Through the COVID-19 pandemic, global surgery efforts in low-to-middle-income countries (LMICs) were significantly impacted by travel restrictions, delay and eventual back-up of elective surgeries, and diversion of resources towards COVID relief efforts, straining an already overloaded system.1 As the US healthcare infrastructure pivoted towards telehealth models, the global surgery community utilized their previous telehealth experience and the newfound interest in digital platforms to expand upon communication, collaboration, and educational initiatives. The rapid implementation of telehealth also highlighted the ongoing challenges of building sustainable infrastructure in LMICs. Alongside the lasting effects of the COVID era, the continued investment and success of telehealth advancements signaled a seismic shift in the foundation of global surgical systems, transforming the way we provide global surgical care.
Telemedicine in global surgery isn’t a novel concept. “Telemedicine” is focused on providing patient care through digital communication platforms, and is considered a branch of “telehealth”.2 For example, in 2001, a New York surgical team performed the world’s first telesurgery, a laparoscopic cholecystectomy, on a patient in France.3 However, the prohibitive costs of installing, training, and maintaining the robotic technology in low-resourced areas as well as the frustrating time delay between video capture of the surgical field and transmission to the surgeon, made those robotic advancements limited at the time. In response, there has been a greater focus on “telehealth”, which focuses on the combination of digital communication solutions and cloud-based software applications, utilizing technology to bypass geographic limitations for service delivery.2
COVID-19 was the catalyst to determine if these training tools could be better utilized for the global surgical community. Virtual learning was already a significant component of LMIC global surgery education. But greater institutional investment and utilization of digital platforms made these telehealth models more accessible on an international basis. Global teaching opportunities broadened to emphasize virtual apprenticeship, simulation training, and virtual learning courses (VLS) with increased access to virtual conferences and surgical expertise.4 Access to remote simulation sidestepped travel restrictions and limited access to provide teaching under direct supervision. Video conferencing allowed strengthening of personal and institutional relationships outside of in-person or email communication. For collaboration, virtual platforms allowed surgeons from across the globe to engage in operative consults with peri-operative support, real-time video and image sharing for virtual laparoscopic support, and telepathology for pathologic diagnosis.1
Examples of innovative telehealth teaching include:4-5
- Training course in Brazil with remote mentoring via live video feed using Google Glass
- Telesimulation and telementoring for laparoscopic training in Botswana
- 5-day emergency surgical skills simulation for trainees in Zambia
- “Safe Surgical Care: Strategies During Pandemics,” a five-module virtual course with participants from 105 countries during the COVID-19 pandemic
- Ongoing educational webinars from International Student Surgical Network (InciSioN), Global Surgery Student Alliance (GSSA), and Harvard Program in Global Surgery and Social Change (PGSSC)
Unfortunately, computer-based internet access is still relatively limited outside of high-income countries, despite technological advancements in the last several decades and significant reliance on access to information and communication. If we wish to maximize telehealth use for global surgery, there are several criteria that need to be met. According to a 2019 report from the International Telecommunication Union, only 19% of individuals from the least developed countries are online, with Africa having the lowest Internet usage rates.6 At bare minimum, internet accessibility would require basic connection, bandwidth, and a stable energy source. But for sustainability, the internet’s maintenance would also require hardware, software, and repair expertise. Further considerations include the cost of accessible telecommunication platforms and applications as these are usually in addition to internet maintenance costs. Many platforms also require a subscription or a one-time purchase, and free platforms can have variable reliability.
An alternative option that has become prominent over the last decade is mobile-broadband subscriptions, as the internet is no longer limited to computer access. As of 2018, about 93% of the world’s population lives within reach of a mobile broadband service, including the least developed countries.6 Therefore, the implementation of mobile and social media applications to spread knowledge about global surgery must be considered if we want to continue making global surgery accessible everywhere. The increased reliance on telehealth platforms due to the pandemic offers an opportunity to jump-start long-term adoption. Medicine’s utilization of social media platforms such as Facebook or Twitter, with hashtags like #MedTwitter and #GlobalSurgery, have already grown substantially over the last few years, providing avenues for rapid dissemination of guidelines while encouraging dialogue and discourse around the globe.5,7
Free communication platforms such as WhatsApp that are available on multiple mobile platforms have allowed clinicians and organizations across the world to initiate partnerships, collaborate, and share resources with one another as well.8 With nearly 2 billion users, WhatsApp has already been used to launch public health campaigns such as combatting COVID-19 misinformation, enhancing breast cancer knowledge, and preventing smoking relapse through use of WhatsApp’s discussion groups, chatbots, channels, and broadcast lists.9-11 WhatsApp also offers a way to maintain contact with mobile populations, allowing continued communication as individuals travel across international borders. This communication forum, with its user-friendly set-up and accessibility in areas with limited mobile bandwidth, has allowed the breakdown of strict hierarchies as well, making it a viable platform for global surgery to grow upon. However, for all of these third-party mobile and social media applications, users must remember the importance of data protection, storage, and encryption, especially when considering patient confidentiality and privacy.
As technology continues to evolve, whether organically or by force, it is imperative for the global surgery community to grow alongside these changes with the aim of increasing surgical access for all.
- Villavisanis D.F., Kiani S.N., Taub P.J., Marin M.L. Impact of COVID-19 on Global Surgery: Challenges and Opportunities. Annals of Surgery Open. 2021;2(1):e046. doi:1097/AS9.0000000000000046
- Hachach-Haram N. A Digital Doorway to Global Surgery. In: Atallah S, ed. Digital Surgery. Springer International Publishing; 2021:351-360. doi:1007/978-3-030-49100-0_26
- Anvari M., McKinley C., Stein H. Establishment of the World’s First Telerobotic Remote Surgical Service. Ann Surg. 2005;241(3):460-464. doi:1097/01.sla.0000154456.69815.ee
- Joos E., Zivkovic I., Shariff F. Virtual learning in global surgery: current strategies and adaptation for the COVID-19 pandemic. International Journal of Surgery: Global Health. 2021;4(1):e42-e42. doi:1097/GH9.0000000000000042
- Ganguli S., Yibrehu B., Shah A., Rosseau N., Niba V., Rosseau G. Global surgery in the time of COVID-19: A trainee perspective. Am J Surg. 2020;220(6):1534-1535. doi:1016/j.amjsurg.2020.07.005
- International Telecommunications Union. Measuring Digital Development: Facts and Figures 2019. ITU Publications. Retrieved from https://www.itu.int/en/ITU-D/Statistics/Documents/facts/FactsFigures2019.pdf
- Leow J.J., Pozo M.E., Groen R.S., Kushner A.L. Social media in low-resource settings: a role for Twitter and Facebook in global surgery? Surgery. 2012;151(6):767-769. doi:1016/j.surg.2011.12.024
- Ewbank C., Groen R.S., Kushner A.L., Gupta S. WhatsApp: An essential m-health tool for global surgeons. Surgery. 2017;161(6):1745-1746. doi:1016/j.surg.2017.01.003
- Partnership for Health Cities. WhatsApp Campaign Guidance During COVID-19: Approach to Developing WhatsApp Campaigns. Prevent Epidemics Resource Library. May 2020. Retrieved from https://cities4health.org/assets/library-assets/ccc_084_whatsapp-campaign-guidance_050820.pdf
- Pereira AAC, Destro JR, Picinin Bernuci M, Garcia LF, Rodrigues Lucena TF. Effects of a WhatsApp-Delivered Education Intervention to Enhance Breast Cancer Knowledge in Women: Mixed-Methods Study. JMIR Mhealth Uhealth. 2020;8(7):e17430. doi:2196/17430
- Kamel Boulos MN, Giustini DM, Wheeler S. Instagram and WhatsApp in Health and Healthcare: An Overview. Future Internet. 2016;8(3):37. doi:3390/fi8030037