Operation Giving Back (OGB), a program of the American College of Surgeons (ACS) Division of Member Services, is building on the success of a pilot initiative in Hawassa, Ethiopia, expanding its humanitarian reach and volunteerism on the African continent. In early 2019, the ACS and the College of Surgeons of East, Central and Southern Africa (COSECSA) Surgical Training Collaborative partnered to launch a training hub in Hawassa. Additional training centers are being established in Lusaka, Zambia, and Kigali, Rwanda.
Girma Tefera, MD, FACS, Medical Director, OGB, and chair, division of vascular surgery, Madison, WI, moderated the Monday, October 25, Panel Session Global Engagement, detailing the achievements and challenges of developing and maintaining surgery training programs in low- and middle-income countries during the coronavirus (COVID-19) pandemic. Panelists included U.S. surgeons involved in OGB’s global engagement activities, as well as partners from Hawassa and Lusaka.
“When we look at the global surgical needs and where we are right now in terms of issues and problems of access and communities that are underserved, we are reminded by the WHO [World Health Organization] that the problem is going to get worse,” Dr. Tefera said. “In fact, it’s expected that the shortfall of primary providers in health care across the low- and middle-income countries will be probably in the range of 18 million or so by 2030. And so, there’s a lot of work to be done.” Workforce retention and training are needed across the globe, he noted, although the countries that are most severely affected are in Sub-Saharan Africa.
In 2016, at the direction of the ACS Board of Regents, OGB put an emphasis on teaching in its global engagement efforts. “Since then, we have been working hard in trying to work on workforce development—training surgeons—and the ecosystem around it, focusing in the Sub-Saharan region, probably for the foreseeable future,” Dr. Tefera said, noting that while surgeons have a long history of volunteering throughout the world, too often that work has occurred in silos and without communication among initiatives. “I think that has really reduced the ability of us to provide a lot more impactful work,” he said.
Dr. Tefera said global surgical workforce training efforts could benefit from the principles used to promote economic recovery in Europe after World War II. “It’s time for us to think about a Marshall Plan for global health in surgery, for global health in general, because doing the same things I don’t think is going to get us to the outcomes that we want, which is basically self-sufficiency, sustainability,” he said, outlining the need to develop shared goals, cultivate long-term involvement, foster open discussion, openly share responsibilities, and have accountability “so that we can all work together in developing those places where we want to really improve the surgical care.” Research infrastructure, quality infrastructure, education infrastructure, and faculty development for local faculty are needed, he said.
Over the past few years, OGB has developed a sustainable learning space in Hawassa with the participation of departments of surgery at 13 U.S. universities. “Together, jointly, this training hub was developed, and the results have been really incredible,” Dr. Tefera said. Even as pandemic-imposed restrictions on in-person activities were enacted, the Hawassa training center adapted and continued its mission.
Overall, the session’s speakers said remote alternatives like virtual meetings had been a boon to maintaining the momentum of OGB in Africa during the pandemic. “We have learned a lot during this COVID era in the absence of physical presence here in Hawassa,” said Anteneh Gadisa, MD, assistant professor of surgery, Hawassa University, citing research training over Zoom as a success. “This platform has really helped us to explore other potential areas where we can work, and it’s been working very well,” he said.
However, the presenters cited Internet connectivity issues among the challenges of the COVID era. “We learned the importance of reliable connectivity. We learned what we can do when we have that, but we also learned how limited we are when we physically can’t be in a location but also can’t communicate reliably,” said Kristin L. Long, MD, FACS, assistant professor, division of endocrine surgery, University of Wisconsin School of Medicine and Public Health, Madison, who has been involved with the Hawassa training hub. She suggested a future investment in technology would enable the program to increase its remote presence and help maximize on-site efforts in Hawassa, thereby helping to create “sustainable, long-term, durable interaction.”
Christopher M. Dodgion, MD, FACS, associate professor, Medical College of Wisconsin, Milwaukee, helped create a virtual trauma evaluation and management course for the Hawassa hub using ACS Committee on Trauma education materials. “We structured the course to be a one-day course where it’s a hybrid of lectures, but also breakout Zoom sessions where we reviewed cases and talked through cases,” Dodgion said, noting the course was a partnership between U.S. faculty and on-site faculty in Ethiopia. The participants represented a broad base of learners, including prehospital providers, nurses, emergency medicine physicians, surgeons, and residents. In the past several months, more than 250 providers have completed the basic trauma education course, he said.
James Munthali, BSc(HB), MBChB, MSc, FCS(Orth), MMed(Orth), H-DipOrth(SA), head of the department of surgery, University of Zambia, Lusaka, said OGB participants from the U.S. plan in-person visits to the Lusaka training hub next year. Local faculty have collaborated with their U.S. partners to set up work groups and organize activities such as journal clubs to lay the groundwork for upcoming initiatives. The visits in 2022 will “formalize what has already been arranged through the use of technology,” such as a research methodology course and skills training, Dr. Munthali said.
William B. Inabnet III, MD, MHA, FACS, chair, department of surgery, University of Kentucky (UK), Lexington, and surgeon-in-chief, UK HealthCare, is involved in the development of the training hub in Zambia. For more than a year, the U.S. and Zambian participants have collaborated through virtual meetings. “It really has been a wonderful opportunity to get to know individuals virtually,” Dr. Inabnet said. “That is no substitute for an in-person visit in making that in-person connection. I think we all long for our meetings to return, to have that in-person human interaction, which I think will solidify the foundation that’s been created.”
Dr. Inabnet and other speakers predict a hybrid approach will likely play a key role in future international partnerships.
“What is going to be the optimal hybrid model is going to require a lot of assessment of what has been successful so far and what we really want to keep going forward,” Dr. Long said, comparing it with how health care providers have adapted telehealth for clinical care during the pandemic. “It’s gotten us through a really tough patch and I certainly think it has a role moving forward, but I think we have to figure out what that role actually is,” she said.
OGB also supports domestic volunteerism. Dr. Tefera provided an overview of this work, including mentorship and virtual lectures for medical students and surgical residents in Puerto Rico. In the U.S., the Health Career Collaborative develops educational experiences for minority students from inner cities, providing mentorship and teaching the students about careers in health care by pairing them with medical schools.