The orthopaedic community is becoming more aware of the disparity
that exists in health care throughout the world. Orthopaedic residents
and fellows and those who have recently finished training are getting
involved
1
. This involvement benefits not only the people in developing countries
but also the orthopaedic residents who volunteer and their residencies.
This article reviews some of the recent concepts of international
health care, suggests avenues for selecting a volunteer program, and
presents approaches to prepare for an overseas assignment.
It is estimated that half of the world's population lacks access
to adequate primary health care, and two-thirds of the population
lacks access to orthopaedic care. Globally, the need for health
care outstrips the available resources. Although there is little
specific epidemiologic data on the exact burden of musculoskeletal
disease in developing countries, the orthopaedic community can help
to ameliorate the burden in a number of ways. Education is the most effective
method of providing a sustainable solution. The objective of educational
organizations should be to train local health-care workers at all
levels in their own environment to provide sustainable and appropriate
care so that the programs become self-sufficient and a continuous
supply of competent medical personnel is ensured.
During the past several years, a number of our orthopaedic surgery
residents in the University of Pennsylvania Orthopaedic Surgery
Training Program have volunteered in the developing world through
Orthopaedics Overseas. Most of them received funding through the Orthopaedic
Research and Education Foundation. Several other medical schools
have programs that allow residents in training to get involved with volunteer
activities in developing countries
1
. The orthopaedic training program at the University of California
at San Francisco includes an overseas elective as part of its curriculum
and sends most of the residents in their program overseas at some
point during the residency; this innovative educational approach has
been very well received
1
. Indiana University School of Medicine offers an exchange program
for residents in association with a teaching program in Kenya. Training
programs in Europe and many other parts of the world also include
residents in volunteer efforts in developing countries.
Programs that involve residents, fellows, and those who have
recently finished training have many benefits. Volunteering allows
individuals not only to share knowledge and skills with health teams
in developing countries but also to gain insight into the diagnosis,
natural history, and treatment of musculoskeletal problems that
are not encountered in their home country. Volunteering also creates
an opportunity for volunteers to become familiar with another culture
and to share information and techniques with colleagues of different
backgrounds while working toward the common goal of improving the
level of care for patients with musculoskeletal problems. At a personal level,
the benefits are immense; most orthopaedic volunteers believe that
they have learned more than they have taught. Volunteers, who arrive
with certain orthopaedic knowledge, skills, and philosophies, return
home with a broader understanding of orthopaedic surgery and of
the world they live in. They often gain a greater appreciation of
the natural history of musculoskeletal conditions; experience in
the management of uncommon presentations of common or uncommon injuries,
conditions, or diseases; and a respect for the successful application
of simpler techniques. Hopefully, these efforts will also stimulate
younger surgeons to become active in overseas service and teaching
as their careers progress.
Although there are several philosophies regarding how best to
assist programs in the developing world, contributions can be made
at various levels, including the donation of money, equipment, and books;
the provision of patient care; teaching; and teaching others how
to teach (helping to set up a residency training program, for example)
(
Table I
). These categories of involvement are all worthy and important,
but the more efficient and lasting strategies involve teaching.
Medical needs are often too great to provide service assistance alone.
Assisting local physician leaders in establishing or running an
orthopaedic residency program may be the most effective way to make
a lasting difference in a local environment.
Charitable contributions to organizations that promote the improvement
of health care in the developing world are a basic and important
means of support. The donation of educational materials is another
way of contributing. Materials, ideally, should be up to date and appropriate
for the level of training of local caretakers. Current texts and
journals are desired, and, for organizations with a training program,
the
Orthopaedic Knowledge Updates,
Orthopaedic In-Training Examinations, Orthopaedic Self-Assessment Examinations,
and recent well-written review books are particularly helpful. Most
centers now have computers, and CD-ROMs containing educational material
are especially easy to send and receive. The Internet has also become
a source of accessible information for health-care teams in the
developing world. The American Academy of Orthopaedic Surgeons (AAOS), through
the International Committee, has donated a large amount of material through
the years to programs in developing countries. The AAOS has had
a successful track record of educational programs and involvement
throughout the world, and it has several programs devoted to educational
support for developing and transitional-economy countries. In the
past four years alone, the International Education Program of the
AAOS has enabled eighty faculty members from medical schools in
the United States to participate in twenty educational programs
in developing countries throughout the world, and its reach is expanding
to new regions such as sub-Saharan Africa and Asia. In addition,
the group has contributed money and educational products to many
countries throughout the world.
The donation of supplies and materials is also usually appropriate
and appreciated. However, in the developing world, supply rooms
are often filled with donated equipment that is broken or obsolete
and cannot be maintained or used. The donation of equipment that cannot
be maintained locally is often not helpful. Appropriate technology can
be thought of as technology that is appropriately needed and used
and that is affordable, effective, locally maintained, and culturally
and politically acceptable. Appropriate donations are ideally "site-specific";
local care providers, program directors, and past volunteers can
be of help in recommending what is most needed. E-mail makes the exchange
of this type of information much easier. The exportation of advanced
technology to many parts of the developing world will be suboptimal
until socioeconomic conditions attain a level at which these technologies
can be appropriately used and maintained.
Developed countries cannot export enough equipment and personnel
to substantially reduce the global burden of musculoskeletal disease
in developing countries. Thus, the challenge is to improve regional
medical care by providing resources that will remain available at
that location and within that culture
2,3
. Education is the most effective method of providing a sustainable
solution. Through educational programs, local people can be taught
how to develop and lead their own health-care systems. For example,
a training program in orthopaedic surgery in Indonesia was begun
as a cooperative effort among the Indonesians, the Australian Orthopaedic
Association, and the Orthopaedics Overseas program in the United
States
4
. Educational support was provided to start residency training programs
in several Indonesian centers. The first certified orthopaedic surgeons
in that country constituted the beginning of a network of musculoskeletal
care that is currently available throughout the country. Today,
there are over 100 trained Indonesian orthopaedists, and the Indonesian
Orthopaedic Association runs its own orthopaedic training programs.
Volunteer orthopaedists assist with the training of subspecialists in
spine surgery, hand surgery, and pediatric orthopaedics. This model
has proved to be similarly effective in Bangladesh, Malawi, Ethiopia,
and other countries.
Physicians rarely volunteer services abroad without working through
a sponsoring organization. A physician should try to join with a
group that offers the type of experience that he or she wants. Several
volunteer opportunities are available for residents, fellows, and
those who have recently completed training. These individuals have
a great deal to share and should not be deterred from becoming involved.
Some organizations send teams of physicians, with their own equipment
and support staff, to treat a specific population. Others, such
as Orthopaedics Overseas, send individual physicians with the idea
of teaching local practitioners and surgeons through didactic methods
and by example. Still others send physicians to areas where emergency
relief is needed, such as war-torn countries or those devastated
by natural disasters. Opportunities include disaster relief work,
service-oriented experiences, teaching-oriented experiences, and
short or long-term opportunities.
Numerous nonprofit organizations seek volunteer help for training
and service programs throughout the developing world
5
. A comprehensive list of other volunteer programs is published
periodically in the
Journal of the American Medical Association6
. Any group that wishes to be listed in the future may send the
relevant information to the Medical News section. Physicians who
are contemplating volunteering should contact their group of interest
for details.
Orthopaedics Overseas, a division of Health Volunteers Overseas,
has a long history of successful involvement focused on teaching
in the developing world. Orthopaedics Overseas is "dedicated to
improving the availability and quality of health care in developing countries
through training and education." Orthopaedics Overseas (www.hvousa.org)
offers a variety of sites throughout the world, with programs in
fifteen countries including Bhutan, Cambodia, Ethiopia, Honduras,
Kenya, Malawi, Nepal, Peru, the Philippines, St. Lucia, South Africa, Tanzania,
Tobago, Uganda, and Vietnam. Final-year residents are welcomed into
many of the Orthopaedics Overseas programs. At many sites, practicing
orthopaedic surgeons are encouraged to bring medical students, residents,
or fellows with them when they volunteer at a teaching hospital. Most
sites require a minimum stay of one month (see
sidebar
).
The International Center for Orthopaedic Education (ICOE), which
is sponsored by the American Orthopaedic Association, the Orthopaedic Research
and Education Foundation, the Orthopaedic Hospital in Los Angeles,
and
The Journal of Bone and Joint Surgery,
offers exchange opportunities in a centralized facility to help
orthopaedic surgeons and organizations match their educational or
resource needs
7
. The ICOE acts as a clearinghouse for worldwide educational activities.
This program attempts to match institutions offering educational
opportunities with applicants seeking educational or service experiences
and is not just limited to physicians in the United States. The listings
include about 2300 institutions in almost seventy-eight countries
on six continents. From the inception of the ICOE in 1994, more
than 6700 applications from 115 countries have been processed
7
. In addition to research, clinical, and observership opportunities,
the ICOE includes listings from organizations that seek volunteers
for teaching and service. The ICOE database is also divided by specialty
listings. For example, the database currently contains more than
500 listings with a specialty in pediatric orthopaedics. The ICOE helps
to coordinate both service and educational experiences for surgeons from
the United States and abroad. The ICOE Program connects individuals
or sponsoring organizations with applicants. Our pediatric orthopaedic
program at Children's Hospital of Philadelphia, for example, has
two international visitors' programs listing opportunities allowing
international visitors to spend time in our department. To list
or apply for any of these opportunities, visit the ICOE website (www.icoe.aoassn.org).
Internet sites may also be of some assistance. The International
Medical Volunteers Association (
www.imv
a.
org) provides an extensive listing of volunteer opportunities abroad
as well as practical advice. This organization "promotes, facilitates,
and supports voluntary medical activity through education and information
exchange." Orthopaedic opportunities are listed within a large number
of medical volunteer programs. A subset of these programs, all of
which were contacted to verify the need for orthopaedic volunteers,
is listed in a directory that was published in the
Journal of the American Medical Association6
.
Former Surgeon General David Satcher stated: "89% of the world's
population lives in developing countries that bear 93% of the world's
disease burden."
8
According to
The World Health Report 2000,
"three-fifths of the world's people in the poorest 61 countries
receive 6% of the world's income-less than $2 a day."
9
Approximately 20% of orthopaedic surgeons practice in the developing world;
however, up to forty million people worldwide may have no access to
orthopaedic care
10,11
.
Two-thirds of the world's six billion people live in countries
defined as "developing," according to World Health Organization
standards. Approximately half of the world's population lacks access
to adequate primary health care. As a result, life expectancy in
developing countries is about fifty-two years of age compared with
eighty to 82.5 years in the world's most economically advanced nations. Globally,
the need for health care outstrips resources, and the problem is compounded
in the developing world by a lack of trained medical personnel, an
absence of medical facilities, and, in many regions, the inability
of patients to access existing facilities because of problems with
the infrastructure of the country
10,11
.
Current trends indicate an epidemiologic shift from predominantly
infectious and nutrition-related diseases in underdeveloped nations
to noncommunicable and degenerative diseases in developed countries.
Improved nutrition, better standards of living, and progress in
health care will lead to aging of the population in the developing
countries. This transition is driven by successful infection-control
programs and a population shift from rural to urban areas
12-14
. However, accompanying the movement toward more urban populations
is an increase in trauma-related injury and resultant disability.
Approximately two-thirds of the world's population lacks adequate orthopaedic
care. The aging of the populations in developing countries and the increase
in trauma-related injury will add to the already substantial burden
of musculoskeletal disease throughout the world. Although solutions
to most health-care problems generally are dependent on economic
development, the orthopaedic community can play an important role.
Orthopaedists have much to offer in terms of educational resources,
training of medical personnel, and development and dissemination
of effective techniques and equipment for use in these areas.
Reflecting the growing concern about the tremendous worldwide
burden of musculoskeletal disease, the current decade has been designated
the Bone and Joint Decade
13,15
. The goals of the decade are to raise awareness of the burden of
musculoskeletal conditions on society, empower patients to participate
in decisions concerning their care, promote cost-effective prevention
and treatment programs, and improve funding for research. Such focus
should lead to innovative methods to begin remedying inequities
of care that currently exist. If orthopaedic surgeons are to participate
in solutions that can lead to more adequate care on a worldwide
basis, it is important that they understand ways to assess the global
burden of disease and the expected trends in the worldwide prevalence
of musculoskeletal disease.
The United Nations has classified countries on the basis of their
stage of economic and social development as least developed, developing,
transitional-economy, and developed nations
16
(Appendix). The list includes forty-eight countries categorized
as least developed, ninety-five developing countries, twenty-two
countries with economies in transition, and twenty-six developed
countries. This classification is based on characteristics such
as gross domestic product per capita, the augmented physical quality-of-life index,
and the economic diversification index.
In developing countries, few local resources are available to
be invested in health care and the resources that are expended are
frequently reserved for providing care for the wealthy. Many prosperous
countries attract physicians from poorer countries, further reducing the
availability of health-care professionals in the most needy countries. This
situation is so disproportionate that five countries-Australia,
Canada, Germany, the United Kingdom, and the United States-have
more than three-fourths of the world's physicians
13
. It is estimated that 80% of the trained orthopaedic surgeons in
the world live and practice in the twenty-six developed nations
9
. This disparity can be illustrated most strikingly by considering
individual countries. For example, if the United States had the
same orthopaedist-to-population ratio as Malawi, the United States
would have only thirty orthopaedists. As a result, general physicians and
surgeons, nurses, and surgical technicians must provide much of
the musculoskeletal care in these less developed countries.
Access to health care is a global concern, especially in developing
countries. In the least developed nations and the developing nations,
problems with access relate to fundamental issues such as infrastructure,
physical facilities, and availability of equipment and trained personnel.
Infrastructure issues include lack of transportation to health-care facilities
and lack of means to communicate with health-care providers. Patients
may be unaware that medical services are available, or the travel
necessary to access these services may be too arduous or the means
may be unavailable. Civil unrest or ongoing warfare with neighboring
countries may also preclude such travel. Furthermore, most cultures
in developing nations have a traditional medical system that is
the first point of contact after illness or injury, and a social
stigma may be attached to circumventing this traditional system,
which may delay or preclude access to conventional treatment. However,
inadequate facilities and a lack of trained personnel are the most
common deterrents to health-care access in much of the world.
The exact severity of the global burden of musculoskeletal disease
has not been determined. The United States data have been compiled
in an AAOS publication entitled
Musculoskeletal Conditions in the United States17
. The Global Burden of Disease project, sponsored by the World Health
Organization and the World Bank, provides estimates of types of
diseases and injuries and is useful in projecting future changes
in the prevalence of musculoskeletal conditions
13
. Efforts in conjunction with the Bone and Joint Decade are currently
under way in an attempt to obtain more accurate data
15
. Information from this monumental project is fundamental to providing solutions
to the worldwide problems related to bone and joint diseases.
The nature of musculoskeletal disease is quite different in the
developed countries than in the rest of the world. In developing
countries, the predominant orthopaedic concerns are related to late presentation
of traumatic injuries, neglected congenital deformities, and the
sequelae of infectious diseases (e.g., hematogenous osteomyelitis,
poliomyelitis, tuberculosis, and leprosy)
2,18,19
. These disorders are currently the most frequently encountered
problems despite epidemiologists' predictions of change based on
economic progress. Many children are deprived of normal physiologic
development because of malnutrition, congenital anomalies, and the
secondary effects of infection. These factors may lead to chronic
musculoskeletal problems that result in disability in adulthood.
The worldwide incidence of poliomyelitis reported in 1998 was 213,000
cases
16
. Although the number of cases has decreased in the past decade,
poliomyelitis remains a substantial disease burden.
The spectrum of disease differs in the developing world, and
even treatment of familiar conditions may be challenging because
of a delay in presentation and/or a lack of resources. The application
of basic orthopaedic principles and a commonsense approach often
yield the best outcomes. Given the broad scope of pathology and
the lack of evidence-based data, it is difficult to provide a "literature-based"
approach to orthopaedic problems that adequately addresses all parts
of the developing world.
In many settings, traumatic injury predominates. Many patients
present weeks to months following the initial injury, and treatment
involves correction of a malunion or d�bridement of posttraumatic
osteomyelitis. Common approaches to managing traumatic injury must
be modified on the basis of local resources. Nonoperative methods are
often preferable, and, when surgical treatment is elected, the simplest,
most cost-effective technique should be chosen
2
. The sequelae of the various types of traumatic injury are a major
concern for all countries. The rate of traumatic injury associated
with sequelae is likely to increase markedly in developing and transitional-economy
nations as a result of both advancing industrialization and increasing
availability of motorcycles and automobiles
14
. Patients with chronic bone and soft-tissue infections after open
fractures, nonreduced dislocations, malunions, and nonunions may
eventually present for treatment but frequently only after a long
delay. The delay adds complexity to the treatment and increases
the overall burden on the society for treating these problems.
Although principles for treating acute osteomyelitis are familiar,
most cases in the developing world are chronic. In many developing
countries, a volunteer will also be exposed to patients with tuberculosis,
late sequelae of traumatic injury, nutritional deficiencies, and poliomyelitis.
Children often make up a sizeable percentage of the population. Despite
the success of worldwide vaccination programs for poliomyelitis, residual
deformities are commonly seen. The reviews by Watts and Gillies
20,21
and by Huckstep
22,23
are particularly helpful, and the chapter on poliomyelitis in the
textbook on pediatric orthopaedics by Tachdjian
24
is excellent.
The economic and social burden resulting from military activity
unfortunately extends well beyond military casualties. Injuries
to civilian populations from land mines and gunfire place tremendous
demands on health-care systems, which are already suffering from
the inevitable results of war. Health-care facilities may be further
devastated as financial resources are diverted from health care
to war efforts
25
. Additionally, health-care facilities may themselves be targets
of aggression. For example, during the peak of the war within Mozambique
(1980 through 1985), one-third of the primary health-care facilities
were destroyed and many health-care workers were killed. The ratio
of health-care providers to the general population decreased from
1:161,000 before the war to 1:396,000 after five years. Similarly, annual
per capita health-care spending decreased from $4.70 to $1.16
25
.
It is estimated that at least one million unexploded land mines
are still dispersed globally. According to the American Red Cross,
approximately 500 civilians are wounded or killed by mines every
week
26
. Many of these injuries occur on civilian transportation routes
and in food-producing areas. Removing mines to create safe areas
is both time-consuming and expensive. Injuries from these devices
continue for many years after the primary conflict has ceased and despite
the political efforts to ban their production and use.
The Global Burden of Disease
predicts that road-traffic accidents will become the third leading
cause of premature death or disability in the developing world by
2020
13
. The relative distribution of causes of death differs markedly
between developed and developing countries (Appendix). Of special
interest to orthopaedic surgeons is the prominence of tuberculosis,
the sequelae of injuries sustained in traffic accidents, and congenital anomalies
as causes of death in developing nations. On consideration of the changes
that are expected to occur between 1990 and 2020 (Appendix), it becomes
clear that the proportion of the total disease burden that is due
to musculoskeletal conditions will increase in the next several
decades. It has been predicted that the percentage of diseases with
an infectious, maternal, perinatal, or nutritional origin will decrease as
the percentage of the disease burden due to noncommunicable diseases
and traumatic injury increases.
Driving this trend is the global shift from rural to urban living,
the overall aging of the population, and the increase in trauma-related
injuries. The rural-to-urban population shift brings lifestyle changes,
which result in increasing numbers of industrial accidents and acts
of criminal violence. The prevalence of communicable diseases, such
as poliomyelitis, may decrease as the population becomes more concentrated
near points of access to medical care
22,23
. However, the number of new cases of tuberculosis often paradoxically increases
as populations coalesce in urban centers, making transmission easier.
The unprecedented current growth of the aging population in both
developed and developing nations puts demands on international,
national, and private health-care resources. There has been a constant
increase in the average age of the population, especially in developing countries.
An increase by as much as 300% in the number of persons over the age
of sixty-five is projected in developing countries by 2025
9
. This rapid growth in the absolute number of older persons will
cause an increase in the number of patients with degenerative diseases,
such as arthritis and osteoporosis. In fact, the number of fractures
related to osteoporosis worldwide has nearly doubled in the past decade,
and almost 40% of women over the age of fifty years will have at
least one
9,16
. Globally, there were 1.7 million hip fractures in 1990, and it
is estimated that there will be 6.3 million in 2050. This increase
is secondary to the absolute increase in the number of elderly persons
worldwide. Because 80% of the world's population now lives in the developing
world, the extremely large potential for increased longevity in those
countries will fuel the rapid increase in diseases specific to aged populations.
Data compiled in the United States have revealed that chronic musculoskeletal
conditions such as osteoarthritis, rheumatoid arthritis, gout, osteoporosis,
low-back pain, and other joint and soft-tissue diseases are the
leading causes of disability, affecting approximately forty million
people in 1995 and a projected sixty million people in 2020
9,13,16
. Although there are no comparable data for developing countries,
a similar increase in the prevalence of disease is expected.
The prevalence of trauma-related deaths remains consistent, accounting for
about 2% of total deaths in developing and developed nations. These
rates will likely increase as motor-vehicle travel and industrialization
increase in developing nations. It is anticipated that traffic accidents
will increase from the ninth most common cause of permanent disability
to the third as a result of the urbanization of the populations
13
. If the predicted decline in communicable diseases in developing
countries occurs, the relative proportion of trauma-related injuries
will rise sharply. In fact, it is expected that, by 2010, nearly
25% of the health-care resources of developing countries will be
spent on trauma-related care necessitated by traffic accidents,
war, and violence
13
. Currently, military activity and the land-mine problems contribute
substantially to both death and disability in developing countries,
where the health-care infrastructure is least able to deal with
the resulting injuries
25
.
The Disability Adjusted Life Year, or DALY, has been developed
to better reflect the burden of disease for nonfatal conditions,
including most musculoskeletal conditions
14
. The DALY has become an accepted measure for assessing disease
burden throughout the world. It is a better measure than mortality
because an assessment of mortality cannot accurately gauge the impact
of most musculoskeletal conditions. The DALY includes the years
of life lost because of premature death and the years of life lived
with a disability.
The Global Burden of Disease,
a report published by the Harvard School of Public Health on behalf
of the World Health Organization and the World Bank, emphasized
the importance of nonfatal outcomes for a host of conditions throughout
the world
13
. The data were reported for 1990 and were projected to 2020. These
findings reflect the majority of conditions that volunteers will
be treating, namely, traumatic injury, infection, and congenital
problems (Appendix).
It is difficult to conceptualize a quick or easy solution to
the overwhelming global problem of musculoskeletal disease, especially
if the predicted burden continues to increase. It is clear that
economic development will lead to an improvement in health-care
systems, which will hopefully initiate a self-sustaining cycle.
Therefore, economic and societal advancement may provide the impetus
for generating solutions. Effective ways of treating specific medical and
orthopaedic conditions require the use of treatment methods that
are sustainable, appropriate, and acceptable within each culture
3
. For example, traction has proved to be a very safe and effective
method of treating femoral shaft fractures in some district hospitals
in Africa, where the high cost and complication rates make more
aggressive treatments inappropriate
27
.
Providing care and teaching in areas of limited resources can
be challenging. Programs and education must be specific to the country's
resources, culture, and religious beliefs. Organized health-care
programs should be encouraged to assess the results of generalized
treatment approaches and, ideally, to evaluate variables such as
resource consumption, complication rates, and functional outcomes.
These multiple efforts coincide with the launch of the Bone and
Joint Decade, the goals of which include raising awareness of the
global burden of musculoskeletal disease and seeking cost-effective
solutions to many musculoskeletal problems
15
.
General Preparation
Guidebooks, newspapers, magazines, and the Internet can provide
easy information on the history, geography, local customs, culture,
religious influence, and traditions of a given country. These factors
may impact the perception of disease and disability. Political unrest is,
unfortunately, a common problem in the developing world and may
influence the delivery of care and the overall volunteer experience.
Common sense, with guidance from one's local hosts, should minimize
the risks. Personal safety must be considered. The United States
Department of State web page (www.state.gov) provides current advisories
and recommendations for travel.
Health Volunteers Overseas also has a useful publication,
A Guide to Volunteering Overseas,
that is a valuable resource for those preparing to visit a developing
country
28
. Copies may be purchased for $15 on their web site (www.hvousa.org)
or by contacting their office. The textbook
Surgery at the District Hospital: Obstetrics, Gynaecology,
Orthopaedics, and Traumatology
is also useful in preparing for a volunteer experience
29
. However, this book is currently out of print and difficult to
find.
Understanding the LocalHealth-Care Setting
and Resources
From the rural health post to the national teaching hospital,
each facility varies in the level of services that can be provided,
which in turn modifies the approach to diagnosis and treatment. Operating
rooms and anesthetic capabilities are often basic; sterility is always
a concern. The suitability of equipment (such as x-ray machines, instruments,
and orthopaedic implants) varies. Often many of the supplies have been
donated. In some circumstances, families are responsible for purchasing the
implants.
The recent creation of the Surgical Implant Generation Network (www.sign-post.org),
a nonprofit corporation, has improved the availability of equipment
for orthopaedic treatment in the developing world. Orthopaedic implants
are mass-produced and donated or sold at low cost to centers in developing
countries. Intramedullary nails that do not require an image intensifier
for interlocking have been developed.
Numerous publications deal specifically with orthopaedic care
in developing countries, and the Health Volunteers Overseas web
site (www.hvousa.org) contains a reference list of pertinent materials
gathered from journals throughout the world. Many of the references
in the present article will also be helpful for an individual preparing
for a visit.
Preparation for Teaching
The material that a volunteer brings should reflect the wishes
of the local hosts. The information should focus on local pathology
and should be of practical value. The volunteer's own personal experience
and interests will also influence what is taught. The hosts may
be interested in subspecialty-level presentations, especially if
it is a program with a residency-training program, or the host may
collect interesting patients for consultation. In addition to lectures and
case presentations, settings that provide opportunities for exchange
of information include outpatient clinics, inpatient wards, the
emergency room, and the operating room. Trainees may include technicians,
nurses, physician assistants, medical students, general medical
officers, general surgeons, and orthopaedic surgeons, with or without residents.
The volunteer experience can be best thought of as an exchange;
in addition to sharing our approach to a variety of problems, volunteers
can learn a great deal from their hosts. This exchange may occur
at a small rural hospital or via a visiting professorship in a large department
at a teaching hospital. Knowledge of the educational level of trainees
is essential to determine what should be presented. When discussing new
techniques, it is important to emphasize the possible complications, the
management of such complications, and postoperative rehabilitation.
Adequate preparation is essential to maximize the effectiveness
and enjoyment of an overseas assignment. No two experiences are
alike. The challenge is to adapt our "western" approach to various
disorders and then to develop a practical means of dealing with
local pathology. In order to be effective in a short period of time,
a volunteer should arrive with detailed knowledge of the host country,
health-care setting, local pathology, available resources, and level
of education of the trainees. All assignments differ with respect
to these variables. Data may be gathered from a variety of sources. Guidebooks
and Internet sites can help to familiarize a volunteer with the country,
while representatives from the volunteer organization and the domestic
program director can provide site-specific information. Speaking
with recent volunteers can be invaluable. Many foreign sites have
fax machines and e-mail, and it may be possible to coordinate activities
in advance with the local program host.
Expectations and goals should be realistic. A volunteer should
try to adapt our modern approaches to medicine to best fit the local
conditions and situation and should not expect the hosts to adapt
to our approach. A volunteer should also accomplish what is possible and
appropriate within the confines of the existing systems and should
be sensitive to methods and techniques that may be successful locally,
as these may be very different from the volunteer's own local standard
or practice. The volunteer should avoid focusing on the latest,
modern high-tech approaches, especially if such approaches cannot
be applied locally. For certain conditions and in certain situations,
it may be best to avoid surgery altogether. In a service-oriented
setting, many patients will be lost to follow-up and there will often
be poor compliance following discharge. Management decisions must take
these factors into account. If a volunteer is not part of an ongoing,
sustainable program, local caregivers will usually need to oversee
the postoperative program (and manage any complications) after the
volunteer has left.
Most volunteer experiences are short term, which can make it
more difficult to establish a relationship with the hosts. However,
long-term friendships are possible and often established and are
easier to maintain with the global availability of e-mail. The attitude
and ability of the volunteer to cope with adverse situations and
challenges is very important. For example, the pace of work at each
site reflects the unique sense of "time" that one encounters locally;
this may be very different from what a volunteer is used to in his
or her own practice or training setting. An open mind and a relaxed
approach will facilitate optimal interactions. Influencing or changing
the local approach to a medical or musculoskeletal problem may be
best accomplished by gentle suggestion. Lastly, the commitment, intelligence,
motivation, and skills of the local health-care providers should never
be underestimated. A volunteer should expect a challenging, fun,
and horizon-broadening experience. Most volunteers look forward
to returning or getting involved at a future point in their career.
In developing countries, musculoskeletal conditions are a common
cause of severe long-term pain and physical disability. The prevalence
of orthopaedic impairment is increasing, and many nations are unable
to provide sufficient care. The problem is exacerbated by a lack
of personnel and facilities, a general aging of the population worldwide, the
concomitantly higher prevalence of degenerative conditions, and
the increasing prevalence of traumatic injury. Preventive medicine,
health education programs, and alternative health administration
schemes will become more important in ensuring long-term care. Sustainable
gains in the level of health care are dependent, in part, on advancing
a developing country's overall level of medical education.
Orthopaedic residents and fellows and those who have recently
finished training are able to help with this situation. This involvement
benefits both those in the developing countries and those who volunteer.
Volunteering allows individuals to share knowledge and skills, to gain
insight into musculoskeletal problems not encountered in their home country,
and to have an opportunity to become familiar with another culture. Hopefully,
these efforts will also stimulate younger orthopaedic surgeons to develop
an international perspective on orthopaedic surgery and to become active
in overseas interaction, service, and teaching as their careers
progress.
Tables showing countries classified according to their stage
of economic and social development and the leading causes of death
around the world, currently and in the future, can be found in the
electronic versions of this article, on our web site at www.jbjs.org
(go to the article citation and click on "Supplementary Materials")
and on our quarterly CD-ROM (call our subscription department, at
781-449-9780, to order the CD-ROM).
Note: The author would like to thank Julia Lou for her assistance
in the preparation of this manuscript.
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