The future of global surgery—domestic and abroad—addressed by field experts

The Global Engagement Panel Session Wednesday morning described the strategic direction of the American College of Surgeons (ACS) in domestic and global volunteerism and addressed the challenges and benefits of providing basic surgical care to medically underserved populations domestically and abroad.

“‘Global’ [in this context] means not only international but also domestic. Operation Giving Back [OGB] supports volunteers, promotes their work, and encourages [the recruitment] of new volunteers,” said Girma Tefera, MD, FACS, Medical Director, ACS OGB.

“Why would you want to join a program in your community to help low-income and uninsured people?” asked Scott A. Leckman, MD, FACS, adjunct assistant professor of surgery, University of Utah School of Medicine, Salt Lake City. “I can give you two reasons: there is a huge need and because you [should] do it for yourself. If you volunteer your skills, you will find the joy and satisfaction that you might not find in your own practice.”

In 2001, Dr. Leckman helped lead the launch of the Health Access Project, a program that improves access to comprehensive health care for low-income and uninsured patients in Salt Lake County. “When I operate on an Access patient, I am typically the only one in the room who is aware of this, and the patients wait in the same waiting rooms as other patients do with the same outdated magazines,” said Dr. Leckman, explaining how the project’s patient care process for the medically underserved is similar to that of other patients. Dr. Leckman helped recruit the program’s first 300 physicians, and today, the project has more than 600 physicians and other health care providers and nine hospitals in the county who are providing free care to qualified individuals.

“What I did is something you can do,” said Dr. Leckman, ending his presentation with a quote from philosopher and physician Albert Schweitzer, MD: “‘Do something wonderful and people may imitate it.’”

William Schecter, MD, FACS, emeritus professor of clinical surgery, University of California, San Francisco, described the background and scope of another domestic volunteerism program, Operation Access (OA)—a not-for-profit collaboration of physicians, nurses, and hospitals that provides outpatient surgery to the uninsured in the San Francisco Bay Area. The idea to launch OA came out of a meeting of the Northern California Chapter of the ACS, said Dr. Schecter, cofounder of OA, when attendees began to question why surgeons weren’t doing more to help the uninsured.

“We knew to get surgeons to care for the uninsured, we would have to create an organized, hassle-free system to do so—with emphasis on hassle free,” Dr. Schecter said.

Since its founding in 1993, OA has donated more than 17,000 services to 30,000 patients, with 92 percent of patients reporting an improved ability to work or care for family, and 98 percent of volunteers reporting they are “very satisfied” with their experience.

To launch a domestic volunteer program, Dr. Schecter suggests realistically assessing your commitment, including time away from family and practice; recruiting competent medical, legal, and financial assistance; and avoiding grandiose thinking by choosing a problem/need where you can make a difference.

“Limit meetings to one hour—and make them fun. This is a volunteer project—the moment you stop having fun the whole thing dies,” Dr. Schecter said. “Expect to lose heart, but remember to take energy from your group and act positively even when you’re wondering why you started this in the first place. This feeling will pass.”

Dr. Schecter also discussed the mission and work of an international project he is associated with called the Alliance for Global Clinical Training, which links academic surgeons and departments in the U.S. with academic surgery departments in low- and middle-income countries.

“We chose the Muhimbili University of Health and Allied Sciences in Tanzania [as the inaugural partner facility] for two reasons—they had an established educational infrastructure, and they were enthusiastic about collaborating with us. They were happy to see us and that’s not always the case,” Dr. Schecter said.

According to Dr. Schecter, the advantages for U.S. surgery departments and educators to participate in the program include the following: it is a ready-made/turn-key project, it offers opportunities for collaborative research, and it is offers the chance for unique resident education experiences.

Haile T. Debas, MD, FACS, Maurice Galante Distinguished Professor of Surgery Emeritus, University of California, San Francisco, and founding director of the University of California Global Health Institute, discussed the importance of building a global surgery consortium. Referring to global surgery as an important component of world health, Dr. Debas noted “that approximately 18 percent of the total global burden of disease is surgical and that 1.4 million deaths could be averted annually with basic surgical procedures.” He called for an integrated response in the U.S., specifically from academic institutions and surgical associations to meet the challenges of global surgery.

Dr. Debas called on enhanced efforts to form a consortium for global surgery, which would ideally include workgroups focused on governance, education, training, clinical implementation, and capacity building to meet the challenges of the global surgical workforce.

Miliard Derbew, MD, FRCS, FCS-ECSA, President of the College of Surgeons of East, Central and Southern Africa (COSECSA), discussed the organization’s efforts to address surgical workforce shortages in Africa. “There are 1,609 surgeons currently working in the 10 countries in the COSECSA region, of whom 35 percent are COSECSA members or fellows. When standardized against the population, the overall ratio is 0.5 per 100,000,” Dr. Derbew said.

To date, COSECSA has 263 trainees, 102 graduates, and 118 accredited trainers, with plans to train an additional 500 surgeons by 2020. Dr. Derbew said the association needs additional trainers and training hospitals to bridge the surgical workforce gap in Africa, and that forming partnerships with organizations in the U.S. and around the globe is key to achieving this goal.

Walter D. Johnson, MD, MBA, MPH, FACS, FAAN, provided the World Health Organization (WHO) perspective on global surgery. “The global surgery landscape changed in 2015 when the United Nations passed the Sustainable Development Goals [SDGs],” Dr. Johnson said. The third SDG called for “participants to ensure healthy lives and promote well-being for all.”

Dr. Johnson noted that simply training surgeons is not enough to alleviate health care disparities around the globe and that training nurses, providing sterile surgical instruments, and making sure that there are adequate sources of clean water are also part of the solution. “We also expect great changes from Dr. Tedros Adhanom Ghebreyesus, who was elected as the new Director-General of WHO,” Dr. Johnson said.

Dr. Ghebreyesus began his five-year term in July 2017. As Minister of Health, Ethiopia, Dr. Ghebreyesus reformed the country’s health system, creating 3,500 health centers and expanding the health care workforce by 38,000 health care providers. Dr. Johnson said WHO member states anticipate Dr. Ghebreyesus will bring the same leadership qualities to WHO and its plan to provide quality health care to underserved communities around the world.