David E. Rapp1,2
1Global Surgical Expedition, Glen Allen, VA, USA; 2University of Virginia School of Medicine, Charlottesville, VA, USA
The COVID-19 pandemic has largely resulted in the suspension of on-site visiting global surgery trips. As a result, many organizations have temporarily transitioned from the direct provision of surgical care to alternate models of assistance, including virtual lectures or focus on equipment donations (1). Determining when and how best to reinstitute on-site surgical trips is difficult. Related considerations balance the benefit of addressing the significant unmet surgical burden resulting from a nearly 2-year suspension of surgical trips with the potential harm caused by returning to in-country visiting surgical trips. For example, international program directors must consider potential deleterious impacts such as occupying beds with surgical patients that may be needed for COVID patients. Given that patients often travel from distant locations to receive specialty care, this also risks contributing to widespread COVID transmission.
Guidance and models for reestablishing in-country global surgery initiatives are seen in recent literature. These reports detail extensive considerations to help balance risk and impact, as well as to ensure safe and ethical visiting surgical trips. Such considerations include understanding the local hospital and operating room capacity, minimizing the use of host countries limited personal protective equipment, limiting trip personnel, and gaining knowledge of local infection and vaccination rates (2,3). Moreover, general guidance regarding the reestablishment of health services through the COVID pandemic or in settings of disaster relief is well-established and also serves as a framework for healthcare leaders to navigate care delivery in crisis or pandemic settings (4-6). Such guidance includes an understanding of the stages of pandemic or disaster evolution and unique considerations such as environmental assessment, reassessment of care priorities, and the management of service backlogs. Combined, this background highlights the important considerations for visiting teams and potential deleterious impacts of reestablishing in-country services. Even so, such efforts may also present unexpected opportunities to help host countries with separate health care objectives— collateral good.
Global Surgical Expedition (GSE) is a medical charity that provides surgical care internationally to populations in need. GSE has a longstanding collaboration with Belize, a country with limited urologic infrastructure and care access. The Statistical Institute of Belize reported 16,952 surgeries performed in 2018-2020, with no urologic surgeries recorded in this report (7). The collaboration between GSE and Belize supports the provision of urologic and urogynecologic surgeries and includes the ministry of health and multiple regional hospitals. Since 2012, GSE has provided over 400 urologic and urogynecologic surgeries in Belize to help treat surgical diseases. In September 2021, a site visit was conducted, in part, to help assess country readiness for reinstitution of surgical trips. This assessment was conducted in collaboration with both site leadership (hospital chief of staff, clinic leadership) and as national health care leadership. During this visit, a clinic was also held to evaluate prospective surgical patients referred by local providers. As part of this site visit, health care leaders outlined an infrastructure and logistical framework to optimize the safety of a prospective surgical trip, with much of this focusing on COVID-19 measures. Multiple preventative measures were developed by local officials and supported by GSE, including vaccination requirement for visiting team members, negative COVID testing prior to clinic arrival, and patient evaluation by schedule appointment time only in order to avoid mass congregation of patients that is commonly seen as patients travel from long distances and wait in the clinic lobby. As one of these measures, local leaders expressed a desire that all potential surgical candidates be fully vaccinated prior to surgery. Foremost, vaccination was felt to be beneficial to optimize surgical safety and reduce risk of stimulating COVID spread given the large influx of patients anticipated. This was deemed important given the more limited resources specific to both the clinic and health care region moreover with respect to treating COVID patients. In addition, peri-operative COVID infection has been demonstrated to increase risk of post-operative mortality and is an important consideration to surgical risk (8). Combined, healthcare leaders felt that the prospect of free surgical care might stimulate patients who were otherwise unvaccinated to seek vaccination, thus helping to support the important national healthcare objective of a fully vaccinated population. Collateral good.
View this article at: https://dx.doi.org/10.21037/jphe-22-9