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Different paths to the same end: a response to the question: quo vadis?

We read with interest and enthusiasm the recent article by Yankah and colleagues “Cardiac Surgery Capacity in SubSaharan Africa: Quo Vadis?” and would like to add our thoughts to this discussion of where we are headed in our efforts to establish sustainable cardiac surgical programs in the developing world. The referenced paper contributes an excellent surveyof the current status of cardiac surgery on the African continent to the growing literature on this topic, and will hopefully raise awareness and stimulate interest among surgeons so that more help can be provided. It also opens the door to the forthcomingdiscussion: Is there an optimalway to foster program development? As residents, perhaps all of us have had the experience of being taught by each intensive care unit staff member that his or her preferred approach to weaning a patient from the ventilator was the only goodmethod. In the end, wehopefully learned that many systems work, and also that the result depends more on the patient than on anything else. Cardiothoracic surgeons involved in international assistance work are similarly coming to realize that the same is true for sustainable program development: different approaches may be effective, but, finally, results are mostly determined by the local team. As Yankah and colleagues point out, there is now general agreement on two issues. First, although a small number of patients can be helped by “evacuation” to established centers where they can be successfully treated, this system is not costeffective, helps very few patients, and contributes nothing to the betterment of the health care system in the native country. Having a surgical team make a one-time trip, the so-called medical tourism or surgical safari, though perhaps slightlymore useful in terms of cost-effectiveness and (almost negligible) teaching, is also generally condemned as not being helpful in the long term. The solution to the shortage of cardiac surgery programs worldwide requires an enduring commitment to a specific site so that mentoring in both medical and leadership skills can be provided. Yankah presents three models: one led by a local surgeon, one consisting of foreign teams making teaching trips once or twice a year, and one where there is an expatriate surgeon living on site and heading the program. He seems to conclude that the first model is the unambiguous best. While we agree that program sustainability depends ultimately on local leadership and local funding, we feel that each site has unique needs and the approach to achieving the desired endmust be individualized.We1 and others2 have reported good results with medical mission trip models similar to Yahkah’s model 2, as well as by having an on-site expatriate surgeon.3 In fact, more than one model may be used in the same place, with changes being made as the program progresses. A successful effort will, in general, result in the local surgeon progressively assuming a leadership role such that “model 2” and “model 3” programs ultimately become “model 1” programs. We commend Yankah and colleagues for their excellent work, and thank them for bringing this important problem to the attention of the journal’s readership.