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March 20, 2019

Financial Investment in Global Surgery—Codevelopment as an Accretive Evolution of the Field

Author Affiliations
  • 1Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
  • 2Massachusetts Eye and Ear, Boston
  • 3Harvard Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
  • 4Departrment of Neurosurgery, Duke University Medical Center, Durham, North Carolina
JAMA Surg. 2019;154(6):475-476. doi:10.1001/jamasurg.2019.0044

Historically, international health efforts were characterized by intermittent bouts of foreign aid aimed to minimize the large-scale spread of disease. While successful efforts engendered progress toward better health, disconnection and brevity could not counterbalance the permanent and intermingled states of global disease, injury, and illness. In recent years, the emerging discipline of global health has necessarily evolved. We now understand that in place of vertical interventions targeting single diseases, we must build infrastructure for the robust development of multiple health care fields using a systems-based approach. The crosscutting nature of surgery lends itself to this development strategy, because it integrates the many components of health systems, from anesthesia services to blood provision and control, to supply adequate intensive care units.

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    1 Comment for this article
    Rahul Jindal, MD, PhD, MBA | Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
    Dear Editor,

    I read with interest the concept of codevelopment to encourage investment in global surgery. I agree that health care providers in high income countries (HIC) have much to learn from colleagues in low and middle income countries [LMICs] (1) .
    Codevelopment should also include in-depth study of health care practices which are effective in LMIC. The model of Aravind Eye Care hospitals concentrating on efficiency and hygiene has eliminated differences between the surgeries done for paid and non-paid patients (2).
    Interest in global surgery has surged within the US surgical community to provide voluntary services, increase
    surgical case load and to “making things happen” and “doing more with less”, exposure to tropical diseases and develop cultural sensitivity. Another advantage of global surgery elective is cultural adaptability which may be helpful not only for US service officers working in hostile environments but also in the rapidly changing demographics in the US (3,4) .
    Operation Giving Back of the American College of Surgeons is currently developing a curriculum for the newly emerging field of global surgery. I suggest that global surgery curriculum should include the study of codevelopment. Despite clear examples of successful adoption of technology from LMIC to HIC, there needs to be evidenced-based approach. Caution must be exercised when we look for "silver bullets" to improve care for the poor. The World Bank's review showed that there are no blueprint planning approaches for improving the performance of health organizations (5).
    Curriculum should also include study of "disruptive innovators", social marketing - the application of marketing techniques to achieve behavioral changes and lowering operating costs by simplifying services provided by using less than fully qualified providers. There is also a need to develop centers of excellence in codevelopment so that trainees from HIC can benefit from short electives in LMIC.


    1. Sabatino ME, Alkire BC, Corley J. Financial Investment in Global Surgery—Codevelopment as an Accretive Evolution of the Field. JAMA Surg. Published online March 20, 2019. doi:10.1001/jamasurg.2019.0044.

    2. Ydstie J. India Eye Care Center Finds Middle Way To Capitalism. https://www.npr.org/2011/11/29/142526263/india-eye-care-center-finds-middle-way-to-capitalism/

    3. Jindal RM. Cultural sensitivity in deployed US medical personnel. JAMA Surg 2018; 153(5):497-498.

    4. Hart D, Singh-Miller N, Shukla A, Jindal RM. A new era of partnership between the Uniformed Services University and The Armed Forced Medical College, Pune, India. Mil Med 2016; 181(8):726.

    5. Peters DH, El-Saharty S, Sladat B, Janovsky K, Vujicic M. Improving health service delivery in developing countries: from evidence to action. Washington DC: The World Bank; 2009.