The burden of burn injury falls predominantly on the world’s poor, with low-income and middle-income countries accounting for 96% of burn injuries. These vulnerable populations are the least likely to have access to adequate medical care and are the most reliant on volunteer organizations. Every underserved area has a unique set of needs, circumstances, customs, resources, and challenges. The authors’ intent is to provide an additional resource for volunteer surgeons who are interested in treating burns. This article reviews planning, organizing, and participating in a burn surgical mission trip.
Key points
- •
The burden of burn injury falls predominantly on the world’s poor; low-income and middle-income countries (LMICs) account for 96% of burn injuries, yet are least likely to have access to adequate burn care.
- •
Volunteer organizations provide a significant portion of the health care coverage in the developing world.
- •
Every underserved area has a unique set of needs, circumstances, customs, resources, and challenges.
Introduction
From a public health standpoint, burn morbidity and mortality are solvable global health crises that are largely ignored. Worldwide, 11 million people require medical attention for burns and an estimated 265,000 die from burns or their complications annually. The burden of injury falls predominantly on the world’s poor, with LMICs accounting for 96% of burn injuries ( Fig. 1 ). Tragically, these vulnerable populations are also the least likely to have access to adequate medical care.
In addition to their physical impact, burns are among the leading causes of lost disability-adjusted life-years in LMICs and cost approximately $80.2 billion per year in lost productivity (wages and skills) alone. In areas where disability insurance and workers’ compensation are nonexistent, this economic impact imparts life-or-death consequences not only for the burn victim but also for all dependent family members. Even in cases where burns are not functionally incapacitating, the stigmata of untreated and visibly deforming burn scars alter the lives of victim and family alike, both socially and economically.
In an era of rapidly advancing medical technology, why do burns remain a top global health problem? In contrast to public health victories, such as the vaccination strategy for polio, successful burn treatment requires intense and prolonged care, in many cases surgery and/or rehabilitation. Burn prevention strategies require government initiative and cooperation from local businesses for the implementation of safety measures. Poverty, corruption, lack of infrastructure, lack of education, and lack of supplies are barriers to burn care from within the developing world. Historically, medical care rather than surgical care has dominated global health initiatives, with surgery nicknamed the “neglected stepchild” of public health. In 2006, however, the World Health Organization and World Bank published the second edition of Disease Control Priorities in Developing Counties , which acknowledged for the first time that surgery could play a significant role in effective and cost-efficient global public health strategy.
Introduction
From a public health standpoint, burn morbidity and mortality are solvable global health crises that are largely ignored. Worldwide, 11 million people require medical attention for burns and an estimated 265,000 die from burns or their complications annually. The burden of injury falls predominantly on the world’s poor, with LMICs accounting for 96% of burn injuries ( Fig. 1 ). Tragically, these vulnerable populations are also the least likely to have access to adequate medical care.
In addition to their physical impact, burns are among the leading causes of lost disability-adjusted life-years in LMICs and cost approximately $80.2 billion per year in lost productivity (wages and skills) alone. In areas where disability insurance and workers’ compensation are nonexistent, this economic impact imparts life-or-death consequences not only for the burn victim but also for all dependent family members. Even in cases where burns are not functionally incapacitating, the stigmata of untreated and visibly deforming burn scars alter the lives of victim and family alike, both socially and economically.
In an era of rapidly advancing medical technology, why do burns remain a top global health problem? In contrast to public health victories, such as the vaccination strategy for polio, successful burn treatment requires intense and prolonged care, in many cases surgery and/or rehabilitation. Burn prevention strategies require government initiative and cooperation from local businesses for the implementation of safety measures. Poverty, corruption, lack of infrastructure, lack of education, and lack of supplies are barriers to burn care from within the developing world. Historically, medical care rather than surgical care has dominated global health initiatives, with surgery nicknamed the “neglected stepchild” of public health. In 2006, however, the World Health Organization and World Bank published the second edition of Disease Control Priorities in Developing Counties , which acknowledged for the first time that surgery could play a significant role in effective and cost-efficient global public health strategy.
International service: a brief history
The surgical community has long been involved in international service in a variety of ways, initially with individual efforts. As World War I and World War II prompted the emergence of surgical specialties, they also shed light on the vast needs in war-stricken and resource-poor settings. The 1940s to 1950s saw the establishment of a variety of foundations, including the Reconstructive Surgery Educational Foundation, which promoted international travel and teaching. Since the 1970 to 1980s, the more common means of surgical volunteering has become via nongovernmental organizations (NGOs). According to a study by the World Health Organization in 2008, volunteer organizations provide a significant portion of the health care coverage in the developing world, providing approximately 40% of health services in sub-Saharan Africa.
Surgical volunteerism is approached in a variety of ways, depending on an NGO’s philosophy and the needs of the underserved area. Some groups, such as Smile Train, focus on teaching and providing recourses, whereas others strive to treat as many patients as possible within a given time frame. Most groups employ teams on regular short-term (1–3 weeks) missions; some surgeons, including several at CURE International, commit to long-term (1+ years) individual posts. Surgicorps invites nonmedical volunteers; Interplast teams are composed of essential medical professionals only. Regardless of the approach, it is universally recognized that the ultimate goal is always patient safety and the delivery of quality medical care.
Recognizing that standards for volunteer missions are essential to the safe and effective delivery of care, the Volunteers in Plastic Surgery Committee of the American Society of Plastic Surgeons/Plastic Surgery Educational Foundation published in 2006 a series of guidelines to ensure safe, quality, and ethical plastic surgery and anesthesia in developing countries during international missions. Due to the paucity of evidence-based surgical research on this topic, these guidelines are derived from a wealth of expert opinion and experience. They have been endorsed by multiple plastic surgery societies and NGOs. Although geared toward pediatric care, much of the advice can be applied to international burn care and the guidelines are a good resource for all plastic surgery volunteers.
Participating in a surgical mission
Every underserved area has a unique set of needs, circumstances, customs, resources, and challenges. It is, therefore impossible to create a comprehensive instruction manual for establishing an international burn mission within the confines of this article. The authors’ intent is to provide an additional resource for volunteer surgeons who are interested in treating burns, specifically to help prepare new surgical volunteers and to share some ideas and adaptations that may promote safe, efficient burn care in the developing world.
Organizing a surgical trip
Establish the Need and Feasibility of Service
Once a need has been expressed in an area, an initial exploratory trip is a necessary component of international service. The team for the introductory trip should encompass only experienced international workers. This initial site visit helps determine the true needs, the feasibility of administering care, and the receptiveness of the local community. To be both efficient and cost effective, the volume of patients requiring care should be high enough to warrant a trip and the team size. An inspection of a hospital and operating room (OR), including the functionality of anesthesia machines/monitors and reliability of electricity, is necessary to determine which major supplies are needed and how many patients the hospital is capable of treating. The importance of this is illustrated in an exploratory trip to Uganda in 2014, in which it was discovered that the “guaranteed” anesthesia capability of the local hospital consisted of an ether mask and a broken blood pressure cuff ( Fig. 2 ). Sterilization capabilities, oxygen supply, suction, and basic laboratory services are required for safe surgical care. For burns, in particular, blood bank availability and intensive care capabilities determine the extent to which complex cases can be performed.
No short-term trip is effective without ground support from the local community. The purpose and goals of the trip should be discussed and agreed on by both the visiting team members and the local hospital staff at the onset. Spending preliminary time with the local hospital staff allows the visiting team to get a sense of their level of comfort and experience with the kinds of surgeries that are planned. This site visit also helps identify local physicians or other medical professionals who are capable of carrying out and willing to carry out the follow-up care once the mission is completed; this key person/team must be established prior to any mission. Translators, if needed, can be sought out and interviewed during this preliminary visit as well. It is imperative to have effective communication and trust with the local community prior to any patient care, to ensure safe postoperative care, to increase the likelihood of patient follow-up at the next team visit, and to encourage the influx of new patients from trip to trip. This may require days of seemingly tedious formalities and paperwork with the local governments and hospital staff but is a necessity. This communication is also helpful in determining the best time for a surgical trip. Overlap with other surgical missions, seasons of poor weather that hinder travel for both patients and the volunteer surgical team, and local holidays that are associated with business/hospital closure should be avoided.
Finally, this initial trip allows for the assessment of the safety and stability of the area prior to bringing in a large team and expensive equipment. Team safety is no small consideration for the team leader, who is ultimately responsible for unexpected safety concerns, such as illness or injury of a team member or threats to the team’s safety. Depending on destination, multiple organizations encourage or require evacuation insurance. In the early 2000s, kidnapping insurance was recommended for medical volunteers traveling to Columbia.
For teams focused on burn care, the need is variable. In LMICs, the lack of access to burn care in the acute setting results in a high incidence of burn-related sequelae, including scarring and contractures. Short-term teams are more likely to encounter a higher volume of patients requiring postburn reconstruction rather than acute treatment, and the choice of surgical team should reflect preparedness for that. The initial survey may unveil a common denominator for many of the burns, such as open fires or unsafe motorcycles. In these cases, it may be prudent to bring a public health or social worker on the team who can help stimulate conversation among the local community about prevention measures. Whether or not it is identified in the initial survey, burn teams heading to developing world environments should also be prepared to encounter victims of nonaccidental burn trauma related to family violence, sexual/gender discrimination, or untreated mental illness. In such cases, teams must be strategic about voicing judgment against the family or local culture, because this may compromise both the opportunity to treat the victim as well as any future relationship with the local community.
Estimate Trip Costs
Trip costs are often grossly underestimated. In addition to flight, lodging, and food costs, fees related to travel, such as visas, entry/exit fees at customs, and the occasional unexpected “tourist fee” (the explanation for which is frequently incomprehensible, but it is often easier to pay rather than argue with local officials) should be anticipated. Hospitals may charge for the use of their facility, even if all instrumentation and supplies are brought. If local staff are used to help assist with patient care, their salary may need to be compensated, especially if they are working longer hours than usual, which is often the case during high-impact short-term trips. Many LMICs no longer accept donations of expired sutures and medications. For a trip involving 5 full surgery days and approximately 70 to 80 surgical patients, medications and sutures alone cost several thousand dollars. The home hospital and/or local medical charity may supply bulk items like gowns, drapes, gauze, gloves, and old surgical instruments; forming a strong relationship with these entities is highly recommend. To avoid long delays, inspections, additional fees, and potential seizure of supplies at customs, the team should be up to date on the local community’s regulations regarding the importation of medication and surgical equipment. Finally, some NGOs assist financially with transportation, food, and housing for patients and family, who otherwise would never be able travel to the hospital for evaluation. Table 1 demonstrates an itemized cost breakdown for 2 potential short-term (2-week) surgical trips.
