Wolf: Little pig, little pig, let me in!
Pig 2: Not by the hair on my chinny chinny chin!
Wolf: Then I’ll huff and I’ll puff and I’ll blow your house down.
~The three little pigs.
My first contact with surgery was at 5, when I had a scalp abscess drained crudely under local anesthesia in a secondary level ‘general’ hospital operating room in Nigeria. It intrigued me, and I insisted on heading straight back to class from the theater to show off my white crepe bandage turban dressing. I still wear that badge of honor- a bald parietal patch at the incision and drainage site.
My mom is both a biologist and an educationist, and this was my privilege. Not money. Not a silver spoon. I would have dropped out of the 4th grade of my dream elementary school except that I walked up to my school Principal and said, “My parents can’t afford to pay fees, and I am not leaving this school this year…” That, and grace, brought me a scholarship. We sold everything from chickens and frozen milk with food coloring in the name of ice cream, to books and stored beans. My advantage was in books. I would read them new before they were sold. Through books, I had access to possibilities I could only imagine, places I could never visit, and people I would never have met. I read Ben Carson’s inspirational trilogy of Gifted Hands, Take the Risk and Think Big. It worked. Even though mom had me stereotyped as a computer engineer, I headed in the direction of a scalpel and an OR.
Along this journey, my blockades were not peculiar, but I now know that my location accentuated some barriers and created some delays. While we necessarily must focus on equity in patient access to surgical care, we should not lose sight of equity in access to global surgical education. The lens through which we address the availability of surgical care must be wide-angled, and catch the critical incline of surgical education. Delays in accessing injury care are implicated in up to 36% of injury deaths. Delay in accessing surgical education, though not as enchanting, is responsible for many more injury deaths.
The 4 delay model, which illustrates barriers limiting access to care, is an archetype of the delays experienced by many seeking a global surgery education; particularly, learners from Low- and Middle- Income Countries (LMICs).
- Delays in seeking global surgical education
“Sticks and stones may break my bones but words will never hurt me…”
~ English Nursery Rhyme
Initially employed as a defense against verbal bullying and intended to build resilience, my surgical take is that this age-old phrase is not entirely accurate. For example, the 6-digit numbers printed on the Ivy league institutions’ website as fees and living costs for an MPH is enough of a scare tactic to make the LMIC applicant back down. They have perhaps only heard about that amount of money from reading about corrupt local politicians’ trials or daydreaming. I did the math. One surgery program I applied for would require that I work within my LMIC as an attending (without spending a dime) for 10 years to raise the program costs and home office requirements. The adage, ‘If you think education is expensive, try ignorance’ does not resonate with that kind of reality. Ignorance is not an option – neither is self-funding unless you rob a bank. Mind you, there are no student loans in these contexts. I had a similar experience with applications for Masters in Public Health. After getting 2 admissions and not being able to get in because of funding, I saw another amazing opportunity with higher fees. Guess what? I did not apply. The first delay.
There is a feeling you get when you suddenly find something that you had been looking for but never knew what it was called. That was my epiphany when I chanced across academic global surgery. Many LMIC trained surgeons have little exposure to the concepts they are immersed in.
“Sounds interesting. What is that?”
Locally and internationally, many surgeons have the misconception that “global surgeons” are high-income country surgeons, who conduct research and charity missions in low-income settings.
I left university with prizes in Public Health and was in the top percentiles of the class in Surgery. I was passionate about both, but thought I needed to pick one or the other. I still have the notebook in which I drew a map of Africa and wrote “Community Medicine/Public Health; General Surgery with what will I reach the world?” How do you study what you do not know exists, even though you are already living it? It was late in training and by chance, I found out that there was an organized structure around global surgery beyond medical mission trip models. My connections with global surgery programs were essentially by “time and chance”. Working at the grassroots is great, but scaling influence and affecting policy produces more effective and efficient results. If people who can best maximize these opportunities do not even know that they exist, well it’s our global loss. The first delay.
- Delays in reaching good quality global surgery education.
“The road to hell is paved with good intentions” ~Henry G. Bohn, 1855. A Hand-book of Proverbs
While the geographical location of a surgical facility, terrain, distance from the site of, say, injury to a health facility, and availability of affordable transportation may result in a second level delay for the trauma patient, parallels exist for the LMIC global surgeon. Unfortunately, many global health events focused on LMICs are held in HICs, and passport power is a grim reality. A sage once said, “If you are not at the table, you are probably on the menu.” Somehow, one’s direction of travel can determine one’s ability to attend global health/surgery conferences. There is a hidden cost to being a scholar from the global south. My country for instance, has experienced the worst passport index decline (by 19 places) ever in the last decade. Apart from dominating the bottom 25% of the rankings, Africa accounts for four of the seven largest drops since 2010. Orientalism as a surreal concept, home office financial requirements, visa interview issues and various sundries affect this access, including providing “sufficient proof that you would leave the Schengen space (after the event)…especially given the current migratory forces…”.
Very few LMICs have academic global surgery programs. African Global surgery centers are few and far between- the sprinkling of them are in southern Africa. Stellenbosh, Witswaterstand, University of Capetown– they can be counted on one hand. Rwanda’s University of Global Health Equity is opening up a Center for Equity in Global Surgery to address this access for the global south. Great centers in proximity to those that need them the most, in partnership with established HIC institutions, focused on trainees that can best relate with these LMIC contexts is the future of global surgery.
Conference equity, defined by the Equity Research Hub as ‘attainment of an equitable level of attendee active engagement, influence and access to a conference regardless of country of origin, location, available funds or affiliation, through the mitigation of known barriers and enhancement of efficacious facilitators’ should be the next global surgery frontier. For instance, global surgery organizations should consider holding a greater number of high-level meetings in LMICs. More visas are offered on arrival with less hoops to jump through in Africa and this is of benefit to all participants for context, cost, and community.
- Barriers to receiving good quality global surgery education.
When an old man dies, a library burns to the ground.
Most injury care research in LMICs has focused on a third delay; delay in receiving care after reaching a trauma capable facility. This is such an anticlimax! The thirsty man in the scorching surgical education desert finally gets to the oasis, but does not find water or is stopped from fetching from the well, because of the color of his sieve, the length of his bailer, or the bias of the guardian of the well.
Racism, xenophobia, and intrinsic bias are generally stacked up against people of color, foreign trained health workers, and people who believe, look, or sound different. It is not news that racial and ethnic minorities are less likely to receive research funding or even get published than their white counterparts. The result is fewer academic promotions and lower incomes throughout their academic career.
In a sense, there is a benefit to observerships, but coming from a Low- or Middle-Income country to a High Income Country for clinical surgical training presents an almost impossible barrier for any hands-on surgical practice unless you, perhaps, start again. On the flip side, I have seen medical students from the west scrub in for surgery on surgical missions. Blame it on the LMIC’s poor regulation or the HIC’s tight legislation (you can’t even practice across state lines unless you are certified), but many things about that do not sit right. No. I can not accept the 6 month breast reconstruction ‘fellowship’ if I do not get to touch patients. What am I reconstructing? No. I can not read that journal article because it is behind a 32 dollar paywall. No. I can not fluently read those articles because it is in a language that I do not understand. You could be in an oasis, thankful for the shade, but thirsty for water, and looking wistfully at the occupied hammock.
- Barriers to remaining in global surgery
You can not tell a hungry child that you gave him food yesterday.
More recently, a fourth delay has been described. It is caused by barriers to remaining in care, and adhering to ongoing care plans, follow-up, and rehabilitation. For the trainee from resource limited places who has the opportunity to obtain a degree or fellowship in surgery with emphasis on global surgery experience, the lure of passivity still exists.
The science of push and pull, stick and stay generally favors “greener pastures”. Barriers of remuneration, work satisfaction, poor working conditions, lack of professional support, demoralization, and attraction to better working conditions can destroy the resolve of the passionate LMIC learner. There is also the challenge of what they are handed by their colleagues who do not understand the system they are hoping to build on their return to ‘reality’. This, in addition to the inevitable hubris they might have acquired from their opportunity in the classic “black skin, white mask” fashion.
My ethos is that the concept of access in global surgery is more than just a target aligned with an indicator for the patient. Many potential global surgery leaders do not know there is a party, or are not reaching the dining hall, much less finding a seat at the table. We must take conscious and conscientious action, and design contextual interventions to dismantle these barriers.
“Global Health, take down that wall!”