**3. Implementation of the development program**

#### **3.1 Direction and leadership**

Before undertaking a program to develop pediatric cardiac services there must be an agreement between all stakeholders regarding what level of development is desired by the local team. Autonomy of choice by the local team is imperative, one should not approach this as *we know what is best for you and your country,* this is a form of neo-colonialism and is to be avoided [6]. You may be experts in pediatric cardiac care, but they are certainly the experts in the subtleties of politics and economics of their countries.

Once a decision is reached regarding the level of expertise the local team wishes to attain it is critical to identify clinical leaders in surgery, critical care, anesthesia, perfusion, and pediatrics. Once again, the autonomy of the local team is important here, they need to decide amongst themselves who will lead the various specialties involved in the care of children with heart disease. There is simply no justification for the visiting team to insist upon certain individuals being named to leadership positions. Such an attempt will lead to a fracture of trust and the development of

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*Ethical Considerations for Global Pediatric Cardiac Surgical Assistance Programs*

co-dependency. However, if during the program it becomes obvious that leadership needs to change, then it is incumbent upon the visiting team to address this issue. A failure of leadership is one of the most common factors in program disruption and

One does not often relate ethics and infrastructure, but when considering the creation or improvement of an existing pediatric cardiac program you must be sure that the necessary elements for providing safe pediatric cardiac care are in place or will be before program initiation. The equitable treatment of the children receiving care in LMIC must be maintained within the constraints of economic reality. The deficiency in pediatric cardiac caregivers in LMIC has resulted in large waiting lists and the needs of the many outweigh the needs of the one. Although ECMO, artificial hearts and left ventricular assist devices can provide a few children in upperincome countries (UIC) with a survivable situation, but when costs are considered many more children could be saved in LMIC with a low-risk operation. Basic infrastructure needs for pediatric cardiac care include an echocardiogram machine, an operating theater (not a hybrid OR suite) adequately provided with climate control, oxygen, air and electrical sources in addition to anesthesia machine and routine open heart surgery equipment. A basic intensive care unit with invasive monitors, adequate oxygen and electrical sources and ventilators to provide routine care. The vast majority of children requiring surgical intervention will be adequately served with these essential elements [8]. A cardiac catheterization lab is a luxurious addition to the diagnostic equipment and justification for this is difficult in a number of LMIC. However, the possibility of acquiring a refurbished catheterization laboratory rather than a state-of-the-art device is a means of providing this diagnostic capability and creating an equitable situation. A donor who provides such sophisticated equipment must be prepared to continue to support the maintenance or the equitable situation they created in diagnostic capabilities can be short-lived. There is simply no justification for providing advanced diagnostic equipment, having the local team develop capacity with it, and then having it removed because of a

Building a team or improving an existing team requires that the visiting team provide individuals that are specialists in pediatric cardiac care and education. Frequently the visiting team will have volunteers including medical students, residents and fellows who are wanting to explore global health initiatives. The team leader of the visiting team must remember that the purpose of the visit is to increase the experience and capacity of the local team. Members of both the visiting and the receiving teams can all benefit from the educational opportunities, but it is incumbent upon the team leader to mentor the recipient team members particularly. A trip to an LMIC is not a place for medical students to learn the intricacies of pediatric cardiac surgery, or cardiology or anesthesia; you are there to teach the local team and they should always be the primary recipient of training [10]. Upperlevel residents and fellows should participate in all aspects of care as the children in LMIC are not the same as the infants that they care for at their home institution. The opportunity to see the ravages of chronic congenital heart disease on a child or adolescent is a lesson in natural history for them, but a daily occurrence for the local caregivers. Global cardiac surgical initiatives are first and foremost an opportunity to exchange knowledge in both directions between visitors and the local team.

*DOI: http://dx.doi.org/10.5772/intechopen.96599*

failure to achieve the desired goals [7].

breakdown and an absence of support for repair [9].

**3.3 Human resources**

**3.2 Infrastructure issues**

co-dependency. However, if during the program it becomes obvious that leadership needs to change, then it is incumbent upon the visiting team to address this issue. A failure of leadership is one of the most common factors in program disruption and failure to achieve the desired goals [7].
