Fresh from a plane trip visiting an Ebola-battered health facility in Liberia, Dr. Paul Farmer spoke about surgery. This was not a non sequitur, but rather a look into how gaps in health systems, resulting from lack of investment in infrastructure – specifically human resources training, contributes to their rapid collapse. In his eyes, having a health system sufficiently strong enough to support surgical activity would have required the barrier nursing, infection control, and procedures and regulations necessary to combat the outbreak. While this statement remains a hypothetical, global surgery has, indeed, entered the global health conversation.
The gulf between access to surgical care and the need for it has long been recognized, but the way in which the global health community has begun to perceive it and how it might be addressed is changing. Traditionally, the primary implementation model for surgical humanitarian interventions has been through surgical mission trips and other charitable platforms, missing the academic institution support that has strengthened efforts combating HIV/AIDS, tuberculosis, maternal/child health, and other issues more often highlighted in the global health agenda. In 2008, Dr. Paul Farmer and Dr. Jim Kim termed global surgery “the neglected stepchild of global health” and, with others, began a conversation wherein surgery is treated not as a first world luxury but as a vital component of primary care and critical to any strategy to address the increasing burden of non-communicable disease. The Lancet Commission Report on Global Surgery, to be published in April 2015, is an example of the academic surgical community around the world coming together to produce an evidence-based document to begin the discourse and serve as a blueprint for achieving surgical equity. In the past five years, an increasing number of “twinning” partnerships, many of them surgical in focus, have developed, pairing differently-resourced academic medical centers in a mutually beneficial collaboration.
As the home of Harvard’s training programs in ENT and Ophthalmology, the Massachusetts Eye and Ear, through its Office of Global Surgery and Health (OGSH), has focused on improving access to otolaryngologic and ophthalmic care. While our faculty and staff had long participated in humanitarian missions, this initiative has provided the structure and resources to coordinate and maintain long-term relationships with academic medical centers in developing countries. In Sub-Saharan Africa, as in most of the developing world, there is a significant shortfall of Ophthalmologists (2.7:million population) and Otolaryngologists (<1: million population), in addition to surgeons and all other healthcare providers. This results not only in a burden of disease that cannot be adequately addressed by existing surgeons, but a lack of the faculty required to produce the next generation of surgical specialists.
Our goal is not simply the transfer of surgical skills, but the development of an academic department capable of generating new generations of surgical educators and supporting their professional development. To this end, the OGSH coordinates onsite faculty rotations and resident assessment with telemedicine/teleradiology, distance learning, surgical skills laboratories, curriculum expansion, research collaboration, and targeted investments in human resources and infrastructure to enrich and augment residency programs and departments. Key to our program is the use of outcome measures and testing assessments to evaluate its impact and support our partner’s ability to leverage for resources. We currently have a pilot program in Mbarara, Uganda and are developing future partner sites.
While global surgery is still in the early stages of developing as an academic field, thousands of dedicated surgeons have made it their life’s work to bring safe surgical care to the most vulnerable in our global community. With their work as a stepping-stone and in the face of an ever-growing surgical disease burden, the surgical community has an opportunity to raise their contributions to a new level.
1 Shrime MG, Sleemi A, Ravilla TD. Charitable Platforms in global surgery: a systematic review of their effectiveness, sustainability, and role in training. World J Surg 2014 Mar 29 [Epub ahead of print].
2 Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008; 32: 533-36.
3 Meara JG, Hagander L, Leather AJM. Surgery and global health: a Lancet commission. Lancet 2014; 383: 12-13.
4 Galukande M, Ozgediz D, Elobu E, Kaggwa S. Pretraining experience and structure of surgical training at a sub-Saharan African university. World J Surg 2013; 37: 1836-40.