I encountered many reactions when I returned from a medical mission in Guayaquil, Ecuador, led by Elizabeth Szalay, MD, a pediatric orthopaedist at the University of New Mexico Hospitals. My fellow residents were inquisitive, asking about case volume, types of procedures performed, and my level of participation in the cases. Family and friends were more interested in my depiction of poverty, neglect, and miracle fixes. But one very thoughtful attending physician didn’t sugarcoat it when he asked, “What if one of the patients has a complication?”
The question reminded me of a weekly interdisciplinary class on medical ethics that I attended during my first 2 years of medical school. The class defined ethics (the study of morality, or right and wrong) and the six primary values of medical ethics: autonomy, beneficence, nonmaleficence, justice, dignity, and truthfulness. Each week we reviewed three cases, addressing each value in turn.
I hadn’t thought much about this exercise since becoming a resident, and I certainly hadn’t run through the list prior to leaving for Ecuador. But the question made me think: is a week’s worth of surgery in a country without many medical resources helpful or harmful?
In Ecuador, 45 percent of the population lives below the poverty line. The infant mortality rate is three times the rate in the United States (19.65 deaths/1,000 live births versus 6.06 deaths/1,000 live births). The number of physicians available to treat Ecuadorians is half that in the United States (1.48 physicians /1,000 residents versus 2.67 physicians/1,000 residents, respectively).
Good intentions aren’t enough
In an online article published by the American Medical Association, Edward O’Neil Jr., MD, argues that the United States “can no longer train our young physicians to become strong clinically but inept socially, lacking true knowledge of the world.” Dr. O’Neil, the author of Awakening Hippocrates and the founder of Omni Med—a nongovernmental organization (NGO) helping healthcare providers in poverty-stricken areas—cites gross health inequities, a moral (religious, professional, or both) impetus to act, and globalization as reasons for physicians to become involved in global health.
But many volunteer missions are not as successful as originally intended. According to the tutorial Pitfalls in Volunteering Abroad offered by the NGO Unite for Sight, short-term and/or top-down interventions, a lack of local community involvement, a lack of understanding of the local political and cultural climate, practicing beyond one’s abilities, and lack of local integration are common reasons for such failures.
Hugh G. Watts, MD, a pediatric orthopaedic surgeon who has extensive experience working in developing countries, explains that teaching must be the main thrust of the intervention, and teaching needs to be tailored to the specific needs of the region being visited. Dr. Watts also highlights the importance of picking technology that is appropriate for the region, emphasizing prevention to make a greater impact than simply providing treatment, and conducting research applicable to the region.
My trip was organized and funded by Project Perfect World, a small NGO helping orthopaedic surgeons provide care in Guayaquil. We worked with three pediatric orthopaedic surgeons at the Hospital de Niños, which is funded by the national lottery to provide care for the impoverished children of Ecuador. Patients are responsible for a $20 copayment per visit, which was covered by Project Perfect World. Many patients must travel hours by bus; parents sleep in chairs or on the floor of the pediatric postoperative ward (one room with 30 beds).
Our team performed 24 procedures, most on patients with developmental dysplasia of the hip (DDH). Although DDH is quite common in the United States as well as in Ecuador, most U.S. children are identified early, by either risk factors (female, breech presentation, torticollis, positional deformations at birth, and ethnic background) or clinical exam, with definitive diagnosis made by ultrasound. Treatment typically consists of a Pavlik harness, resulting in reduced, concentric hips in most patients.
Developing countries, however, often do not have a system to diagnose DDH in infants, and the condition is not identified until the child starts walking with a limp due to significant leg length discrepancy from the dislocated hip. Although the long-term success and utility of osteotomies for DDH is still being debated, most pediatric orthopaedic surgeons would agree that treating children of walking age with surgical hip reduction and osteotomy results in improved functional outcomes.
Unfortunately, the countries that need surgeons trained to perform these procedures are the least likely to have them. Surgeons on medical mission trips may be the only opportunity for these children to receive treatment for DDH.
Did we help or harm?
Reflecting now on my experience partnered with these concepts, I feel fairly confident that our trip helped the Ecuadorians. Teaching, both in the clinical setting and through lectures, was a primary focus of our trip. We teamed with two local pediatric orthopaedic surgeons in both the clinic and the surgical suite, where we exchanged common practices, both theirs and ours.
With regard to cultural integration, we had the assistance of Sister Annie, an American nun who established and runs a home and clinic for those afflicted with Hanson’s Disease (more commonly known as leprosy). Working with Sister Annie were several of her volunteers from Rostro de Cristo, a lay volunteer organization of the Catholic Church, who provided assistance in translation, organized social services such as lodging and transportation for patients, and also helped us understand the context of our interventions in light of our patients’ culture and living circumstances.
Although our services were short term, our follow-up was long term. We worked with the local physicians to discuss and document the follow-up required by the patients. We applied appropriate technology for the region and economy, primarily using spica casts, basic plates, and K-wire. Finally, we practiced within the scope of Dr. Szalay’s typical practice.
I believe that our interventions were performed well within standard ethical practice. Surgical interventions were only performed in patients whom we believed would greatly benefit with minimal risk (beneficence and nonmaleficence). Our patients and their families were educated on the need for surgical intervention and possible risks both by the local physicians and again by our staff through local translators (autonomy and truthfulness). We were providing care to the poorest in the region who otherwise could not receive this care (justice). And, finally, we treated all patients and their families with dignity.
Of course, improvements are always possible. The University of New Mexico Hospitals are working with Project Perfect World to fill the void in preventive practices. Although the local pediatric orthopaedic surgeons were well trained, they lack the technology and resources needed to employ common practices—such as the Ponseti technique for clubfoot and ultrasound screening for DDH—that would have identified and enabled earlier treatment, preventing later surgeries. Improvements in these areas will have a long-term impact on this community.
Jenna Godfrey, MD, MSPH, is a PGY-4 resident at the University of New Mexico Hospitals who made her first medical mission trip last year.