Public health measures such as vaccines and clean water are certainly critical and foundational to transforming health in a limited resource setting. However there are times as a long term medical missionary when the huge health disparities between specialty medical care in the developing and the developed world motivate one to initiate specialized treatment programs where none exist. We will discuss the factors to consider in beginning and sustaining these programs in extremely limited resource settings with examples from neonatology, hematology, and oncology at Kibuye Hope Hospital, a 170 bed teaching hospital in rural Burundi.