Medical professionals from developed countries are capable of performing medical missions in low-income countries, such as Ecuador, where a percentage of the population has limited access to high-quality medical care1. Martiniuk and colleagues highlighted the importance of medical missions and the immense impact that they have on health systems in low- and middle-income countries. This study demonstrated that many medical missions were short-term, lasting ~1 day to 1 month, with South America being the fourth most visited location2. Most health professionals engaging in these missions were from the United States, and cleft lip and palate deformations were the focus of most of the missions2. Professionals that participate in a typical medical mission include physicians, nurses, social workers, and medical trainees3.
Rele Ologunde and Kumaran Shanmugarajah, stated that there has been an epidemiological change in recent decades, as nowadays noncommunicable diseases are responsible for 80% of deaths in low- and middle-income countries. A large part of that percentage is amenable to surgical treatment4. In fact, 11.2% of the global burden of diseases is surgically treatable5, which highlights the necessity to recognize surgery as a priority for public health systems. Several international organizations sponsor medical missions in response to the great demand for medical assistance in developing countries. These missions play an important role in improving surgical care and in elevating surgery as a global health priority1,4.
Despite numerous high-quality missions worldwide, programs continue to face challenges with systematic evaluations of the local health networks, lack of interoperability within the local health networks, and public health structure undercutting local health practitioners’ livings from free “mission services”6. When a mission ends, the location remains in similar conditions before the international intervention, lacking access to medical care, and awaiting an eventual return of these professionals. Eventually, native populations rely more on visiting physicians than local doctors3. Becoming reliant upon visiting physicians, can create untoward network effects in a 2-fold manner: (1) the patients may wait for the “free services” of missions thereby putting the local physicians and health care systems out of practice due to no revenues, and (2) potential surgical complications that may go untreated for months causing devastating outcomes in patients. Therefore, the creation of a sustainable model whereby these services are rendered side-by-side with the local populace will further solidify the local populace’s health systems and physicians, allowing for regular surgical follow-up and a continuum of care.
It is imperative that missions assess their contributions not only in the number of successful surgeries or treatments but as importantly, with long-term improvement in the quality of medical services in the underserved community7. One of the possible solutions to this problem is to complement the medical and surgical critical care missions with medical training for local doctors, which provides added value to the mission.
The Northwell-Quito 2020 medical surgical mission to Ecuador was envisioned and successfully executed to help achieve Northwell Health’s goal of becoming a globally recognized leader in high quality, socially conscious health care, and health education. The team was composed of a diverse group of 30 physicians, nurse anesthetists, nurses, surgical technicians, health system executives, community volunteers, and trainees from across the health system (Table 1). The mission was sponsored by the Surgery Service Line of Northwell Health.
Table 1 -
Team characteristics.
| Total team members |
30 |
| Male:female |
14: 16 |
| Northwell employee: community volunteer |
26: 4 |
| Attending physicians |
12 |
| General surgery and subspecialties |
5 |
| Plastic surgery |
1 |
| Critical care |
1 |
| Anesthesiology |
2 |
| Nephrology |
1 |
| Psychiatry |
1 |
| Emergency medicine |
1 |
| Nurse anesthetists |
2 |
| Nurses/surgical technicians |
11 |
| Resident trainees |
1 |
| Nonphysician executives |
1 |
| Nonphysician educators |
1 |
| Volunteers without medical background |
2 |
Physician specialties included general surgery, minimally invasive surgery, colorectal surgery, plastic surgery, anesthesiology, critical care medicine, emergency medicine, and psychiatry. Twelve attending physicians participated in the mission, with varied involvement in clinical care, executive-level organization, and community education. One general surgery resident trainee participated. Nursing services were provided by team members with certification in nursing education and intensive care unit care.
Patient selection and surgical results
Northwell partnered with Hospital Padre Carollo, Fundación Tierra Nueva, and the Ecuadorian Ministry of Public Health to provide surgical services to the indigent and underserved population of Ecuador. Transportation and support services for indigenous patients from the Amazon regions of Ecuador were provided by Timmy Global Health, a nonprofit organization providing health services to over 80,000 underserved patients in four countries. The dean, public health director, and professors from Universidad de San Francisco Quito hosted Global Health Week at the university with Northwell Health staff that included surgeons, psychiatrists, and basic research scientists.
Patients were screened for operative indications before arrival of the Northwell team by the Hospital Padre Carollo staff. On the first day of the mission, patients were evaluated by the Northwell surgical and anesthesia teams, then scheduled for surgery. In addition, plastic surgery patients operated on during prior mission trips were seen for follow-up appointments. A total of 127 patients were seen for preoperative evaluation or postoperative follow-up. The partnership developed by the Northwell surgical teams and local hospital staff has allowed the patients to be evaluated preoperatively and postoperatively by the local surgical teams, thereby bolstering the local populations’ health care programs. Furthermore, the patients from the more remote areas in Ecuador—such as the Andes Mountains and Amazon Basin—have social workers that are in communication with the local surgeons to help coordinate appropriate follow-up.
The Fundacion Tierra Nueva in Quito, Ecuador has been working with underserved communities for over 30 years and has a series of clinics and outreach programs to identify patients that can benefit from a surgical mission. The sustainable partnership formed between Northwell, and the local hospitals produce 2 yearly editions of the medical mission. The coordination is a joint partnership spearheaded by Dr Rafael Barrera (Northwell) who, together with the local coordination by Dr Patricia Jarrin (Tierra Nueva Hospital, Ecuador), develop the activities in several phases.
Of the 56 scheduled operations, 53 were performed over 5 days. In total, 30 general surgery operations and 23 plastic/pediatric surgery operations were performed (Table 2). There were 19 pediatric patients (range 3 mo–18 y), all of whom underwent plastic surgery procedures. An additional 4 adults underwent plastic surgery procedures. All 30 general surgery patients were adults (range 19–89 y). The Northwell team performed four laparoscopic vertical sleeve gastrectomies, which also provided the additional purpose of training Hospital Padre Carollo surgeons who participated in the surgeries. These patients underwent preoperative screening, medical clearance, dietary evaluation, as well as nutrition and exercise education over several months before the arrival of the Northwell team.
Table 2 -
Operative summary.
| Total cases completed |
53 |
| Types of cases |
| Plastic surgery |
23 |
| Cleft lip repair or revision |
9 |
| Palate fistula repair |
5 |
| Alveolar cleft repair |
2 |
| Repair entropion |
1 |
| Frenulectomy |
1 |
| Biopsy periorbital lesion |
2 |
| Contracture release |
1 |
| Steroid injection |
1 |
| Fat grafting |
1 |
| General Surgery and Subspecialties |
30 |
| Hernias |
23 |
| Incisional/ventral |
6 |
| Umbilical |
9 |
| Inguinal—open |
3 |
| Inguinal—laparoscopic |
5 |
| Laparoscopic sleeve gastrectomy |
4 |
| Anorectal |
3 |
| Complications |
0 |
Four scheduled procedures were not performed due to: inadequate preoperative optimization (1 patient), failure to appear for surgery (2 patients), or declining surgery (1 patient). One additional case was added later. In addition, 1 patient suffered a preoperative vasovagal episode; he was admitted and underwent a cardiac workup before successful and uncomplicated laparoscopic inguinal hernia repair. There were no serious complications for any patients. During the follow-up evaluations on January 24, all patients were appropriately recovering, and subsequent follow-up care was arranged in partnership with physicians at Hospital Padre Carollo.
One full day of academic training focused on first responders and trauma. Instructional simulations trained attendees in different skills in trauma and acute care which included a course for nonmedical providers in first aid, cardiopulmonary resuscitation, and hemorrhage control. In addition, there was a disaster tabletop exercise with triage instructions.
The Northwell team also provided training to local surgeons and anesthesiologists in abdominal wall laparoscopic surgery, bariatric surgery, and transversus abdominis plane block. Surgeons from Hospital Padre Carollo and Calderon’s General Hospital as well as general surgery and anesthesiology residents from Universidad Catolica de Quito received 100 hours of surgical experience. Of note, the surgeries were also transmitted live via Zoom for other students and residents that could not attend the procedure.
Clinical logistics
Northwell team members brought medications, surgical supplies, and equipment to the mission site. The Ecuadorian Ministry of Public Health provided letters of sponsorship to expedite transit through immigration and customs for the oversized baggage containing medical equipment. Excess baggage fees were sometimes waived depending upon the airline utilized. Hospital Padre Carollo generously assisted with on-site services, including surgical equipment sterilization, anesthesia machines, consumables (oxygen, specialty medications, etc.), as well as facilities for patient evaluation, surgical procedures, postanesthesia recovery, and inpatient admission.
Logistics of surgical flow
On the day of surgery, patients were evaluated by the surgery and anesthesia teams in the morning. Both the surgeons and anesthesiologists obtained written consent from each patient at this time. Intravenous access was obtained, and patients remained in the ward until the time for their procedures.
Three operating rooms with 4 operating tables were utilized simultaneously by 3 surgical teams. One room was a converted labor and delivery suite, which was used as the primary laparoscopic room due to a lack of direct overhead lighting. Another room with a pediatric-sized table was used for the majority of the pediatric craniofacial cases. The final room was set up with 2 tables for general surgery procedures.
Adjacent to the operating room, a 4-bed postanesthesia care unit was staffed and maintained by an anesthesiologist and team nurses. Upon adequate anesthesia recovery, patients were discharged to their respective hospital wards, or discharged home. Patients with large incisional hernias, patients who underwent laparoscopic sleeve gastrectomies, and pediatric patients were kept overnight due to travel logistics. Patients residing in an indigenous community in the Amazon requiring assistance with travel and accommodations for their procedures, underwent their procedures on the first operative day of the mission to facilitate transport home the following day.
Operative reports and orders were entered into the electronic medical record for every patient. Interpretation services were provided by Spanish-speaking team members, local medical students, and Hospital Padre Carollo surgical residents as needed.
At the mission’s conclusion, a detailed electronic inventory was created with a catalog of supplies to be stored in a temperature-controlled space in Quito for future missions. All supplies with expiration dates within the following year were donated to Hospital Padre Carollo for use.
Research, education, and outreach
Northwell’s Center for Global Health (CGH) conducted a Global Health Week during the mission hosted by Universidad de San Francisco Quito with the goal of setting the groundwork for a global research initiative and educational partnership, as well as providing disaster relief training to the local community. The Northwell team was fortunate to tour the facilities and school, the university’s microbiology lab, and discussed resident and fellowship programs, as well as graduate student opportunities.
Research topics for discussion included the Genetics of Cleft Lips and Palates, Fetal Hemoglobin at High Altitude, and Flavivirus (Zika/Dengue). This research initiative will facilitate innovative protocol design, medical trainee research project development, and research collaborations between the institutions. Meetings further discussed housing logistics for collaborators and the potential development of a multi-site research program for the CGH to include the incorporation of a Puerto Rican site.
The week additionally included presentations by team members including a Grand Rounds presentation by a Northwell CGH emergency medicine attending and a research presentation by a Northwell CGH immunologist for university staff and students; the lectures were updates on State of the Art in the respective specialties.
Outreach efforts to rural areas focused on the development of a mental health program, led by the team’s psychiatry and emergency medicine physicians. In addition, members of the Northwell team led a full-day training in Emergency and Disaster Response for the local Ecuadorian community and organized workshops for local surgical and anesthetic residents in escalation policies.
Future directions and areas for improvement
As a result of process improvements made during the prior year’s (2019) mission in the inventory and cataloging of medications, supplies, and equipment, our teams were able to focus on transporting only essential items and supplies, limiting resource waste. In addition, the inventory was transferred to an electronic record this year for simpler review and maintenance for future missions.
Upon arrival, it was noted that some anesthesia medications were no longer usable due to inadequate temperature control. To avoid repeating this error moving forward, unused medications were appropriately discarded, donated, or moved to temperature-controlled storage for future missions.
Of note for future improvement, lighting in the operating theaters could be improved. Through our experiences, we found a battery-powered surgical headlight to be invaluable for use during larger general surgery cases. Some team members carried headlamps designed for camping to assist with visualization, but we found the focus of these lights to be too broad to sufficiently aid during the operations. Additional headlights should be included for future missions to help with adequate visualization and operative safety.
On a prior mission, we ran into communication difficulties with local nursing staff due to translation issues. This year, we had more than adequate interpretation services with the help of 8 team members fluent in Spanish, as well as 2 local medical students from the Quito community, and several bilingual surgical residents at Hospital Padre Carollo.
Before the trip, team members received written materials about safety and conduct at the mission site. In addition, a team meeting was hosted to address any health and safety concerns associated with participation in the mission. Mild cases of altitude sickness and traveler’s diarrhea were reported by a minority of team members. No team member departed the mission due to illness, and no team member was the victim of any crime during the mission. Before the trip, all team members received a duffle bag, t-shirt, sweatshirt, and water bottle creating an environment of interprofessional teamwork and bonding across various health care disciplines and furthering esprit de corps, which helped every member recognize their importance to the international mission. The surgical mission enforces safety policies and procedures as expected by Northwell Health. The team was assembled by specific specialists and expertise to deliver the best care seamlessly. In addition, the team had Global Rescue Insurance in addition to local malpractice insurance. The Ecuadorian Ministry of Health provides temporal licenses to all team members, which requires an application for privileges, presenting medical licenses and graduate degrees, and the guarantee of the local Foundation—which in this case is the Fundacion Tierra Nueva-Hospital Canto a la Vida. This process is coordinated and must be completed 3 months in advance.
Conclusions
In sum, the Northwell Health Surgical Service Line in conjunction with multiple local Ecuadorian hospitals and medical schools has pioneered a sustainable joint global health venture. In addition to assembling a team of board-certified surgeons, anesthesiologists, and nurses to provide perioperative care, the team sought to build a sustainable model for future medical operations. The team has developed a streamlined approach to patient selection, follow-up care, and sustainable interinstitutional surgical collaboration and training. Further, the establishment of a pipeline of donated materials will continue to lower costs and promote sustainability moving forward. Finally, to ensure mission success during each trip, training at all levels—that is, attending to attending, resident to resident, and student to student—are critical towards continuing the advancement of medical care through the establishment of medical relationships created through teaching and trust.
Ethical approval
No IRB approval was undertaken for this manuscript, and all local patients and team members were required to sign a waiver of disclosure. The authors declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network.
Sources of funding
None.
Author contribution
R.B. was the principal investigator for the study and oversaw the entirety of the study. He contributed to the background of the manuscript and was responsible for editing the manuscript. C.P. was the primary researcher for the study and facilitated data collection data analysis and writing the manuscript. D.A. contributed to writing and editing all sections of the manuscript. The remaining authors contributed equally to the organization and logistics of each mission. They also contributed to production of the manuscript.
Conflict of interest disclosures
The authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
None.
Guarantor
None.
Acknowledgments
The authors acknowledge the efforts of all the Ecuadorian and Northwell volunteers especially the surgeons, nurses, dentists, social workers, and physician assistants in each mission over the years. Northwell Health sponsored all medical supplies during the mission trips described here.
References
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3. Barrera R, Aronowitz D, Badauoi C, et al. Global clinical experience of a long-term surgical mission trip. IJS Global Health 2020;3:e13.
4. Rele Ologunde MM, Kumaran Shanmugarajah JS. Surgical care in low and middle-income countries: burden and barriers. Int J Surg 2014;12:858–63.
5. Debas HT, Gosselin R, McCord C, et al. Disease Control Priorities in Developing Countries, 2nd ed. Oxford University Press; 2006:1245–59.
6. Montgomery LM. Short-term medical missions: enhancing or eroding health? Missiology 1993;21:333–41.
7. Berry N. Did we do good? NGOs, conflicts of interest and the evaluation of short-term medical missions in Sololá, Guatemala. Soc Sci Med, 2014;120:344–51.
