Global Surgery & Anesthesia

I am a pediatric general surgeon currently working at the Women and Childrens Hospital in Buffalo. I was drawn to the area of public health and global health while studying in university and medical school, and then became more interested in the intersection of these areas with surgical services in resource-constrained settings when I pursued training in surgery. In the last eight years I have been part of a collaboration with the Department of Surgery at Makerere University and Mulago Hospital in Kampala, Uganda that has grown into the group "Global Partners in Anesthesia and Surgery" (www.globalpas.org) This started when I was a resident in surgery at the University of California, San Francisco. To gain more skills in public health, I obtained an MPH during my surgical residency. Much of my observations are based on the clinical work and projects that I have been involved in through our Uganda collaboration, what my local Ugandan colleagues have taught me, and what others (clinicians and public health specialists) have shared with me about their work in other similar settings. Below are some thoughts on the questions posed above. I very much look forward to the thoughts of others on these ...

I am a pediatric general surgeon currently working at the Women and Childrens Hospital in Buffalo. I was drawn to the area of public health and global health while studying in university and medical school, and then became more interested in the intersection of these areas with surgical services in resource-constrained settings when I pursued training in surgery. In the last eight years I have been part of a collaboration with the Department of Surgery at Makerere University and Mulago Hospital in Kampala, Uganda that has grown into the group "Global Partners in Anesthesia and Surgery" (www.globalpas.org) This started when I was a resident in surgery at the University of California, San Francisco. To gain more skills in public health, I obtained an MPH during my surgical residency. Much of my observations are based on the clinical work and projects that I have been involved in through our Uganda collaboration, what my local Ugandan colleagues have taught me, and what others (clinicians and public health specialists) have shared with me about their work in other similar settings. Below are some thoughts on the questions posed above. I very much look forward to the thoughts of others on these questions?



1. What characterizes strong, egalitarian academic surgery and anesthesia partnerships?

I dont think that factors that determine the success of partnerships in surgery and anesthesia differ too much from what makes other partnerships work in "global health." I think we would probably all agree that local needs need to be identified and prioritized, and both (or more sides) need to agree to work on goals in a stepwise fashion. Relationships and mutual trust take time to develop. Both sides need to be realistic about what resources can potentially be mobilized to meet the needs, and the motivations for getting involved in this work should be transparent. Sometimes the hardest part is trying to identify the highest priority areas to intervene. There are often significant needs related to training, infrastructure, and service delivery/access--all areas. Interventions in any of those areas could have an impact. Every group may have a different area of focus depending on their resources, experience, and expertise. "Egalitarian" suggests that the relationship should be mutually beneficial in the areas that the collaboration agrees are important.


1. How do you think groups can effectively move in that direction?

Probably the most important factor is to find local "champions" for specific projects, and to find ways to support these champions in moving these projects forward. Without great local support and commitment for a project, it cannot move forward. As mentioned above, often there are needs in many areas, and these are related, so there is a real need to prioritize. Our group has focused more on supporting local training programs than on direct service delivery. Other groups have focused (sometimes exclusively) on service delivery. If shared objectives and goals cannot be met, then these need to be re-evaluated. I think as a clinician primarily working in North America, there is no substitute for on-the-ground clinical work to really see all of the barriers to training and service delivery in the local context; this helps one better understand those challenges from the perspective of our local partners. As with other projects, sustainability is really important and sometimes very hard to ensure at the beginning of a project. We felt as well that an interdisciplinary approach, especially as surgeons with anesthesia,is critical, and between surgical specialties in areas where there is an overlap of needs, such as emergency care, trauma, critical care, and nursing, and innovative ways to help patients who need care get there.

Some of the areas where we have focused are in recruitment of trainees in surgery and anesthesia, mentoring, and teaching, with a focus on relationships with a host of local counterparts. Clinically, we have focused on trauma and emergency surgery, with prehospital and hospital based trauma courses. In some areas, projects have moved forward, in others they have stalled time to time. We have very much wanted to determine ways we can work with other groups to enhance our collective impact, and I think this is really important in places where multiple groups have similar goals, objectives, and local collaborators.

I think we all feel it is important to not "re-invent the wheel;" we should share what has worked and what has not worked with our projects so we can all learn from it. We tend to be biased to talking about areas that we have been successful, but probably learn more when things stall.

It also really depends on the particular focus of the partnerships. Some are faith-based, others are NGO or private groups focused on delivery, and others academic. As more of an academic group we have tried to document needs and challenges, and our efforts to intervene in various areas. This information, we think, has the opportunity to help other groups as well.

1. What key infrastructure must be enhanced to support such partnerships?


I think some way of initially documenting shared goals and objectives, is important to start, so both sides are clear about what is expected. This could be in the form of an MOU (memorandum of understanding), or validation or support from local groups, or other. Some formal kind of agreement is important for both sides to refer back to as the collaboration moves forward. In our case, it took the form of an MOU that spelled out areas of emphasis and collaboration.

We found it difficult to generate the resources we needed to meet local needs through formal and traditional intramural and extramural academic grants, and therefore we sought non-profit status in order to pursue support from foundations or private donors.

It is important to determine how delivery of surgical services fits into the local institutions, groups, programs, and how those relationships work. Supporting, for example, local MOH representatives focused on surgery and perioperative care, and including them in all discussions, or creating a forum for providers to meet with policymakers is important.

A specific challenge we have is that as many of us know, surgery and anesthesia haven't generally been part of the discussion in "global public health" so we have to advocate the importance of these problems to the major donor organizations, but also we have to propose realistic and feasible solutions and document their cost effectiveness and impact too. Most surgeons and anesthesiologists are used to a clinical focus, we need to share a more public-health related focus with these groups and organizations; and the converse is true too, we need to engage in conversation with public health groups about the importance of surgical care at the population level.

1. What outcomes could be measured to evaluate the quality and sustainability of these partnerships?


Outcomes can be project specific; ie if focused on recruitment, has there been an increase in number of trainees? or if focused on delivery, can it be measured in the number of patients cared for, or if based on programs related to skills transfer, evaluations of participants could be completed at some interval to assess skills, and even more ideally, some documentation of mortality or morbidity related to specific surgical conditions. I think we view sustainability (at least partially) as the need to meet needs over time, and the way that resources are mobilized to do so; ie where are these resources coming from and what happens if they dry up? For some areas of collaboration, these kinds of "hard numbers" are hard to come by. Surveys or testimonials of project participants can help, ideally designed and implemented locally. Some groups have developed more subtle ways of measuring success such as the "most significant change" technique used by some larger NGOs (such as Oxfam). One area that is hard to measure is the degree of local ownership for each project or activity; it can be hard to measure some of these areas of capacity-building that we all think are very important but it is critical to do so.

Just as in other areas of global health or work in health disparities more generally, the intentions are always good. We should be aware of what works, and pitfalls in the work, whether investing resources on a small or larger scale. We should be thinking at each step, what the potential negative consequences of projects-focus areas-collaborations could be, especially in an area where resources are often so limited locally. For example, in projects focused on skills building-knowledge transfer, can the projects effect internal or external migration (ie "brain drain") of human resources in a way that doesnt benefit local service delivery? For projects related to service delivery, is there any teaching-training involved and is the delivery sustainable? For projects related to equipment or supply transfer, is that sustainable? In areas where multiple groups are involved with similar goals, are the groups collectively improving the local environment or are there any negative effects? In projects related to research, are these resources context specific, promoting local skills acquisition, and are they taking away from service delivery? Do the costs even of the international travel for these partnerships justify their benefits?

With respect to surgery and anesthesia and related global health issues, a few recent publications address some of these questions.

Welling, D.R., et al., Seven sins of humanitarian medicine. World J Surg, 2010. 34(3): p. 466-70.

Holm, J. and L. Malete, Nine problems that hinder partnerships in Africa. Chronicle of Higher Education, 2010.

Meier, D., Opportunities and improvisations: a pediatric surgeon's suggestions for successful short-term surgical volunteer work in resource-poor areas. World J Surg, 2010. 34(5): p. 941-6.

Nthumba, P.M., "Blitz surgery": redefining surgical needs, training, and practice in sub-Saharan Africa. World J Surg, 2010. 34(3): p. 433-7.

Van Hoving, D.J., et al., Haiti disaster tourism--a medical shame. Prehosp Disaster Med, 2010. 25(3): p. 201-2.

Gosselin, R.A., Y.A. Gyamfi, and S. Contini, Challenges of meeting surgical needs in the developing world. World J Surg, 2011. 35(2): p. 258-61.

Maki, J., et al., Health impact assessment and short-term medical missions: a methods study to evaluate quality of care. BMC Health Serv Res, 2008. 8: p. 121.

Hamed Umedaly: I am a cardiothoracic anesthesiologist in Vancouver BC Canada and part of the clinical teaching faculty of the University of British Columbia. I was born in Uganda and came to Canada as a refugee in 1972 at the Age of 13. I trained in Medicine and specilaized in in Anesthesia in Vancouver at UBC. I had an interest in International Medicine and did some primary health care work briefly in Kenya and Northern Pakistan in my late 20's but then developed an interest in Perioperative medicine which I mistakenly thought was not relevent to the the important problems in Africa, as much as primary , public health and infectious diseases. I realized I was wrong when a surgical collegue of mine brought me to Uganda as they work was severely limited by anesthesia capacity . This is when I realized the immense burden of unmet surgical and perioperative care. I have been to Mulago Hosital for times over 6 yaers and have focuused most of my efforts on teaching anesthesia residents in clinical care and probem based learning. Respectfully and humbly here my thoughts on these key questions posed by Sarah Arnquist.

* What characterizes strong, egalitarian academic surgery and ...

Hamed Umedaly: I am a cardiothoracic anesthesiologist in Vancouver BC Canada and part of the clinical teaching faculty of the University of British Columbia. I was born in Uganda and came to Canada as a refugee in 1972 at the Age of 13. I trained in Medicine and specilaized in in Anesthesia in Vancouver at UBC. I had an interest in International Medicine and did some primary health care work briefly in Kenya and Northern Pakistan in my late 20's but then developed an interest in Perioperative medicine which I mistakenly thought was not relevent to the the important problems in Africa, as much as primary , public health and infectious diseases. I realized I was wrong when a surgical collegue of mine brought me to Uganda as they work was severely limited by anesthesia capacity . This is when I realized the immense burden of unmet surgical and perioperative care. I have been to Mulago Hosital for times over 6 yaers and have focuused most of my efforts on teaching anesthesia residents in clinical care and probem based learning. Respectfully and humbly here my thoughts on these key questions posed by Sarah Arnquist.

* What characterizes strong, egalitarian academic surgery and anesthesia partnerships?

Strong , mutually beneficial perioperative partnerships should be based on sincere needs based goals of both insitiutions, but ultimately where the rubber hits the road... on the gaps and disconnects in the care that patients need. While this can and should be based on an academic model of university teachers and learners, there must be ecomomic model that clarifies that a basic healthacare system is worthwhile from an economic standpoint. This is the only way that any and all educational and technical improvements will be sustained and self sufficient. The "exit" timeline must be part of the early discussions. The exit should be more of an ongoing professional realationship rather that an end .The partnership must not compete with the the development of a local system but instead enhance that development.

* How do you think groups can effectively move in that direction?

They relationships must be mutually respectful, honest and collaborative. The problems in Ugandas delivery of surgical care were present in North America and Europes history. The major chalenges are in capacity have come from a lack of investment . Very good and smart people are Uganda but have been attracted to where the investement have been ID and public helath, the most important thing we can do is attract them to acute medicine with the potential for the collaborative ability to care for patients with a durable perioperative infrastructure . Yes this requires technology, monitors, drugs , biomedical engineering support, blood banking , critical care and pain management but these are the substrates of the the development where we can collaborate. The big hope in Uganda is seeing this tide change with more excellent minds, with a good work ethic being attracted to acute medicine. This is the most important job that we can facilitate. So how can we enhance this attraction ? If the north american and european interest could enhance their academic and clinical teaching program... by assisting the local over burdened faculty with this challenge, we can cascade the capacity and quality to be self sustaining. The model in Uganda for both anesthesia and surgical care will be differnent based on limited capacity One cannot have specilaist surgeons and anesthesiologist care for all patients. But if can can improve the Universties abilty to prepare a critical mass of local experts to teach, then we can build an infrastructure for sustainability.
Besides the attraction to important worthwhile work, the residents need to make a living. The residents need to be funde. I have conflicting thoughts on this. Yes for $ 5000 per year we can fund a resident . Should we ? or is is this perpetuating the wrong model. Should we not do our very best to convince the Ugandan authorities/trusts that this is worthwhile and a way to retain these experts in Uganda.


* What key infrastructure must be enhanced to support such partnerships?

Key question ! This is what makes perioperative care a major unmet and orphaned child of health care systems and global health. Education is key but without infrastructure perioperative is only a concept. It takes investment and sustainment... from reliable O2 supplies to drugs and electricity. But again these partnerships need to adovate for local investement and appropriate technology. We can help break the cycle but we need to show the funding agencies that this is worthwhile and will allow them to use effeciantly utilize the resources they presntly waste. We can model the respectful fair and equal collborations between anesthesia medicine, surgery, nursing and biomedical engineering . We also need to model that higher quality outcomes from surgery come not only for enhanced operative care but also from pre intra and post operative care.


* What outcomes could be measured to evaluate the quality and sustainability of these partnerships?"

While this needs to asked at the outset but it difficult to have the perpectives and form the the relationships that are so important to get to the point of asking these important questions which will be unique to the challenges. Outcomes should be tangible, for example , Targets for the number and quality of trainees and ensure they meet goals. ensure the development of local societies of professionals of perioperative care. The quantity and quality of care and length of stay. Sustainablity needs to be the key outcome of any program. As such "donor" programs must only to utilized to break the cycles which should be taken over by local funding once the "business model" makes sense lest we continue to promulgate the damaging cycle of dependency. We should be the vectors of change , the catalysts not the fuel. There is/are talent , energy and resources. All projects should be collborataive partnerships. While projects that are exclusive and self contained provide important care they may not leave anything behind, they actually be preventing the local development of a sutainable care program. Probably the most important outcomes are the hardest to measure.... the optimism and humanity of the care providers and the comfort of the patients. Overall all partnerships should have an education basis and built around true sustainability.... an exit plan with ongoing professional colloboration and relationships.

Well said Hamedy. Integration of economics into existing health care systems
will be pivotal in going ahead. While this may be hard in developing
countries, it is really up to the governments to invest in the health of
their citizens. As non-cocommunicable diseases continue to rise, management
of these disease becomes even harder to manage due to the lack of advance
tertiary care as well as basic emergency response system. I agree we should
foster relationships that act as catalyst, inorder to foster sustainability.
If we continue to ignore this problem we still be having life expectancy
rates of 40 in developing countries in the year 2030 and asking ourselves
what went wrong even after giving billion of dollars in aid.

Mary Ndumia BSN, MPH

My name is Robert Riviello. My home base is in Boston, MA, USA where I am on staff at Brigham and Women's Hospital (BWH). There I work in the department of surgery as an acute care surgeon (trauma, burn, emergency general surgery). I sit within the BWH Center for Surgery and Public Health as well as the Harvard Medical School Program in Global Surgery and Social Change. I currently spend 9 months yearly in Boston, and 3 months yearly in Rwanda. For the last two years the time in Rwanda has largely been focused on strengthening surgical services at the district hospital in partnership with the MOH and Inshuti Mu Buzima (Partners in Health), a non-profit focused on health systems strengthening. One week ago I had the privilege of participating in the first Strengthening Rwanda Surgery working group meeting - the beginning of a partnership between the Rwanda Surgical Society and international partners with the mission to improve and increase training and delivery of surgical services.

1) What characterizes strong, egalitarian academic surgery and anesthesia partnerships?

It seems to me that strong egalitarian partnerships have to start with real relationships characterized by clear communication and mutual respect. While these relationships ...

My name is Robert Riviello. My home base is in Boston, MA, USA where I am on staff at Brigham and Women's Hospital (BWH). There I work in the department of surgery as an acute care surgeon (trauma, burn, emergency general surgery). I sit within the BWH Center for Surgery and Public Health as well as the Harvard Medical School Program in Global Surgery and Social Change. I currently spend 9 months yearly in Boston, and 3 months yearly in Rwanda. For the last two years the time in Rwanda has largely been focused on strengthening surgical services at the district hospital in partnership with the MOH and Inshuti Mu Buzima (Partners in Health), a non-profit focused on health systems strengthening. One week ago I had the privilege of participating in the first Strengthening Rwanda Surgery working group meeting - the beginning of a partnership between the Rwanda Surgical Society and international partners with the mission to improve and increase training and delivery of surgical services.

1) What characterizes strong, egalitarian academic surgery and anesthesia partnerships?

It seems to me that strong egalitarian partnerships have to start with real relationships characterized by clear communication and mutual respect. While these relationships must necessarily deepen over time, a common ground of trust has to be established to move forward.

Then it is important to outline goals that are mutually beneficial. Some of these goals could include:
- strengthening the training experiences of residents from both sides of the partnership
- increasing the delivery of surgical services either centrally, at the regional or district level, or both
- research collaborations (topics relevant to both centers)
- exchange of expertise that each party brings to the table - for instance, the North American partner likely brings resources and technical expertise, while the local partner brings knowledge of the local burden of disease, practicing in constrained environments, and understanding of the political-cultural context.

Thirdly, I think it is important that academic partnerships around surgical delivery be multidisciplinary in nature. On the clinical side this means participants from all aspects of the surgical team - surgery, anesthesia, and nursing. Recognizing the cross-cutting nature of this mission, it is also valuable to have experts in public health, epidemiology.

2) How do you think groups can effectively move in that direction?

Involvement from the outset, or from early on, of local governing bodies is critical. This can, perhaps should, include the local/national surgery/anesthesia/nursing societies - in whatever form they exist. The formal link through the Ministry of Health is also critical, as they will ask for interim progress reports, helping to promote mutual accountability. Also, mutual engagement and participation through formal bodies such as the regional colleges of surgery (in Africa, WACS, COSECSA, PAACS are examples), and Northern partners (such as the American College of Surgery, the Royal College of Surgery - Ireland, and the World Federation of Societies of Anesthesiology).

Funding is clearly an important piece of effectively moving forward. This may come through philanthropy inspired by the mission of collaborative work which improves the delivery of surgical care to poor and marginalized populations, it may come by joint grand funding applications, it may come from institutional support, or from charitable giving. Such funding needs to be allocated among the various identified needs. These include, but are not limited to strengthening the anesthesia and surgical training at the local site, supporting North American dedicated residency/fellowship time and funds to global surgery endeavors, supporting faculty bidirectionally for travel and "time-away" from their home institutions.

3) What key infrastructure must be enhanced to support such partnerships?

First, there should be a needs assessment of infrastructure, personnel and medical education training programs conducted within the local environment – reports may be provided to the Ministry of Health, and partnered bodies, to track deficits and subsequent improvements.

The infrastructure and systems needs will vary greatly from site to site. Some key items that need to be in place, or should be developed, for an effective partnership include:
a) clinical infrastructure for care delivery - this includes and emergency / casualty department, sufficient operating rooms, sufficient basic equipment to delivery anesthesia, surgical, and nursing care, and sufficient ward space. Other critical components include a functioning supply chain and procurement mechanism, functioning inventory of supplies, functioning basic laboratory and radiology services, and ideally a blood bank of some capacity. I don't know that all of these conditions must be in place to begin, but they should be the goal. Having these in place will allow enough clinical volume such that the clinical experience is sufficient for trainees from both sides to collaborate over rather than compete for. Further, this will allow the clinical platform for mutual research projects as well.
b) Basic computer technologies capable of storing research databases, analyzing data.

4) What outcomes could be measured to evaluate the quality and sustainability of these partnerships?

A surgical and anesthesia databases could be set up that is accessible by both institutions. This should track:
- number of resident experiences at both centers
- number of surgical and anesthesia providers trained at the overseas center
- follow-up number of these providers who remain within country at 6 months, 1 year, … annual follow up.
- Number of collaborative publications
- the volume and case-mix of surgical services (operations) provided at the host institution

I am a general surgery resident at the Brigham and Women's Hospital and a clinical research fellow at the Center for Surgery and Public Health in Boston, MA. Currently I am in Zambia working with the Ministry of Health to assess the ability of hospitals to deliver emergency and essential surgical care, safe anesthesia, emergency obstetric care and newborn resuscitation. This is a year- long study that involves site visits to each of Zambia's 100 hospitals and interviews with regional Ministry of Health Directors. When we finish the field work in August 2011, the Ministry will use the data to develop proposals to solicit funding for each clinical program. The funding for this project is through a Fulbright US Scholar grant, an American Association of University Women Fellowship and the Center of Expertise.


1. What characterizes strong, *egalitarian *academic surgery and anesthesia partnerships?
For the project I am currently working on, egalitarian has meant that I came with skills and an idea but actively sought input from the Zambian stakeholders before forging ahead with the study. In this case, we undertook a 3 month period of "pre-study" during which we visited 15 hospitals and administered a WHO survey ...

I am a general surgery resident at the Brigham and Women's Hospital and a clinical research fellow at the Center for Surgery and Public Health in Boston, MA. Currently I am in Zambia working with the Ministry of Health to assess the ability of hospitals to deliver emergency and essential surgical care, safe anesthesia, emergency obstetric care and newborn resuscitation. This is a year- long study that involves site visits to each of Zambia's 100 hospitals and interviews with regional Ministry of Health Directors. When we finish the field work in August 2011, the Ministry will use the data to develop proposals to solicit funding for each clinical program. The funding for this project is through a Fulbright US Scholar grant, an American Association of University Women Fellowship and the Center of Expertise.


1. What characterizes strong, *egalitarian *academic surgery and anesthesia partnerships?
For the project I am currently working on, egalitarian has meant that I came with skills and an idea but actively sought input from the Zambian stakeholders before forging ahead with the study. In this case, we undertook a 3 month period of "pre-study" during which we visited 15 hospitals and administered a WHO survey while actively soliciting input on ideas that were important to the hospital surgical and anesthesia staff. The assessment evolved dramatically, and we identified 3 related areas of concern to the hospitals and developed modules for each. It was a substantial amount of work to do this and required even more paperwork to revise the study, but the findings are markedly more relevant to the population and have greater potential to support the health care system than did our original design. In short, this extra undertaking required one third of our field work time and produced no publishable data, but the effort was essential to tailor the study to Zambia's needs and strengthened our partnership. And the study is far better for it.

2. How can groups effectively move in that direction?
Our partnership in Zambia is research oriented rather than clinical, so I will speak from that perspective: Propose a good idea, then ask your host country partners how to make it fit. Actively ask for input and build it into your research plans, then be open and willing to change your proposal. In fact, assume that your proposal will probably change substantially. Our goal was to maintain scientific rigor while tailoring the study to the most important needs for Zambia’s surgical services, and a period of study evolution was central to this. Also practicing simple cultural norms fosters good will. For example, in Zambia, I wear a skirt in professional settings, spend minutes (not seconds) greeting officials and pay special attention to elders. There is far more history and culture to be known on my part, but demonstrating openness has gone a long way in our partnership.
3. What key infrastructure must be enhanced to support such partnerships?
First of all, more research funding for international partnerships is needed, and I encourage everyone in this field to advocate for international surgery and anesthesia research funding. Second, relationships are challenging to initiate and maintain from abroad, and internet technology has the potential to change this if access in LMICs is sufficient. Internet, Skype and conference calls are all valuable in bridging distance. Use what is available. For example, in Zambia, most people can get occasional internet, and at the request doctors, midwives and nurses who have participated in the study, we are setting up a website for them to follow the study findings and updates on Ministry initiatives. Interestingly, this has empowered the clinicians ask questions of higher-ups and to propose initiatives of their own. And the Ministry is considering requiring websites for research projects so that stakeholders can be involved. This is a new mode of information exchange and action in Zambia, but the potential for IT is great and relatively inexpensive.
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4 . What outcomes could be measured to evaluate the quality and sustainability of these partnerships?

Good research should inspire programs and influence policy. How do we measure this? It is too early to see how our work will unfold into new initiatives. But I will look for ideas that draw on our study and that come from our partners, specifically, programs and policy that are driven by Zambians. I welcome dialog from participants here on how to evaluate the quality and sustainability of partnerships. It is a key question.

Hello, everyone! Thank you for participating in this panel. All of your insight and commentary will serve as a useful resource to those interested in the global aspects of anesthesia and surgery. On that note, I had a few questions I would like to ask the moderators, as well as anyone else who would like to add their thoughts.

- What are the challenges in training and retaining people for surgery and anesthesia in Uganda and other resource limited settings?

- What are the challenges in funding surgery programs/departments in these areas (e.g., in-county funding and from external sources)?

- What are some of the challenges related to gaining in-country & international political support for increasing the presence of surgery and anesthesia resources in existing country health structures (esp. in resource-limited settings)? And what makes it challenging for people in-country (e.g., working with international organizations and/or academic centers)as well as for people working internationally?

Thank you!

Hi Ted, Thank you for the questions. In Zambia, anesthesia is administered largely by clinical officer anesthetists, who are similar to nurse anesthetists in training. The country is in crisis in terms of anesthetist availability for two reasons: The pay is low, barely enough to afford a modest house with electricity, and the opportunity to increase one's salary is via private practice or by migrating to a neighboring country. Thus retention is very low once an anesthetist has the experience to apply for a higher paying position. The second problem is work load: There are so few anesthetists that the work load is unreasonable. In rural areas, essentially all anesthetists are on call 24/7 all year long, and some cover two hospitals. Both of these lead to poor recruitment into the anesthetist program such that all who apply are a accepted and there is room for more, and many of those leave public practice. Further complicating the clinical officer anesthetist shortage is that a similar training track, called the medical licentiate, pays far more. The licentiate program is much smaller and cannot meet the demand. The Ministry of Health is aware of these issues, and the hope is ...

Hi Ted, Thank you for the questions. In Zambia, anesthesia is administered largely by clinical officer anesthetists, who are similar to nurse anesthetists in training. The country is in crisis in terms of anesthetist availability for two reasons: The pay is low, barely enough to afford a modest house with electricity, and the opportunity to increase one's salary is via private practice or by migrating to a neighboring country. Thus retention is very low once an anesthetist has the experience to apply for a higher paying position. The second problem is work load: There are so few anesthetists that the work load is unreasonable. In rural areas, essentially all anesthetists are on call 24/7 all year long, and some cover two hospitals. Both of these lead to poor recruitment into the anesthetist program such that all who apply are a accepted and there is room for more, and many of those leave public practice. Further complicating the clinical officer anesthetist shortage is that a similar training track, called the medical licentiate, pays far more. The licentiate program is much smaller and cannot meet the demand. The Ministry of Health is aware of these issues, and the hope is that a higher pay scale could alleviate the anesthetist problem, but as of now no concrete plans are in place.

Surgery has similar issues. Most surgery is carried out by medical officers, who are medical school graduates who have one year of clinical training. They complete a mandatory three year post, usually running a hospital in a rural area. Most go on to residency and never return to a remote area, but either stay in an urban hospital with a private practice in the side or assume a practice another country. There is an internal brain drain in Zambia where doctors take administrative positions in the Ministry of Health or NGOs, where the compensation and work conditions are much more favorable. So trained surgical and anesthesia staff are drawn from clinical positions into administrative ones, thus worsening the shortage without leaving the country.

Dan Poenaru here, pediatric surgeon working long-term in Kenya.

The contributions to this topic have been excellent, varied, and inspiring. I would just wish to add one small perspective: the "political" one. This factor seems consistently ignored in most of our discussions on academic and/or clinical partnerships in resource-poor settings, yet I believe that it affects greatly such partnerships and therefore all the questions asked in this discussion.

By political perspective I refer to hidden personal and corporate agendas in the institutions in which we enter, agendas which are either intentionally and non-intentionally avoided in the necessary preliminary discussions and agreements. This may include unknowns such as the desire (or lack thereof) of existing local faculty to actually have well-trained young colleagues who may eventually challenge their authority, threaten the status quo and vie for their positions. It may also include hidden animosities between local training institutions and competition for external resources. It may even include ulterior motives in entering training partnerships where the real but hidden goal is seeking material resources rather than advancing training… I can’t forget the “partnership” I encountered in a well-known African national teaching hospital with an equally well-known American surgical volunteer organization ...

Dan Poenaru here, pediatric surgeon working long-term in Kenya.

The contributions to this topic have been excellent, varied, and inspiring. I would just wish to add one small perspective: the "political" one. This factor seems consistently ignored in most of our discussions on academic and/or clinical partnerships in resource-poor settings, yet I believe that it affects greatly such partnerships and therefore all the questions asked in this discussion.

By political perspective I refer to hidden personal and corporate agendas in the institutions in which we enter, agendas which are either intentionally and non-intentionally avoided in the necessary preliminary discussions and agreements. This may include unknowns such as the desire (or lack thereof) of existing local faculty to actually have well-trained young colleagues who may eventually challenge their authority, threaten the status quo and vie for their positions. It may also include hidden animosities between local training institutions and competition for external resources. It may even include ulterior motives in entering training partnerships where the real but hidden goal is seeking material resources rather than advancing training… I can’t forget the “partnership” I encountered in a well-known African national teaching hospital with an equally well-known American surgical volunteer organization: a large group of surgeons and anesthetists descended upon the centre and were left to “teach” a large number of surgeries in the hospital, without realizing that those surgeries were actually regularly performed by the hosts at all other times. Inviting the “partners” however brought more media attention, freed the local surgeons for a week from their teaching responsibilities, and naturally brought nice equipment which was generously left behind… Be sure that this “partnership” will be energetically supported by the hosts, and the volunteers will get a warm invitation to come back next year :).

How do we avoid these political traps? Not easily. It takes time and perseverance, lots of careful observation, lots of discussion, political finesse, and them some more time. And above all, it starts with the willingness – no, the commitment – to look below the surface and ask the hard questions. Only in that hard-to-achieve atmosphere of full transparency and honesty will true mutual trust be able to grow, as the soil for all the good other things which have been discussed above.

Dan thank you for bringing up the not-so-often spoken political issues. I also think it is healthy and productive to get these out in the air. Most days that I am engaged in this work, I am aware that the “asks” of the different bodies engaged in academic partnerships are not all the same. For instance, most US-based academic medical centers will have as a primary motivator (if not the sole motivator) for engaging in partnerships the goal to expand training opportunity for their own trainees. The local host institution may be primarily looking for mentorship for its own trainees. An NGO assisting in linking the 2 institutions may be most focused on providing care to marginalized populations. Without oversimplifying the complexities of these relationships, it seems to me that only productive way forward is to identify areas where the various goals and values align neatly. As people bridging these partnerships, it is incumbent on us to find these “win-win” scenarios, and then to pursue them, and maximize these synergies. For instance, in the not-so-theoretical example above, one win-win solution is creating “global surgery fellowships” where North American junior faculty in surgery, anesthesia and nursing are supported to work full-time ...

Dan thank you for bringing up the not-so-often spoken political issues. I also think it is healthy and productive to get these out in the air. Most days that I am engaged in this work, I am aware that the “asks” of the different bodies engaged in academic partnerships are not all the same. For instance, most US-based academic medical centers will have as a primary motivator (if not the sole motivator) for engaging in partnerships the goal to expand training opportunity for their own trainees. The local host institution may be primarily looking for mentorship for its own trainees. An NGO assisting in linking the 2 institutions may be most focused on providing care to marginalized populations. Without oversimplifying the complexities of these relationships, it seems to me that only productive way forward is to identify areas where the various goals and values align neatly. As people bridging these partnerships, it is incumbent on us to find these “win-win” scenarios, and then to pursue them, and maximize these synergies. For instance, in the not-so-theoretical example above, one win-win solution is creating “global surgery fellowships” where North American junior faculty in surgery, anesthesia and nursing are supported to work full-time with the local host institution. This person can contribute to all the goals of mentoring local surgical trainees, providing oversight to visiting surgical residents, and increase the clinical care provided to under served patients.

There are many motivations for different organizations to be involved with global surgical issues. I agree that Universities will have different motivations than an NGO. Universities may want to expand the training of their constituents. However, they may be searching for new research opportunities, new innovative methods combining engineering, business and others to find sustainable method for surgical care in a global environment. The partnerships that develop may be based on the resources available. I have attached a pdf from our book that explores motivations that may be determined from the target audiences and financial considerations as well.

Those political factors and hidden agendas Dan brings up are critical issues which can impact any partnership. Key to meeting theses challenges are transparency and true partnership among the various actors.

Perhaps allowing local providers time off from their public hospital duties while visiting attendings are in town is an appropriate goal (we have all met very overworked/heroic local providers working full time for little pay at the public facility while also working almost as hard with private patients to be able to make enough money to support their families)- but it must be in the open and agreed to by all parties, so there are no misunderstandings and hard feelings.

In addition it must be viewed by all as a partnership of equals, which can be difficult when one side (usually the side from the “west”) has the majority of the critical financial resources. Any perceived inequality can effect the relationship particularly with students/residents who are away from their home program. From my experience at a rural orthopedics hospital in South Africa which had a nice arrangement with a major US medical institution, on paper it sounded like a great arrangement.  Wonderful opportunity for the senior resident ...

Those political factors and hidden agendas Dan brings up are critical issues which can impact any partnership. Key to meeting theses challenges are transparency and true partnership among the various actors.

Perhaps allowing local providers time off from their public hospital duties while visiting attendings are in town is an appropriate goal (we have all met very overworked/heroic local providers working full time for little pay at the public facility while also working almost as hard with private patients to be able to make enough money to support their families)- but it must be in the open and agreed to by all parties, so there are no misunderstandings and hard feelings.

In addition it must be viewed by all as a partnership of equals, which can be difficult when one side (usually the side from the “west”) has the majority of the critical financial resources. Any perceived inequality can effect the relationship particularly with students/residents who are away from their home program. From my experience at a rural orthopedics hospital in South Africa which had a nice arrangement with a major US medical institution, on paper it sounded like a great arrangement.  Wonderful opportunity for the senior resident and for the rural hospital and their patients.  In reality- the actual experience varied with the resident.  If the resident was sincere in their desire to work- it was a win for all.  But often the residents came looking for vacation or really didn't want to work as hard as one has to work in rural settings (and although residency is hard, it's nothing like working in resource limited areas).  And the local doctors felt they had no authority over the resident, nor did they have the time to try to exert any authority- they were working under incredibly difficult conditions to just keep things going.  So if the resident didn't really want to work- the local doctors didn't really interfere and did not give the home institution negative feedback about any resident for fear of jeopardizing support.

A final component is a commitment to continuous evaluation of the ongoing partnership and programs, always looking for ways for improvement as well as looking out for the unintended consequences that can show up despite the best efforts of everyone involved.

N

One simplified (and hopefully not overly-simplistic) way to articulate the “political” dilemma is that in global partnerships our Western origin confers us the strength of specialty and resource availability – while at the same time placing us in a vulnerable position socially due to foreign and often little known culture, customs, language and etiquette. How can we enter such partnerships without the social handicap?

One potential solution are “hybrid” training models which combine long-term expatriates on-site with visiting specialist (and super-specialist) faculty. The long-term faculty have hopefully become familiar, at least in part, with the local customs and culture – and yet they remain “iso-cultural” with the visiting faculty, therefore enabling open and transparent transactions.

The current training program in pediatric surgery in Kijabe, Kenya, attempts to follow this model. The program is accredited by COSECSA (the College of Surgeons of East, Central and Southern Africa), yet run by 2 (and more recently 3) long-term expatriate (volunteer missionary) board-certified pediatric surgeons. Their African-based expertise is complemented by several (almost a dozen) short-term pediatric surgical subspecialists (pediatric urology, plastics, ENT, neuro) who contribute for 1-3 weeks at a time, many on a regular basis. “Political” issues, while naturally present, are diminished through similar ...

One simplified (and hopefully not overly-simplistic) way to articulate the “political” dilemma is that in global partnerships our Western origin confers us the strength of specialty and resource availability – while at the same time placing us in a vulnerable position socially due to foreign and often little known culture, customs, language and etiquette. How can we enter such partnerships without the social handicap?

One potential solution are “hybrid” training models which combine long-term expatriates on-site with visiting specialist (and super-specialist) faculty. The long-term faculty have hopefully become familiar, at least in part, with the local customs and culture – and yet they remain “iso-cultural” with the visiting faculty, therefore enabling open and transparent transactions.

The current training program in pediatric surgery in Kijabe, Kenya, attempts to follow this model. The program is accredited by COSECSA (the College of Surgeons of East, Central and Southern Africa), yet run by 2 (and more recently 3) long-term expatriate (volunteer missionary) board-certified pediatric surgeons. Their African-based expertise is complemented by several (almost a dozen) short-term pediatric surgical subspecialists (pediatric urology, plastics, ENT, neuro) who contribute for 1-3 weeks at a time, many on a regular basis. “Political” issues, while naturally present, are diminished through similar underlying objectives and frank communication.

Many other models doubtless exist, and they should all be assessed based on their ability to manage cultural and political strain in a positive and constructive manner.

I have read the Quality assurance project publications and I believe the approach can also be employed to improve anaesthesia and surgery in resource-limited countries like Uganda.
we can no longer generalise or continue blaming health workers for 'stealing' medicines and refusing to work in rural areas. we need to facilitate and build capacity among health workers to understand their local situation, make changes that will result into improvement and have a forum to share success stories and best practices.
There should be a system that ensures regular objective support supervision to rural health facilities coordinated at regional referral hospitals for the case of the Ugandan health system.
surgical and anaesthesia trainees need mentors and the mentors and mentees need facilitation to do a good job for the future.
Internal and external exchange visits should be encouraged to 'Expose' surgeon and students to different working environments in order to stimulate change. Personally, my visit to Michigan health systems and a mission hospital in Kenya changed the way I look and work in different clinical situations.
For students we need atleast minimum standards in training. Let us find a way of eliminating 'improvising' during training. For some students who are used ...

I have read the Quality assurance project publications and I believe the approach can also be employed to improve anaesthesia and surgery in resource-limited countries like Uganda.
we can no longer generalise or continue blaming health workers for 'stealing' medicines and refusing to work in rural areas. we need to facilitate and build capacity among health workers to understand their local situation, make changes that will result into improvement and have a forum to share success stories and best practices.
There should be a system that ensures regular objective support supervision to rural health facilities coordinated at regional referral hospitals for the case of the Ugandan health system.
surgical and anaesthesia trainees need mentors and the mentors and mentees need facilitation to do a good job for the future.
Internal and external exchange visits should be encouraged to 'Expose' surgeon and students to different working environments in order to stimulate change. Personally, my visit to Michigan health systems and a mission hospital in Kenya changed the way I look and work in different clinical situations.
For students we need atleast minimum standards in training. Let us find a way of eliminating 'improvising' during training. For some students who are used to improvising, it is hard for them to think of 'standards' even when they take on leadership role.
We need to encourage local audits and a feedback mechanism to stimulate 'local' continous quality improvement initiatives and promote a safety culture.
capacity and skills in conducting research in surgery is still limited even among senior colleagues and as a result, little is known regarding the challenges that surgeons face!

For those interested but unable to attend the conference...

I will be tweeting from the conference tomorrow... follow #globalsurgery @globalpas or @mlipnick

I will also try to post presentation's powerpoints to this thread along with some commentary tomorrow.

The political agendas brought up are defining for clinical partnerships, and from what I have observed from visiting surgeons and anesthesiologist in Zambia, can lead to unmet expectations for all parties. I wonder if we can learn something from the care and rigor of research studies and partnerships: As a researcher, these issues seem diminished, perhaps because of the Ethics/IRB process. In our case, we also sought approval from the Ministry of Health, which further aligned our partnership. because of this process, our goals were made explicit, partnership was essential, and oversight committees reviewed every detail and asked questions before approval. Could clinical partnerships go through a similar formal process that gives consideration to the goals of each party and leads to a memorandum of understanding? Could standards be set in place for ethical partnerships?

The hybrid model described by Dan would address many of the problems encountered. But for much of the world, having a resident expatriate is not possible, yet working across a cultural gap remains critical. How do we do this? Personally, I contacted the Peace Corp, who put me in touch with a language teacher who was familiar with working in professional and diplomatic settings ...

The political agendas brought up are defining for clinical partnerships, and from what I have observed from visiting surgeons and anesthesiologist in Zambia, can lead to unmet expectations for all parties. I wonder if we can learn something from the care and rigor of research studies and partnerships: As a researcher, these issues seem diminished, perhaps because of the Ethics/IRB process. In our case, we also sought approval from the Ministry of Health, which further aligned our partnership. because of this process, our goals were made explicit, partnership was essential, and oversight committees reviewed every detail and asked questions before approval. Could clinical partnerships go through a similar formal process that gives consideration to the goals of each party and leads to a memorandum of understanding? Could standards be set in place for ethical partnerships?

The hybrid model described by Dan would address many of the problems encountered. But for much of the world, having a resident expatriate is not possible, yet working across a cultural gap remains critical. How do we do this? Personally, I contacted the Peace Corp, who put me in touch with a language teacher who was familiar with working in professional and diplomatic settings. I unabashedly sought his counsel about cultural differences and expectations: Dress, time, language, greetings, gifts. His insights were invaluable, and I continue to ask for advice from professionals in my daily work. Can cultural differences simply be anticipated and openly discussed? Is this enough?

Hi, I am a paediatric surgeon working in Karachi, Pakistan. This has been a very thought-provoking discussion so far – I’d like to add my two bits to it.

Development and progress in health care in general, and surgical care in particular, cannot be dealt with in isolation. For instance, the general level of education in a community will have a significant impact on the kind of health providers that are available for further education and skill specific training. Taking national health care to the next level is inextricably linked to the general progress and development of a community or country. It is important to understand the challenges in health care provision in this context and look at solutions that take this multi-factorial approach into account. Medical colleges in Pakistan churn out several hundreds of doctors every year, but a majority of them migrate to the Gulf or western countries, since financial remuneration and quality of life is far better abroad than in Pakistan.

Solutions that are sustainable are often those that changes a community fundamentally – economics and education are two obvious areas that impact health directly. Programs and policies must take into account that these sustainable solutions are often ...

Hi, I am a paediatric surgeon working in Karachi, Pakistan. This has been a very thought-provoking discussion so far – I’d like to add my two bits to it.

Development and progress in health care in general, and surgical care in particular, cannot be dealt with in isolation. For instance, the general level of education in a community will have a significant impact on the kind of health providers that are available for further education and skill specific training. Taking national health care to the next level is inextricably linked to the general progress and development of a community or country. It is important to understand the challenges in health care provision in this context and look at solutions that take this multi-factorial approach into account. Medical colleges in Pakistan churn out several hundreds of doctors every year, but a majority of them migrate to the Gulf or western countries, since financial remuneration and quality of life is far better abroad than in Pakistan.

Solutions that are sustainable are often those that changes a community fundamentally – economics and education are two obvious areas that impact health directly. Programs and policies must take into account that these sustainable solutions are often developed over longer periods of time. Donors and grants often ask for short term achievements and targets, and these are often the worst enemies of long term solutions. So, although it is important to have targets and defined outcomes, it is important to make them realistic with a clear focus on the bigger picture.

In the narrower context of health, while I believe it is important to emphasize on surgical care given the years of neglect, progress in surgery must go hand in hand with overall progress in health delivery. As Dr. Umedaly noted, pre and post operative care are at least as important as the surgical procedure and anesthesia. A patient undergoing an amputation for a diabetic foot often requires good care for his diabetes, sepsis, renal and cardiac conditions. Developed world universities that collaborate with developing world partners may well look at surgical care as a starting point, but look to expanding the collaboration to other specialties, especially critical care.

Task Shifting Presentation from the recent conference.

Entertaining presentation on enduring partnerships.