On November 14, 1995, an event changed a young
mans 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,
Im 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 Campbells 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 mans 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 patients 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
|Round Table Participants
Dean K. Matsuda, MD
Arthroscopy Southern California Permanente Medical Group Kaiser West Los
Angeles Medical Center Los Angeles, California
R. Richard Coughlin, MD, MSc
Medical Center San Francisco, California
Rebecca S. Yu,
Northern California Permanente Medical Group Kaiser Oakland Medical
Center Oakland, California
Richard C. Fisher, MD
Colorado School of Medicine Denver, Colorado
Dean K. Matsuda, MD: What is the relationship
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
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
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
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
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
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
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 shouldnt 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 countrys 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
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
Im 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
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 volunteers time and
effort more efficient and effective. Join the fun. The need has never been
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 cant 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.
- R. Richard Coughlin, MD, can be reached email
- Richard C. Fisher, MD, can be reached at email
- 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
- 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
HVO incorporates with
Orthopaedics Overseas as founding division
establishes first program in Ethiopia
James Cobey, MD, serves as
first Chair of the Board
New Sponsor - ASSH
Orthopaedic Education and Research Foundation funds fellowship for senior
Receives US Surgeon Generals Certificate
of Recognition for enriching the lives of disabled Vietnamese through
New sponsor - AAOMS
First oral surgery program starts in Nepal
90 volunteers serve at 13
New sponsor - AACN
Barry Gainor, MD, becomes chair of the board
assignments completed at 50 programs
New sponsor - ACP
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
Receives grant from USAID for
rehabilitation training project in Uganda
David Frost, MD, becomes chair
of the board
372 volunteer assignments completed at 57 programs
New sponsor - ADA
Dental programs start in Grenada, St. Lucia and Trinidad
grant from USAID for rehabilitation training project in Mozambique
New sponsors AAD, AOFAS
New sponsor - AANA
Receives grant from USAID for rehabilitation training project in Vietnam
New sponsors ABA, AAHS
383 volunteers completed 411 assignments Total
value of educational materials and medical equipment sent since 1986 exceeds
New sponsors - AAOS & AAP
USAID-funded project in Mozambique ends
First nurse anesthesia
program starts in Uganda
First burn management program
started in India
Louis Rafetto, MD, becomes the 5,000th volunteer
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
American Society of Hematology
and American Society of Clinical Oncology join as new sponsors
new programs initiated
433 volunteers completed 474 assignments in
USAID-funded project in Vietnam ends
278 volunteers served in 34
506 volunteers completed 546
assignments in 23 countries
11 new programs opened
KnowNET a web-based platform that serves as an e-library for program
Ministry of Health of the Royal Government
of Bhutan recognizes Health Volunteers Overseas for its contributions to
improving health care
Nurse anesthesia division
receives award from the AANA Council for Public Interest in Anesthesia
488 volunteers completed 543
12 new programs opened
Julia Plotnick, MPH,
RN, FAAN, RADM, USPHS (ret.), became chair of the board of directors
Elizabeth Kay, MD, becomes
Chair of the Board
Cynthia Howard, MD, becomes the 2,000th volunteer
USAID-funded project in Uganda ends
Volunteers completed 495
assignments at 65 project sites in 26 countries
Six new programs
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 organizations 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