WHERE WE WORK
International and Domestic
Regardless of the track chosen, the main focus of the Paul Farmer Global Surgery Fellowship curriculum revolves around advocacy, education, research, and the provision of surgical care. Research Fellows and collaborators are expected to work collaboratively and participate in the education and training of other residents and medical students who are working as part of the Global Surgery Team.
Serving in resource-poor settings is an integral part of the Fellowship experience. We are working in 11 countries on over 50 projects, and this continues to grow. We currently have engagements in the following countries:
National Assessment of Pediatric Surgeon Practice in Brazil
Improving the quality of pediatric surgery in low- and middle-income countries (LMICs) remains a critical task for academic global surgery. Little is currently known about the state of pediatric surgery in LMICs, especially when it comes to providing surgical care to infants.
Brazil is a middle-income country with vast regional disparities encompassing surgical care that ranges from rural low-income status to high-income level surgical care in the urban Southeast. Thorough assessment of Brazil’s pediatric surgical outcomes and pediatric surgical workforce can act as a frame of reference for pediatric surgery globally with applications in LMICs across the globe. The purpose of this study is to assess regional practice differences among pediatric surgeons and identify factors associated with regional differences in perioperative infant mortality in Brazil. We seek to comprehensively evaluate, for the first time, the practice patterns of pediatric surgeons in an LMIC and compare to retrospective data on infant perioperative outcomes from all regions of Brazil in order to identify factors responsible for differences in infant surgical mortality.
Measuring Surgical Quality in Low Resource Settings- A pilot in Amazonas
Amazonas is the largest geographic state in Brazil, with 1.5 million km² encompassing 62 municipalities. The state is home to nearly 4 million inhabitants, of whom 1.8 million live in the capital, Manaus. The state itself and most cities within it are accessible primarily by boat or airplane, with only a scant few cities reachable by roads. For many, access to a secondary or tertiary level hospital is frequently days away, requiring high transportation costs that can be prohibitive for many.
Surgical quality is difficult to measure as current metrics designed for use in high resource settings are resource intensive, retrospective or rely on electronic medical records. Our team developed a tool to measure surgical quality in low resource settings and through a multi-institutional collaboration including Universiadade de Sao Paulo (USP), the Program in Global Surgery and Social Change (PGSSC) at Harvard Medical School, and Universidade Estadual do Amazonas (UAE), we are carrying out a pilot to test this too in Manaus, Amazonas. The results of this work will inform public health policies to improve quality of care in Amazonas.
Knowledge, attitudes, and practice of obstetrics and gynecology (OBGYN) residents in modes of delivery
Brazil continues to be one of the countries with the highest cesarean section (CS) rate in the world. The CS rate in the public-sector averages 35-45% while the private sector rate is as high as 80-90%. The rise in CS rate is complex and multifactorial. It cannot be solely explained by increasing preference of pregnant women for CS. In Brazil, there have been no studies to date assessing the knowledge, attitudes, and practices that OBGYN trainees have with respect to the rising CS rate. Since the CS rate has been rising for several years, there is concern that this has affected the practical experience that residents in obstetrics have managing labor, vaginal deliveries, and operative deliveries. Since the private sector has a much higher CS rate than the public sector, it is possible that trainees in private hospitals have been more affected. Lack of experience managing labor due to limited clinical exposure could make residents less comfortable offering vaginal deliveries to their patients when they become independent physicians. This, in turn, could perpetuate the vicious cycle of high CS rate in Brazil.
Thus, the aim of this study is to assess the knowledge, attitudes, and practices (KAP) of OBGYN residents in regard to the rising CS rate, management of labor, vaginal deliveries and CS. Furthermore, this study will serve to establish a methodology that can be used to assess the KAP of OBGYN residents in other LMICs where current studies are lacking. The survey results will be compared across training cadres from both high-income countries (HICs) and LMICs in areas of high, appropriate, and low CS rates.
Access to Minimally Invasive Gynaecology Surgery in Brazil
Minimally invasive hysterectomy for benign disease has been shown to have better outcomes than open surgery. The risks to the patients are decreased and the length of stay and cost are also lowered. As a result, there has been a significant increase in minimally invasive surgery (MIS) in high income countries. However, trends in gynaecological MIS in Brazil have not been studied.
In partnership with the Universiadade de Sao Paulo (USP) we aimed to describe the trends of gynecological MIS in Brazil in the last years as well as factors associated with access to MIS such as geographic region and health sector. The results of the survey will paint a picture of the evolving MIS field in Brazil to then advocate for more widespread and equitable access to this type of surgery.
Assessment of head-neck surgical capacity in guinea through measuring the impact of interventions by Mercy Ships’ Africa Mercy in Guinea
Mercy Ships is a 38-year old international faith-based organization aiming to increase healthcare delivery throughout sub-Saharan Africa. Mercy Ships deploys the Africa Mercy, the world’s largest private hospital ship, to work with host nations to deliver transformative, life-saving healthcare and health services, whilst providing a training platform for healthcare professionals. To date, little is known about the impact of Mercy Ships on the local population. This prospective descriptive study seeks to:
Analyze the number, outcomes, and procedural costs of surgical head-neck interventions of Mercy Ships in Guinea
Estimate the counterfactual situation of head-neck surgical care in Guinea in the absence of Mercy Ships
For both components of this work, data will be collected through conducting a Financial Risk Protection Survey and exit interview aimed to assess health expenditure, financial risk protection, and asset wealth. Volume and outcomes of the interventions done by Mercy Ships will be assessed through operative logbooks, ward logbooks, and provider interviews to assess the number of procedures, diagnoses, and deaths.
Evaluation of the efficacy of a cash transfer voucher model to increase access to surgical care
Although Mercy Ships provides surgical care free of cost, 20-30% of identified patients do not show up for surgery. Patients far away (from five to hundreds of kilometers) often cannot pay for transportation costs to arrive at the hospital and the associated opportunity costs for not being able to work and earn income. A cash transfer model is implemented to evaluate the impact of vouchers to cover financial expenses related to transport. The study will be the first-ever randomized control trial of cash transfers on patient follow-up in the field of global surgery.
Our Haitian collaborators and colleagues represent some of the earliest founding relationships at the PGSSC. Current engagement in Haiti is focused on:
Assessing and supporting the development of surgical and neurosurgical capacity.
Identifying opportunities and barriers in the development of surgical, obstetrical, and anesthesia policy.
Promoting and collaborating on global surgery research, training, and education.
Our collaborative efforts are dependent on close working relationship with partners at the Ministère de la Santé Publique et de la Population (MSPP), Zanmi Lasante (ZL)/Partners in Health (PIH), St. Boniface Haiti Foundation (SBHF), among others.
National surgical stakeholder analysis:
With only 824 annual operations (goal of 5,000) and 5.9 surgical, anesthetic, and obstetric providers (goal of 20) per 100,000 people, surgical capacity in Haiti requires coordinated national health policy. The surgical stakeholder analysis project seeks to describe the current state and political priority of surgery in Haiti using the Shiffman and Smith political priority framework. Capitalizing on the expertise and networks of Haitian leaders in surgery and health policy, this project aims to support the context for future national surgical planning initiatives.
Neurosurgical stakeholder analysis:
Haiti has only four neurosurgeons for a population of approximately 11 million (0.038 providers/100,000 people). The social determinants of neurosurgical disorders and societal drivers of the current state of neurosurgical care in Haiti are not well understood. Using grounded theory methods, this study is designed to provide a better understanding of social barriers and opportunities for local capacity-building in the clinical neurosciences.
Cost-effectiveness of renal replacement therapy:
It is estimated that 15-20,000 patients in Haiti require urgent hemodialysis due to end stage kidney disease. Recently, the Haitian government has supported the development of renal replacement therapies, including new dialysis centers, across the country. While kidney transplantation is widely accepted as the optimal clinical and cost-effective solution, low and middle countries (LMICs) like Haiti are often overlooked when planning for transplantation. This cost-effectiveness analysis seeks to provide a better understanding of the resources required to provide RRT and to support the further development of a national renal replacement therapy strategy.
Haiti surgical research equity:
The 2010 Haiti earthquake destroyed much of the country’s clinical infrastructure. Given the importance of local research initiatives in the development of local health care capacity, this collaborative effort seeks to better understand the surgical research needs in Haiti. Our work is principled on supporting local journals, local research training programs, and other key components of equitable research partnerships.
FHADNNEC/WFNS 1st Annual Scientific Meeting:
Scheduled for January 2019, this inaugural meeting of the Fondation Hatienne pour le Developpement de la Neurologie et de la Neuro-Chirurgie (FHADNNEC) is co-sponsored by the World Federation of Neurosurgical Societies (WFNS) and will include didactic and practical courses in neurotrauma and emergency and essential neurosurgery. The course will run in Port-au-Prince and Fond-des-Blancs, and its target audience will include 50 Haitian senior residents in general surgery, orthopedics, and neurosurgery.
CAT-ASHAC trauma training course:
Developed by the Association Haïtienne de Chirurgie (ASHAC) in collaboration with the American College of Surgeons (ACS) and L’Hôpital Bernard Mevs/Project Medishare, the CAT-ASHAC trauma course is a training opportunity for surgeons across Haiti to develop skills in trauma surgery and management. With components that include principles from both general trauma surgery and neurosurgery, it is among the first efforts of its kind in Haiti.
Surgical Innovation Center
Single-site innovation center: Karunya Collaboration
Over the past two years, we have developed a collaborative relationship with Karunya University and have helped create a “Center of Excellence in Surgical Innovation”. The PGSSC has delivered multiple conferences and workshops focusing on developing local, low-cost solutions for challenges faced by rural surgeons, and supported student-led projects through seed funding. The goal is to expose and engage local students and faculty in non-medical academic programs to surgically relevant and cost-effective innovations that can impact local and global communities which lack surgical care.
State-wide, multi-institutional innovation conference: hosted by Saveetha University
Owing to the success in Karunya and the growing need in India for university-level exposure to innovation science, the PGSSC has been requested to expand the existing program to a state-wide forum. This will enable a broader scope of students to benefit and, for the first time, will include a diverse range of academic disciplines, including medical, business, engineering, and design colleges from both urban and rural regions of Tamil Nadu with the goal of empowering Indian graduates to create and develop innovative solutions to meet the high burden of unmet surgical care both nationally and globally.
Narayana Health – Boston Children’s Hospital: Vascular Anomalies Care Partnership
Narayana Health, the foremost provider of low-cost, high-quality healthcare in India, has requested to collaborate with the Vascular Anomalies Center at the Boston Children's Hospital. Narayana Health is a chain of multispecialty hospitals with 14,000 employees, 23 hospitals, 7 heart centers, and 19 primary care facilities across India. The business model works on the "economy of scale" to use high volume surgery to increase the hospitals' buying power and subsidize rural and urban poor care. Narayana's mission is to deliver high quality, affordable healthcare services to the broader population in India. We will hold the first, national, interdisciplinary training workshop on vascular anomalies in India.
STARS Program at Narayana Health
Building upon the success of the inaugural 2017-2018 STARS program, the PGSSC will again partner with Narayana Health (NH) in Bangalore to organize the second annual STARS program for 2018-2019. STARS is an applied clinical research training program organized under the aegis of the PGSSC, which leverages the clinical research resources of Narayana Health, one of India’s largest and most distinguished healthcare networks, to advance equitable global health research. For the upcoming year, we will again offer an intensive, immersion-based research training program for 4 students from low and middle-income countries (LMICs). This program remains centered on cornerstone principles of investigation, innovation, and implementation.
Spinal Anesthesia Training Program
The PGSSC, Boston Children’s Hospital, and local collaborators will continue to move forward the innovative pilot trail that is evaluating the ability of rural medical doctors to safely administer spinal anesthesia, allowing more rural surgeries to occur. In coordination with this program, the PGSSC has collaborated with the BCH Simulation Center to land a simulation training curriculum in 3 rural hospitals focused on improving the quality and coordination of care delivery by providers during anesthestic emergencies.
Compañeros en Salud (CES) has been providing medical care in the state of Chiapas since the mid 1990s and has focused on the provision of quality primary health care in the rural areas of Mexico. It has also collaborated closely with the government health system and large academic institutions such as the Tecnico de Monterrey to address gaps in care. CES has addressed the lack of access to quality primary care in rural areas and they have now identified lack of surgical care in the area of Jaltenango a gap. We are partnering with CES to build research capacity parallel to the scale up of the surgical care planned to take place at Hospital Basico Comunitario de Angel Albino Corzo (HBCAAC). Our objective is to build research capacity among trainees and local staff by strengthening partnerships to develop robust surgical data collection around surgical quality indicators and the six world development surgical indicators.
National Vision for Surgical Care 2025
Halfway through 2018, four countries have developed National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) to strengthen surgical care on a country level. All four countries (Senegal, Ethiopia, Zambia, and Tanzania) are located in Africa, and no country beyond the African Region had started the NSOAP process. Pakistan, a lower-middle income country in South Asia with a population of 205 million people, is the first country to start the process through developing the National Vision for Surgical Care 2025 (NVSC2025), a pre-“provincial SOAP” (provincial plan) guiding as a guiding federal document for individual provinces creating their own provincial plans.
On November, 15th and 16th, national and international stakeholders from the ministries, government, professional societies, civil society, and academic and health care institutions came together to discuss and draft the NVSC2025 document. The PGSSC is part of the Technical Working Group catalyzing the process on a national and provincial level, building on experiences in the Zambian and Tanzanian NSOAPs.
Assessment of the strength of Pakistan's Surgical System: tracking the Lancet indicators for Global Surgery
The purpose of this study is to track the six global surgery indicators recommended by the Lancet Commission on Global Surgery (LCoGS). Results from this study will measure and reflect the ability of the Pakistani surgical system to provide safe and timely care to patients in need of an operative procedure. This work allows full assessment of the strength of the surgical system and seeks to identify priority areas for system improvement and a step forwards towards the NVSC2025 and supporting SDG 3.8. Consequently, this data can and hopefully will be used as a backbone from which to invest in Pakistan’s surgical system - financially, programmatically, and at a policy-level.
Surgical site infections machine learning project
Using PGSSC-generated data collected from Rwanda, one of the PGSSC Visting Student meets with an MIT-based research team on a weekly basis to explore opportunities focusing on post-operative surgical site infection (SSI) rates using text-based and image-based analysis. Technologies that are being used include machine learning and computer vision approaches.
Using mHealth technology to identify and refer surgical site infections in Rwanda
Randomized controlled trial focused on improving surgical follow up post-operatively. We developed an mHealth application to assist community health workers (CHW) to identify surgical site infections. The trial is evaluating the effectiveness of the app and comparing return-to-care between three arms (standard of care = i.e. no follow up, home visits by CHW with the mobile app, and CHW calling patients using the mhealth app). We are evaluating the impact on timely and appropriate return-to-care of patients with surgical site infections in Rwanda to improve patient outcomes and reducing healthcare costs.
Non-Operative Technical Skills for Surgeons (NOTSS) in variable resource settings
NOTSS are cognitive and interpersonal skills aimed to complement surgeons’ technical skills in the operating room to ensure adequate teamwork and optimal patient outcomes through mitigating risks and facilitating open communication in the operating room. NOTSS are built on four pillars (situation awareness, decision making, communication and teamwork, and leadership), all of which are essential to achieve the projected outcomes. The framework has further been adapted to variable resource contexts (VRC) to implement in low- and middle-income countries.
In Rwanda, the PGSSC has conducted NOTSS-VRC training workshops twice during the past two years, equipping entire surgical teams with the necessary non-operative technical skills to function as a team in the OR. In 2019, teams in district hospitals will be taught, in addition to the yearly course for incoming surgery, OBGYN, orthopedics, ENT, and anesthesia residents in Kigali.
Operational Research Training
Partnership with Partners in Health to carry out a year-long research training program for local staff and health care providers. These include three training sessions of one week each, with mentorship for data collection and analysis, and manuscript preparation in between.
In November 2018, the sixteen member states that comprise the Southern African Development Community (SADC) ratified an inter-governmental resolution that aims to strengthen Surgical, Obstetric and Anaesthetic (SOA) care. A key outcome of the resolution includes the development of National Surgical, Obstetric and Anesthesia Plans (NSOAPs). PGSSC supports the region to both formulate and implement NSOAP policies within broader national health strategic planning processes. We conduct our work at the interface of three groups of actors -- national NSOAP teams, SADC regional organizing structures and global entities -- to support the NSOAP process with a special focus on financing and governance. Team deliverables span across research, training and advocacy to advance the NSOAP policy process at the domestic and regional levels.
Safe Surgery 2020
Monitoring and Evaluation of SS2020 interventions
In Tanzania, 19.3% of deaths and 17% of Disability-Adjusted Life Years (DALYs) are attributable to diseases amenable to surgery. The quality of healthcare services, surgical provider capacity, as well as data collection and reporting quality have been identified as priorities, through feasibility assessments and literature reviews. Surgical site infections (SSIs) and maternal sepsis have been shown to be major causes of morbidity and mortality in Tanzania.
To strengthen surgical services in Tanzania, the GE Foundation has partnered with the Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDEC) as well as the President's Office, Regional Administration and Local Government (PORALG) to launch the Safe Surgery 2020 (SS2020) initiative. Under the project management of the Dalberg advisory group, the SS2020 partners are Jhpiego, Assist International, and the Program in Global Surgery and Social Change.
Interventions by Jhpiego and Assist International (training and mentorship, safe caesarean birth training, sterilization training, safe obstetrics training course, data quality improvement intervention, and others) are currently being implemented in 10 intervention health facilities in the lake zone region in Tanzania.
The PGSSC’s role has been to evaluate the impact of the implementation of SS2020 interventions on addressing the top surgical priorities of the health facilities. The PGSSC and partner organizations have designed a quasi-experimental, mixed-method study with 10 intervention and 10 control sites to study the impact of these interventions on surgical quality, utilization, surgical, anesthesia and obstetric provider capacity, as well as data collection and reporting capacity.
Data Quality Improvement Intervention
Accurate data collection has been and is key in helping to ensure that the impact of the SS2020 interventions are thoroughly captured. The data quality improvement intervention has been designed by the PGSSC in an effort to strengthen local capacity to collect quality prospective data on indicators selected as SS2020 process and outcome measures related to the surgical safety checklist, surgical site infections (SSIs), post-operative sepsis and maternal sepsis. The intervention is being implemented through Jhpiego’s mentorship program.