depression as the leading contributors to health burden worldwide. This is greater than HIV, tuberculosis and malaria combined.

For anyone who has traveled to India or China, it is quite apparent that the rapidly mechanized world has not been associated with effective road safety. In most countries, pedestrians share the road with teems of motorized two-wheelers, bicycles, animals, trucks and other forms of transport vehicles. Further, it has been estimated that nearly one quarter of all hospital beds worldwide are occupied by road traffic crash survivors.

It should be mentioned that with increasing life expectancy, even in resource-poor places, the musculoskeletal diseases of aging, such as fragility fractures, degenerative spinal conditions and sequelae from diabetes mellitus, have substantially increased the need for “human capital” to manage these conditions.

The World Health Organization highlighted the enormous disparity and need for health care workers worldwide with an estimated lack of 4 million people. This is more than 1 million deficit alone in Africa. Seventy-five percent of the world does not have immediate access to an orthopedic surgeon.

Clearly, Sub-Saharan Africa remains the area of the greatest disparity of health care services and health care workers, as seen by the unacceptable rates of health indicators, such as maternal and infant mortality, and life expectancy.

There has been a growing appreciation for the role of surgery and the surgeon in the global health discussion. Once considered expensive and resource-draining, surgery has been shown to be cost-effective and increasingly has been applied to the essential health service proposals rolling out through Ministries of Health.

Matsuda: What options can orthopedic surgeons consider to help those in need?

Coughlin: Fortunately, there are numerous avenues for orthopedic surgeons to become volunteers overseas. There are local/national/international non-governmental organizations, as well as governmental ones. Many professional organizations, such as American Orthopaedic Foot & Ankle Society and American Society for Surgery of the Hand, universities and a significant number of faith-based or denominational programs, such as CURE and Mercy Ships, are available for volunteering. The major determinant for the most of us is time.

The other major division of involvement is determined if the individual is interested in relief, as was seen so enthusiastically in Haiti and other elective assignments. Generally, assignments can be differentiated along the extent of being service/pathology-oriented vs. those more focused on the teaching/training model, such as Orthopaedics Overseas. Either type can include both operative and non-operative opportunities.

Many orthopedic surgeons can only be away from their practices for or 2 weeks. Organizations that focus on relief or service-based programs, such as Operation Rainbow or faith-based missionary trips, will be most practical. Teaching usually is not the focus, but can be implemented to some extent. These trips are the least expensive and disruptive to the orthopedic surgeons practice, while providing optimal surgery time if service-based. The downsides are the limits to the distance one can travel considering jet-lag and the reliance on a good infrastructure for screening and postoperative care.

Orthopedic surgeons with the luxury of more time can still choose between service and relief work, but have more opportunities to provide for teaching and training. This ultimately will have the greatest long-lasting or sustainable impact to the local health care system. Clearly, the financial aspects are considerable but the rewards of cultural immersion, greater impact and sustainable teaching/training implementation are worthy.

Matsuda: Who would you typically train, and what methods are most effective?

Fisher: The emphasis of Health Volunteers Overseas has always been health care training, and we continue to serve a broad spectrum of professionals as evidenced by the diversity of our divisions. Historically, the target audience for Orthopaedics Overseas has been the junior-level orthopedic surgeon, general surgeon or orthopedic resident. The teaching has emphasized basic procedures and sustainable treatment modalities.

Fisher said a formal medical conference provides another perspective of the culture of medicine. Shown here, a conference he attended in Bhutan in 2009 was complete with a traditional dinner around the fire and participant folk dancing. Image: Fisher RC

Recently, some program sites have requested subspecialty training for their senior-level physicians. A division of hand surgery was added a few years ago. Orthopedic nurses, operating room nurses and techs, and physical therapists have been included wherever possible. Combining members of this group with orthopedic surgeons in a single teaching session has helped promote the idea of the “care team.” It is not a common concept in many countries.

Additionally, we train orthopedic technicians. They have various designations in different countries: orthopedic clinical officers in Malawi, orthopedic techs in Bhutan and cirugio techincos in Mozambique. Their function is similar to our physician assistants or nurse practitioners, but in addition, they often work in rural hospitals without an orthopedist present. In this setting, orthopedic technicians provide the first line orthopedic care and handle routine clinical problems and emergencies. They can do emergency procedures, such as open fracture debridement and closed reductions.

Much like training programs in the United States, volunteers participate in clinics, hospital rounds, OR cases, teaching conferences, and at times, emergency room activities. Didactic lectures are often a part of the schedule, although perhaps the least effective. Volunteers are at times asked to speak at local medical society meetings and occasionally at national conferences.

Perhaps the most important aspect of teaching is the daily contact in clinical situations with discussion, debate and information exchange. Tips are given and received. Most volunteers agree their learning exceeds their teaching. But actually, the true value of the visit is probably the colleague-to-colleague exchange. Over time, I have concluded that the most important traits for effective teaching in this setting are humility, good listening ability, patience and common sense.

Matsuda: What was your most memorable or valuable experience gained from your volunteer experience? Why?

Fisher: I am privileged to have worked in many places and have known some very special people. These include amazingly grateful patients and talented physicians who survive in a harsh world. But these are common experiences for Health Volunteers Overseas volunteers, and they occur at the quiet moments we cherish so much.

A formal medical conference provides another perspective of the culture of medicine, which shouldn’t be missed. They involve lavish stage decorations and opening speeches by dignitaries such as the prime minister, the crown prince, mayor, and always, the minister of health. The topics presented usually give a neat insight into the country’s major medical problems and treatment methods. The conference I attended in Bhutan in 2009 was no exception. It was complete with a traditional dinner around the fire and participant folk dancing.

Rebecca S. Yu, MD: My most valuable experience with Orthopaedics Overseas was my first assignment in Bhutan as a fourth-year resident. Having been awarded the OREF traveling fellowship, I had the opportunity to serve under the supervision of an attending physician. This was a huge benefit for me – assuring me that I had the ability to do it on my own. It made my first solo assignment much less stressful. I was only a resident, but I was able to contribute through teaching and actual surgery.

I removed the largest ganglion cyst I had ever seen and fixed a femur fracture with a Kuntscher rod, which I also had never seen. I was able to correct a syndactyly in a 16-year-old girl. The experience helped me realize that I wanted volunteering to be a regular part of my practice.

Matsuda: What are the challenges that face those of us who have ever considered or are now considering volunteering overseas in places of medical need?

Coughlin: Obviously, time away from practice means revenue lost with expenses continuing. This is extremely challenging for the solo practitioner. Now, surgeons change jobs more frequently than they have in the past, so there is the opportunity to schedule an assignment before starting a new position. Time away from family can be solved by bringing them along. Many veteran volunteers have found that sharing these types of experiences has become some of the most valuable and rewarding family time spent.

The fear of the unknown probably has kept many from taking the plunge into volunteerism into “strange cultures.” Usually, shorter trips with veteran, well-organized programs will introduce the orthopedic surgeon to less-resourced environments and remind the surgeon that the principles of orthopedic surgery are universal despite the lack of technology.

“I’m not a professor, so what can I teach” is a challenge. My response is that there is plenty from simple anatomy, biomechanics to more systems-based quality improvement concepts and safe surgery.

Potential volunteers also want to know about the risk of HIV or other illnesses. Volunteers are at greater risk on the roads of many developing countries than they are for any exposures to exotic illnesses. Although not downplaying the potential, there have been rare sero-conversions in volunteer health care workers to HIV and having antiretrovirals available for exposure is prudent.

Yu: Just do it. It really is that easy. If you make volunteering a priority in your practice from the beginning, the downsides will never seem like downsides. You will be able to plan for the time away in terms of reduced income and scheduling challenges.

Some orthopedic surgeons worry about lost referrals or disappointed patients. But to be honest, your referring physicians and patients will come to see this as an important part of your practice and of who you are as a physician. Your reputation can only benefit. Taking these trips might seem easier to work into your schedule if you are in private practice where you have more control. But even if you work as part of a large group or foundation-type practice, if you make volunteering a consistent priority from the get-go, it is not hard to do.

I started in practice in the fall of 2004. I took my first Orthopaedics Overseas trip in the spring of 2007. I established myself in the community, and then left for a whole month. When I got returned, my job, referrals and patients were all still there waiting for me.

Matsuda: What would you tell the Orthopedics Today readers as we conclude this Round Table discussion?

Fisher: Under the capable leadership of Nancy Kelly for the past 25 years, Health Volunteers Overseas has become a wonderful resource for promoting education around the world. The dedicated staff provides the needed support for orthopedic surgeons wishing to volunteer in developing countries. They offer guidance in program selection, travel logistics and suggested teaching content. They help to make the volunteer’s time and effort more efficient and effective. Join the fun. The need has never been greater.

Yu: It is easy these days to get caught up in the minutiae of daily practice and to get stuck in a routine. Taking the time to volunteer your expertise in an area of need not only benefits the patients you serve, but also benefits you in ways you can’t imagine until you experience it. It reinvigorates you and reminds you of why you went into medicine in the first place. You come home with new perspective. You will eagerly look forward to the next trip.

Reference:

• www.hvousa.org

• R. Richard Coughlin, MD, can be reached email Coughlin@orthosurg.ucsf.edu.
• Richard C. Fisher, MD, can be reached at email Richard.Fisher@ucdenver.edu.
• Dean K. Matsuda, MD, can be reached Southern California Permanente Medical Group, Kaiser West Los Angeles Medical Center, 6041 Cadillac Ave., Los Angeles, CA 90034-1702; email Dean.K.Matsuda@kp.org.
• Rebecca S. Yu, MD, can be reached at email Rebecca.S.Yu@kp.org.
• Disclosures: Coughlin, Fisher, Matsuda and Yu are board members of Orthopedics Oversees. Fisher is also a member of the board of directors for Health Volunteers Overseas.

Milestones for the Health Volunteers Overseas 1986 • HVO incorporates with Orthopaedics Overseas as founding division • Anesthesia division establishes first program in Ethiopia • James Cobey, MD, serves as first Chair of the Board 1999 • New Sponsor - ASSH • Orthopaedic Education and Research Foundation funds fellowship for senior orthopaedic residents • Receives US Surgeon General’s Certificate of Recognition for enriching the lives of disabled Vietnamese through rehabilitation services 1987 • New sponsor - AAOMS • First oral surgery program starts in Nepal • 90 volunteers serve at 13 program sites 2000 • New sponsor - AACN • Barry Gainor, MD, becomes chair of the board • 353 volunteer assignments completed at 50 programs 1988 • New sponsor - ACP 2001 • Jill Derstine, MD, becomes the 3,000th volunteer 2002 • Receives Daily Point of Light Award • Receives AAA Award for Excellence from the American Society for Association Executives for nurse anesthesia project in Belize 1989 • Receives grant from USAID for rehabilitation training project in Uganda 2003 • David Frost, MD, becomes chair of the board • 372 volunteer assignments completed at 57 programs 1990 • New sponsor - ADA • Dental programs start in Grenada, St. Lucia and Trinidad • Receives grant from USAID for rehabilitation training project in Mozambique 2004 • New sponsors – AAD, AOFAS & ASDS 1992 • New sponsor - AANA • Receives grant from USAID for rehabilitation training project in Vietnam 2005 • New sponsors – ABA, AAHS & SRS • 383 volunteers completed 411 assignments • Total value of educational materials and medical equipment sent since 1986 exceeds $18.4 million 1993 • New sponsors - AAOS & AAP USAID-funded project in Mozambique ends • First nurse anesthesia program starts in Uganda 2006 • First burn management program started in India • Louis Rafetto, MD, becomes the 5,000th volunteer placement 1995 • New sponsor - APTA • First physical therapy programs opens in South Africa & Vietnam First pediatric training program open in Fiji • Internal medicine training programs open in Kenya & Uganda Jose Aponte becomes Chair of the Board 2007 • American Society of Hematology and American Society of Clinical Oncology join as new sponsors • 12 new programs initiated • 433 volunteers completed 474 assignments in 23 countries • USAID-funded project in Vietnam ends 1996 • 278 volunteers served in 34 programs 2008 • 506 volunteers completed 546 assignments in 23 countries • 11 new programs opened • HVO KnowNET – a web-based platform that serves as an e-library for program materials – launched • Ministry of Health of the Royal Government of Bhutan recognizes Health Volunteers Overseas for its contributions to improving health care 1997 • Nurse anesthesia division receives award from the AANA Council for Public Interest in Anesthesia 2009 • 488 volunteers completed 543 assignments • 12 new programs opened • Julia Plotnick, MPH, RN, FAAN, RADM, USPHS (ret.), became chair of the board of directors 1998 • Elizabeth Kay, MD, becomes Chair of the Board • Cynthia Howard, MD, becomes the 2,000th volunteer • USAID-funded project in Uganda ends 2010 • Volunteers completed 495 assignments at 65 project sites in 26 countries • Six new programs opened • Health Volunteers Overseas was selected for inclusion in the 2010-2011 Catalogue for Philanthropy as “one of the best small charities in the Greater Washington region.” Selected from a field of more than 250 organizations, the organization’s work was cited for its excellence, cost-effectiveness and impact. • Discussions initiated with the Society of Gynecologic Oncologists about becoming a sponsor • Multi-year major gift commitment of $50,000 received • Entered into a partnership with the American Dental Association to manage the “Adopt-A-Practice: Rebuilding Dental Offices in Haiti” – a project which will raise $350,000 to rebuild 35 dental practices during a 2-year period