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TEMPLATE FOR SURGICAL TRAINING IN RESOURCE‐POOR COUNTRIES

Establishment of a sustainable, locally administered surgical training programme in one of the world’s least-developed nations is a notable achievement. It is a truly remarkable achievement to have then met the surgical needs of all major public hospitals with locally trained general surgeons and have further trained and retained a dozen in specialty surgical disciplines. The history of the Papua New Guinea (PNG) surgical programme that Kevau and Watters have described offers a needed template for international collaboration promoting the development of surgical services in low-income countries.1 Globally, three major policies have affected the surgical services of resource-poor countries over the last 50 years. The first two were described by Ronald Lett, president of the Canadian Network for International Surgery, as ‘colonialism’ and the ‘dark ages’ of international surgery.2 The ‘colonial era’ was characterized by highly dedicated expatriate surgeons and dramatic technology, such as the flying doctors and floating hospitals, that provided good television and effective fund raising but, in the end, limited patient care and unsustainable surgical services that were ineffective in addressing the needs of populations. The ‘Dark Ages’ Lett defined as the years after the 1978 Declaration of Alma Ata when, with the goal of ‘health for all by the year 2000,’ greater investment in public health came at the expense of resources for acute clinical care, including surgery. As a result, Lett argued, much of the developing world was left without access to even essential surgical care by the year 2000. A third, more recent, and sinister influence now exacerbates the problem – the workforce policies of wealthy nations that have relied on doctors, including surgeons, from poor countries to fill positions in wealthy countries’ so-called ‘areas of need’. For example, more than 10% of Australia’s current medical workforce graduated from medical schools in low-income countries.3 Fitzhugh Mullan calculated that emigration to Australia, the UK, the USA and Canada has drained some low-income countries of up to 40% of their doctors. Education and training opportunities, and prospects for better remuneration, are often cited by doctors as reasons for their emigration. Despite this history, Kevau and Watters have shown that resource-poor countries can, with appropriate support, develop local programmes that train and retain their own specialist surgeons. Furthermore, they have made clear the principles, which should guide wealthy nations’ and established colleges’ engagement to support such development. The key elements of the process adopted in PNG deserve to be emphasized.