Robert Riviello

The "other" neglected diseases in global public health: surgical conditions in sub-Saharan Africa.

Doruk Ozgediz and Robert Riviello discuss the burden of premature death and disability and the economic burden of surgical conditions in Africa.

Global cancer surgery: delivering safe, affordable, and timely cancer surgery

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US

Role of Collaborative Academic Partnerships in Surgical Training, Education, and Provision

6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

Enhancing formal educational and in-service training programs in rural Rwanda: a partnership among the public sector, a nongovernmental organization, and academia.

The global disparities in both surgical disease burden and access to delivery of surgical care are gaining prominence in the medical literature and media. Concurrently, there is an unprecedented groundswell in idealism and interest in global health among North American medical students and trainees in anesthesia and surgical disciplines. Many academic medical centers (AMCs) are seeking to respond by creating partnerships with teaching hospitals overseas. In this article we describe six such partnerships, as follows: (1) University of California San Francisco (UCSF) with the Bellagio Essential Surgery Group; (2) USCF with Makerere University, Uganda; (3) Vanderbilt with Baptist Medical Center, Ogbomoso, Nigeria; (4) Vanderbilt with Kijabe Hospital, Kenya; (5) University of Toronto, Hospital for Sick Children with the Ministry of Health in Botswana; and (6) Harvard (Brigham and Women’s Hospital and Children’s Hospital Boston) with Partners in Health in Haiti and Rwanda. Reflection on these experiences offers valuable lessons, and we make recommendations of critical components leading to success. These include the importance of relationships, emphasis on mutual learning, the need for “champions,” affirming that local training needs to supersede expatriate training needs, the value of collaboration in research, adapting the mission to locally expressed needs, the need for a multidisciplinary approach, and the need to measure outcomes. We conclude that this is an era of cautious optimism and that AMCs have a critical opportunity to both shape future leaders in global surgery and address the current global disparities.

Surgery in Global Health Delivery

Global disparities in the distribution, specialization, diversity, and competency of the health workforce are striking. Countries with fewer health professionals have poorer health outcomes compared with countries that have more. Despite major gains in health indicators, Rwanda still suffers from a severe shortage of health professionals. This article describes a partnership launched in 2005 by Rwanda’s Ministry of Health with the U.S. nongovernmental organization Partners In Health and with Harvard Medical School and Brigham and Women’s Hospital. The partnership has expanded to include the Faculty of Medicine and the School of Public Health at the National University of Rwanda and other Harvard-affiliated academic medical centers. The partnership prioritizes local ownership and—with the ultimate goals of strengthening health service delivery and achieving health equity for poor and underserved populations—it has helped establish new or strengthen existing formal educational programs (conferring advanced degrees) and in-service training programs (fostering continuing professional development) targeting the local health workforce. Harvard Medical School and Brigham and Women’s Hospital have also benefited from the partnership, expanding the opportunities for training and research in global health available to their faculty and trainees. The partnership has enabled Rwandan health professionals at partnership-supported district hospitals to acquire new competencies and deliver better health services to rural and underserved populations by leveraging resources, expertise, and growing interest in global health within the participating U.S. academic institutions. Best practices implemented during the partnership’s first nine years can inform similar formal educational and in-service training programs in other low-income countries.

Global Surgery 2030: a roadmap for high income country actors

Surgical conditions account for a significant portion of the global burden of disease and have a substantial impact on public health in low- and middle-income countries. This article reviews the significance of surgical conditions within the context of public health in these settings, and describes selected approaches to global surgery delivery in specific contexts. The discussion includes programs in global trauma care, surgical care in conflict and disaster, and anesthesia and perioperative care. Programs to develop surgical training in Botswana and pediatric surgery through international partnership are also described, with a final review of broader approaches to training for global surgical delivery. In each instance, innovative solutions, as well as lessons learned and reasons for program failure, are highlighted.

Medical missions, surgical education, and capacity building.

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the worlds new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.

A pilot comparison of standardized online surgical curricula for use in low- and middle-income countries.

Campbell and colleagues provide additional evidence hat a highly structured short-term experience in a resourceimited environment enhances training of North Amerian surgical residents. In this case, residents worked ith Operation Smile, which has provided high-volume umanitarian surgical care in many low-income counries for 25 years. Trainees from high-income countries ave also reflected that similar experiences provide a nique way of meeting required competencies. As ampbell and colleagues state, surgical trainees of this eneration have an increasing interest in global experinces, and more training programs are providing these pportunities. As these programs proliferate, we want to challenge the urgical community to move beyond the needs of North merican trainees to consider the educational needs of stuents, residents, faculty, and health personnel in host instiutions and hospitals. Local specialist surgeons and aneshesiologists are often few, overstretched, and battle xtreme resource limitations on a daily basis. The priority nd feasibility of meeting needs varies in every context, but top priority stated by partners is the development of local apacity. This can include bedside and intraoperative teaching with short or long-term visiting faculty, skillsbased workshops, sharing of educational materials, or collaborative research training and projects. Local feedback is essential to evaluate any program sending North American trainees to a limited-resource environment. We must inquire if the experiences of our trainees detract from those of local clinicians rather than complement them. Reciprocity in such arrangements might not be exact; for example, it is not possible for overseas trainees to practice hands-on in the United States. However, local training needs can be met in other ways, ideally in the home environment, but some programs also incorporate well-structured short-term international experiences for trainees and faculty overseas.

Geriatric emergency general surgery: Survival and outcomes in a low-middle income country

IMPORTANCE Surgical conditions are an important component of global disease burden, due in part to critical shortages of adequately trained surgical providers in low- and middle-income countries. OBJECTIVES To assess the use of Internet-based educational platforms as a feasible approach to augmenting the education and training of surgical providers in these settings. DESIGN, SETTING, AND PARTICIPANTS Access to two online curricula was offered to 75 surgical faculty and trainees from 12 low- and middle-income countries for 60 days. The Surgical Council on Resident Education web portal was designed for general surgery trainees in the United States, and the School for Surgeons website was built by the Royal College of Surgeons in Ireland specifically for the College of Surgeons of East, Central and Southern Africa. Participants completed an anonymous online survey detailing their experiences with both platforms. Voluntary respondents were daily Internet users and endorsed frequent use of both print and online textbooks as references. MAIN OUTCOMES AND MEASURES Likert scale survey questionnaire responses indicating overall and content-specific experiences with the Surgical Council on Resident Education and School for Surgeons curricula. RESULTS Survey responses were received from 27 participants. Both online curricula were rated favorably, with no statistically significant differences in stated willingness to use and recommend either platform to colleagues. Despite regional variations in practice context, there were few perceived hurdles to future curriculum adoption. CONCLUSIONS AND RELEVANCE Both the Surgical Council on Resident Education and School for Surgeons educational curricula were well received by respondents in low- and middle-income countries. Although one was designed for US surgical postgraduates and the other for sub-Saharan African surgical providers, there were no significant differences detected in participant responses between the two platforms. Online educational resources have promise as an effective means to enhance the education of surgical providers in low- and middle-income countries.

Non‐technical skills and health care provision in low‐ and middle‐income countries: a systematic review

BACKGROUND Geriatric patients remain largely unstudied in low-middle income health care settings. The purpose of this study was to compare the epidemiology and outcomes of older versus younger adults with emergency general surgical conditions in South Asia. METHODS Discharge data from March 2009 to April 2014 were obtained for all adult patients (≥16 years) with an International Classification of Diseases, 9th revision, Clinical Modification diagnosis codes consistent with an emergency general surgery condition as defined by the American Association for the Surgery of Trauma. Multivariable regression analyses compared patients >65 years of age with patients ≤65 years for differences in all-cause mortality, major complications, and duration of hospital stay. Models were adjusted for potential confounding owing to patient demographic and clinical case-mix data with propensity scores. RESULTS We included 13,893 patients; patients >65 years constituted 15% (n = 2,123) of the cohort. Relative to younger patients, older adults were more likely to present with a number of emergency general surgery conditions, including gastrointestinal bleeding (odds ratio OR [95% CI], 2.63[1.99-3.46]), resuscitation (2.17 [1.67-2.80]), and peptic ulcer disease (2.09 [1.40-3.10]). They had an 89% greater risk-adjusted odds (1.89 [1.55-2.29]) of complications and a 63% greater odds (1.63 [1.21-2.20]) of mortality. Restricted to patients undergoing operative interventions, older adults had 95% greater odds (1.95 [1.29-2.94]) of complications and 117% greater odds (2.17 [1.62-2.91]) of mortality. CONCLUSION Understanding unique needs of geriatric patients is critical to enhancing the management and prioritization of appropriate care in developing settings.