A New Model of Global Reconstructive Surgery Training With Reduced Carbon Footprint of Outreach

Abstract

This economic evaluation compares carbon dioxide emissions from air transportation for surgical mission trips vs team training trips.

Climate change and global warming pose a threat to human and planetary health, increasing the global burden of disease and exacerbating inequalities. In scaling access to surgical care globally, it is essential to consider climate-related costs and methods to reduce greenhouse gas emissions.¹

In low- or middle-income countries (LMICs), 9 of 10 people lack access to basic surgical care.² To address unmet surgical burden of disease, health care teams on short-term mission trips traditionally travel to LMICs with large surgical teams and all necessary equipment, perform surgeries, and depart after 1 to 2 weeks. While mission trips fill a substantial global need, their impact and ethics have been questioned in recent years.³ Additionally, these trips may fail to build local surgical capacity while generating substantial carbon dioxide (CO₂) emissions from air transportation of people and supplies.

ReSurge International is a US nongovernmental organization that delivers reconstructive surgical care in LMICs. Through the ReSurge Global Training Program, a reconstructive surgery curriculum involving virtual coursework, surgical team training trips, long-distance mentorship, and competency tracking, ReSurge partners with health care teams and communities to build local surgical capacity while empowering local surgeons to operate independently.⁴ Team size is much smaller, medical freight is minimal, and surgical volumes have increased after each trip as local surgeons build proficiency. In this study, we compared CO₂ emissions from air transportation in prior ReSurge mission trips vs ReSurge surgical team training trips.

Methods

We performed a retrospective analysis of ReSurge mission trips and training trips to Vietnam. Travel team size, medical freight weight, procedure volume, and change in 5-year hospital procedure volume were recorded. The CO₂ emissions from air transportation of personnel and medical freight were calculated using the International Civil Aviation Organization CO₂ emissions calculator and then used to estimate CO₂ emissions generated per procedure performed.⁵ To control for differences in travel distances between mission and training trip locations, we calculated CO₂ emissions for all trips using a standard itinerary from the US to Vietnam (Table 1). The Stanford University Institutional Review Board deemed this economic evaluation exempt from review because it is non–human participant research.

Table 1. International Civil Aviation Organization Passenger and Freight–Related Carbon Dioxide (CO₂) Emissions.

Trip	Departing airport	Arriving airport	Distance, miles	Aircraft	Aircraft fuel burn, kg CO2	Passenger CO2 emissions, kg CO2	CO2 emissions/kg freight, kg CO2
San Francisco, California, to Ho Chi Minh City, Vietnam	SFO	SIN	8435.3	359, 789	177 596.2	1365.2	9.1
	SIN	SGN	677.9	320, 321, 359, 787	15 781.1	192.0	1.3
	SGN	SIN	677.9	320, 321, 359, 787	15 781.1	192.0	1.3
	SIN	SFO	8435.3	359, 789	177 596.2	1365.2	9.1
Total	NA	NA	18 226.4	NA	386 754.6	3114.4	20.8

Abbreviations: NA, not applicable; SFO, San Francisco International Airport; SGN, Tan Son Nhat International Airport; SIN, Singapore Changi Airport.

Detailed methods and pictures of medical freight on each trip type are provided in the eMethods and eFigure in Supplement 1. Data analysis was performed between January and December 2023.

Results

Cumulative CO₂ emissions from passenger and medical freight transportation and CO₂ emissions per procedure performed are shown in Table 2. We found an 83.7% reduction in total CO₂ emissions from air transportation on training trips compared with mission trips (26 609.4 vs 163 430.8) and an 88.5% decrease in CO₂ emissions per procedure performed on training trips (46.8 vs 405.5). There was also an increase in total hospital procedure volume (+508) and procedure volume per surgeon per year following training trips compared with mission trips.⁶

Table 2. Carbon Emissions (CO₂) per Procedure Performed in Surgical Team Training Trips and Short-Term Mission Trips.

Trip type	Hospital location and date of trip	Team size	Total passenger CO2 emissions per round-trip travel, kg CO2	Medical freight weight, kg	Total medical freight CO2 emissions per round-trip travel, kg CO2	Cumulative CO2 emissions per round-trip travel, kg CO2	No. of procedures performed	Change in 5-y hospital procedure volume	Cumulative CO2 emissions per procedure performed, kg CO2a
Surgical team training	Hanoi, Vietnam; June 2015	2	6228.8	27.2	564.7	6793.5	14	NA	NA
	Hanoi, Vietnam; December 2016	3	9343.2	27.2	564.7	9907.9	30	NA	NA
	Hanoi, Vietnam; January 2018	3	9343.2	27.2	564.7	9907.9	16	NA	NA
	Total	8.0	24 915.2	81.6	1694.2	26 609.4	60.0	+508	46.8
	Mean (SD)	2.7 (0.6)	8297.1 (1796.4)	27.2 (0)	564.7 (0)	8861.8 (1796.4)	20.0 (8.7)	NA	NA
Short-term mission	Phan Rang, Vietnam; February 2012	14	43 601.6	607.81	12 619.8	56 221.4	138	NA	NA
	Phan Rang, Vietnam; February 2013	13	40 487.2	584.68	12 139.5	52 626.7	154	NA	NA
	Quy Nhon, Vietnam; April 2014	14	43 601.6	528.89	10 981.2	54 582.8	111	NA	NA
	Total	41.0	127 690.4	1721.4	35 740.4	163 430.8	403.0	0	405.5
	Mean (SD)	13.7 (0.6)	42 522.5 (1796.4)	573.8 (40.6)	11 913.5 (842.4)	54 435.9 (1798.1)	134.3 (21.7)	NA	NA

Abbreviation: NA, not applicable.

^a Cumulative CO₂ emissions per procedure performed (kg CO₂) = (cumulative CO₂ emissions per round-trip travel)/(total number of procedures performed + change in 5-y hospital procedure volume).

Discussion

The findings suggest that the ReSurge curriculum and training model allows for sustainable global surgical care, reducing CO₂ emissions from passenger and medical freight air transportation. The model operates cyclically, focusing on repeated, consistent interactions with health care partners in LMICs both virtually and in person. Such interactions enable ReSurge to identify highly engaged partners at local hospitals. Furthermore, training on local equipment with local supplies enables discovery of health care solutions that meet the needs of physicians and patients in the local environment. Additionally, team members have returned with approaches to conserve resources in their own institutions.

To our knowledge, this study was the first to assess climate-related costs associated with air transportation of personnel and supplies in traditional mission and surgical team training trips. A study limitation was the small sample size. Findings of this study support a transition to greener health care and represent a step toward reducing climate-related costs associated with health care education and delivery in LMICs while increasing efficiency in reconstructive surgical training.

Supplement 1.

eMethods. Estimating Carbon Emissions

eFigure. Medical Freight on (A) Short-Term Mission Trips and (B) Surgical Team Training Trips

Supplement 2.

Data Sharing Statement