Article 1
Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh E A, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SL, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Yip W. Lancet. 2015 Aug 8;386(9993):569-624.
If a patient doesn’t arrive at a trauma center within the first hour of a life-threatening traumatic injury, their chances of survival decrease dramatically. Across the globe, 5 billion people do not have access to surgery within a two-hour distance. In 2015, poorer surgical outcomes in less-resourced areas prompted the establishment of the Lancet Commission on Global Surgery. The commission’s broad goal is ambitious: to reduce the global burden of disease that can be addressed through surgical intervention. It serves as a call to action to address the lack of safe, timely, and affordable surgical care resulting in an estimated 16.9 million lives lost each year. Meara et al. analyzed barriers to surgical access, including insufficient infrastructure, workforce shortages, and a lack of comprehensive data on needs and outcomes. The report advocates for the integration of surgical care into national health care services, emphasizing its significant impact on reducing mortality and morbidity, particularly in low- and middle-income countries (LMICs). Nine years after the commission's establishment, some progress has been made in addressing surgical disparities. Trauma surgery plays a particularly important role in meeting the global demand for timely and organized surgical access, emphasizing the importance of prompt patient care. The report outlines how stakeholders in government, surgery and anesthesia, and education can contribute to the commission's goal.
The authors emphasize the necessity for robust data collection to better understand surgical burdens and guide effective policy decisions, using six surgical indicators for data collection: (1) access to timely essential surgery, (2) specialist surgical workforce density, (3) surgical volume, (4) perioperative mortality, (5) protection against impoverishing expenditure, and (6) protection against catastrophic expenditure. Mapping the surgical burden of LMICs through these indicators provides a comprehensive understanding of the issues contributing to the gap in surgical care. This reporting is critical, particularly as LMICs are projected to incur $12-13 trillion in economic losses between the fiscal years of 2015 and 2030, a situation that could be mitigated by timely surgical care. Strategies to reduce the surgical burden suggested by Meara et al. include increasing the surgical workforce, improving healthcare facilities, and incorporating surgical services into primary healthcare. The commission asserts that guidelines and recommendations alone are insufficient to ensure adherence; systemic interventions are essential for substantial change. These interventions require collaboration among government officials, community health workers, and district hospitals to implement recommendations effectively.
Ongoing research and quality improvement initiatives are important aspects of standardizing surgical care delivery, ensuring it meets the needs of populations worldwide. The field of trauma surgery is particularly important in addressing the disparity gap in global surgical care, especially in low-income countries. The Lancet Commission’s 2015 report highlights that surgical conditions represent a significant portion of the global burden of disease, with an estimated 16.9 million lives lost each year due to conditions requiring timely surgical intervention. Continued implementation of the targeted trauma care initiatives proposed by the Lancet Commission nine years ago has the potential to save lives and strengthen health systems in resource-limited settings. By addressing these disparities and enacting change at both individual and systemic levels, we can promote health equity and enhance overall health outcomes on a global scale.
Article 2
Local Staff Perceptions and Expectations of International Visitors in Global Surgery Rotations. Mulenga M, Rhodes Z, Wren SM, Parikh PP. JAMA Surg. 2021 Oct 1;156(10):980-982.
Despite the increasing popularity of global surgery rotations, little research has been undertaken to gauge perception of visiting clinicians and their impact on local healthcare workers, faculty, and staff.
The author of this single-site study distributed a Qualtrics survey to all clinical and administrative staff at a rural mission hospital in Kenya in August and September 2020. Of 119 total staff, 63.9% responded to the survey. A little over half of them were clinical workers. 98.4% agreed that the international visitors provided significant benefits, particularly in education, research and clinical care.
Some respondents perceived outside education negatively when it did not align with local practices (41.7%), caused disturbances in workflow (37.5%), and increased patient complications (33.3%). Likewise, local staff perceived obstacles in visiting staff’s language competency, knowledge of local practices, and implicit biases regarding the African community. The author therefore suggests pre-trip workshops regarding cultural competency, roles, and expectations of visiting staff as well as increased interactions between local staff and visiting staff due to the varied motivations of visiting staff.
The study provides valuable insight into local perceptions of visiting clinicians, however certain limitations exist. Firstly, the small sample size and single-site nature of the design warrants additional study before definitive conclusions can be drawn. Secondly, the thematic analysis is limited in its interpretation and generalizability with respect to the dialect and literal translation of individual racial and ethnic groups. Due to the impact that international volunteers can have on local staff, it is essential to continue to monitor these relationships on a larger scale to further facilitate better bonds within the medical community as well as continued research into patient outcomes to improve patient care.
Article 3
Academic Partnerships in Global Surgery: An Overview American Surgical Association Working Group on Academic Global Surgery. Debas H, Alatise OI, Balch CM, Brennan M, Cusack J, Donkor P, Jaffe BM, Mazariegos GV, Mock C, Mutiibwa D, Numann P, Nyagatuba, JKM, O'Neill JA Jr, Tarpley JL, Tesfaye S, Tefera G, Tuttle TM. Ann Surg. 2020 Mar;271(3):460-469.
This article discusses the role of American academic institutions in enhancing global surgery initiatives. The American Surgical Association Working Group highlights effective strategies and recommendations to foster sustainable partnerships between institutions and surgeons from high income countries and low- and middle-income countries (LMICs). The key themes throughout the article emphasize the importance of collaboration, best practices for partnerships, potential challenges, education/training strategies, research opportunities, and a call to action for active participation in global surgery initiatives. Successful partnerships include ethical and cultural sensitivity, strong administrative leadership, and performing thorough assessment of local needs. To increase the sustainability of the collaboration, the academic institution should seek specific permission from the LMICs’ health authorities including a formally signed memorandum of understanding. The sustainability of the partnerships is built upon open communication and mutual understanding of the perceived benefits. The authors recognize the potential challenges including financial barriers and respectfully navigating cultural differences. The incorporation of global surgery into medical education- beginning in medical school and continuing throughout residency training is the result of the commitment of trainees and faculty, as well as the recognition of these partnerships as a source of education, training and research opportunities for both parties. Observerships and other visiting training programs can be beneficial when they are appropriately designed, including enough time to maximize the experience. Additionally, it is noted that US trainees in LMIC settings would benefit from the volume of open procedures performed. In turn, the host institution benefits from the academic contributions including implementation of courses, morbidity and mortality conferences and improvement of perioperative care.
Research collaboration can be of great value, addressing pressing surgical challenges in low-income regions, promoting the generation of evidence-based practices. Research can begin in the academic institution with the ultimate goal of returning trained research participants to their LMIC of origin.
Multiple examples of successful US-LMIC institutional partnerships exist. These partnerships include but are not limited to: Vanderbilt-Kijabe and Kenya, Kwame Nkrumah University of Science and Technology/University of Washington, The Memorial Sloan Kettering Cancer Center Global Disparities Initiative in Sub-Saharan Africa, and ACS-COSECSA Surgical Training Hub-Hawassa Collaborative. The relationships between US academic institutions that actively participate in global surgery initiatives have produced significant contributions. These collective efforts can improve surgical care and outcomes globally. The article provides a framework for best designing these partnerships. It serves as a call to action for more structure and thoughtful engagement in the field of global surgery.
