Recent data estimate that 11% of the global burden of disease can be attributed to surgical conditions, including trauma, malignancies, congenital anomalies, and complications of pregnancy.1 However, extreme deficits currently exist in human resources for surgical care, and the inadequacy of surgical capacity in developing countries is well documented.2 As a result, approximately two billion people worldwide lack access to adequate surgical care.3
Solutions for addressing this disparity require both immediate relief efforts, such as short-term humanitarian missions, and long-term investments in human resources and surgical care infrastructure. These actions call for the collaboration of key stakeholders to improve access to care and health outcomes, build capacity in the next generation of the surgical workforce, and expand the breadth of formative research in the field.
Although models exist for organizing short-term surgical missions in low- and middle-income nations, far less focus has been placed on models for developing multi-institutional partnerships that build capacity and support education, research, and service in surgery. The current literature in this area focuses primarily on dyadic collaborations, largely between U.S and Canadian academic medical centers and international teaching hospitals. These partnerships seek to respond to medical students’ and residents’ rising interest in global health by providing training and service provision opportunities.4 Although these programs enable collaborative learning experiences, few focus on fostering research and sustainability related to global health work. In this report, we present our innovative model for a multi-institutional partnership focused on global health surgery and discuss key outcomes from our partnership’s early years.
In an attempt to respond to the need to build capacity in global health surgery—specifically, oral cleft surgery in resource-poor settings—the Global Surgery Partnership (GSP) was founded in 2011 by an established children’s hospital (Children’s Hospital Los Angeles [CHLA]), an academic medical center (University of Southern California [USC]), and a nonprofit organization (Operation Smile). The goal was to create a bridge between academia and charitable surgical care delivery founded on the core principles of education, research, and service. These principles represent critical aspects of the partner institutions’ missions and have important implications for one another (see Figure 1). Bringing together the three partners’ separate strengths (see Table 1) allows for a comprehensive approach to building global surgery capacity.
The GSP leveraged the strengths of the three partners to establish a network by which leadership and resources can be pooled around education, research, and service activities in global plastic surgery. The pooling of these assets broadens the scale and impact of the GSP’s activities beyond what each institution could accomplish individually. Because resources to support these efforts are limited, the participating institutions were eager to enter into this partnership to advance the work within their respective sectors, as well as to broaden their reach in the larger global health community.
To help build capacity in the global surgical workforce, the GSP has three core programs for surgical residents and public health graduate students. The programs reach U.S.-based and international learners and focus on areas such as surgical technique, research study design, and large-scale data collection.
Two of the three core programs focus on surgical training. The first, initially established by one of the partners in 2005, is an observational program for international plastic surgeons. Similar to an apprenticeship, this program provides international plastic surgeons and trainees the opportunity to study in the United States under the mentorship of surgeons at CHLA. From the program’s inception to date (January 2015), 21 surgeons from 12 countries have rotated through CHLA and the USC Division of Plastic and Reconstructive Surgery. Participating surgeons come from international research teams through the GSP, from Operation Smile partner institutions abroad, and from among the international surgeons who participate in Operation Smile mission trips.
In 2010, the GSP built on the observational program and created the Tsao Fellowship in Global Health. This surgical global health fellowship, which combines reconstructive surgery training with core competencies in research and public health, is designed for plastic surgery residents who are between their third and fourth years of integrated residency in U.S. programs accredited by the Accreditation Council for Graduate Medical Education. The two-year fellowship curriculum is divided among three key areas: (1) the completion of a master of science degree in clinical and biomedical investigations, (2) research involvement, and (3) international operative training through surgical missions and hospital exchanges.
Tsao fellows complete their graduate degree at USC with a focus on research methodology, analytics, and public health. They receive research mentorship from CHLA surgeons and USC Department of Preventive Medicine faculty, while using their clinical experiences abroad to access relevant patient populations. Tsao fellows also have opportunities to operate during medical missions with Operation Smile, at Operation Smile partner hospitals abroad, and with international surgeons in the CHLA/Operation Smile network. To date, the program has hosted three fellows, of whom two have graduated and the third is in the current program cycle.
The GSP’s third educational program, introduced in 2011, engages USC master of public health (MPH) students through in-class assignments and individual internships. The GSP contributes to the MPH curriculum by providing faculty with project-related course assignments and case-study-inspired competitions. For example, for the USC Global Health Case Competition, student teams have been asked to research real-world challenges faced by the GSP partners and present consulting recommendations back to GSP investigators. The GSP also selects USC MPH students to participate in etiologic and behavioral research projects related to oral cleft epidemiology and surgical outcomes. The selected students learn how to coordinate international multidisciplinary teams to execute research projects and gain invaluable exposure to the challenges of international ethics boards, data collection, and data analysis. A total of six graduate students have participated in this initiative to date. Two completed a parental survey on perceived causes of clefts in Guwahati, India. Two helped implement the first pilot of an epidemiologic–genetic cleft etiology study in six underserved countries, and two helped lead data collection for this study in six cities in the Philippines.
The GSP has initiated two international research projects: the International Family Study and the Cleft Severity Study.
The International Family Study is a case-control, epidemiologic-genetic study investigating the etiology of cleft lip and palate in underserved multiethnic populations. The study, which began in May 2013, is collecting saliva samples and demographic/exposure data from case-trios (child with cleft and the child’s biological parents) and control-trios (newborn without cleft and the child’s biological parents). A genome-wide association analysis for each trio is conducted using DNA extracted from the saliva samples. Demographic, exposure, family history, and lifestyle information gathered via questionnaires provide data for further analysis. To date, collections have occurred in association with Operation Smile missions in Vietnam, Peru, Democratic Republic of Congo, Philippines, Honduras, Mexico, and Morocco.
The Cleft Severity Study is working to establish a standardized classification system (the Cleft Severity Index) for cleft lips and palates by collecting demographic information, ascertaining cleft phenotype, and conducting facial measurements of cleft patients around the world using an iPhone application developed for the study. The classification scale will be used to study surgical outcomes and recommend surgical algorithms of care. The study also seeks to analyze trends in cleft lip and palate morphology as it relates to geography and surgical outcomes, which may lead to better treatment algorithms in the future. To date, the iPhone application design has been completed and the IRB submission has been approved. Data collection began in November 2014.
Under the umbrella of the GSP, each of the three partner institutions is actively engaged in the research process. As the academic research institution, USC spearheads the process by providing IRB oversight, data analysis tools, and support from a large network of research professionals. CHLA coordinates the logistical management and training of local data collectors. Operation Smile provides research staff and access to the study populations necessary to conduct these types of clinical research initiatives.
This collaboration also allows sustainable research capacity to be built within existing institutional infrastructures. For example, the International Family Study relies heavily on in-country data collection conducted by local research staff and on partnerships with local co-investigators to lead ethical reviews and ensure quality data collection. In countries where Operation Smile centers exist, CHLA and USC provide research training for local staff on study protocols, data collection, ethics, confidentiality, and sample collection. In cities where local researchers are based, established institutions are approached for partnership and are engaged in the intellectual development of the study in the interest of involving scientists from underserved regions. Within the context of a diagonal model of health care delivery (i.e., a model in which specially focused care and short-term solutions are balanced with long-term investments in capacity and infrastructure), this engagement creates a broader academic culture of investigation and can inspire new topics and methodologies for research.5
Every year, Operation Smile conducts nearly 172 surgical missions to treat children with cleft lip and palate and other facial deformities in over 60 countries. The nonprofit organization mobilizes medical volunteers to provide assistance in all aspects of surgical care delivery during these missions. Each mission involves up to 60 medical personnel and relies on both international and local clinicians with expertise in plastic surgery, anesthesia, nursing, and pediatric care. After short-term missions, local Operation Smile staff continue postsurgical care and follow-up appointments for up to one year in collaboration with local nonprofit organizations or foundations.
Through the GSP, senior physicians, surgical residents, and medical students from CHLA and USC are recruited to serve as volunteers with Operation Smile and are provided with the opportunity and infrastructure to gain experience in global health. As mentioned above, Tsao fellows complete a large portion of their international surgical training and graduate research work through Operation Smile missions. To date, the three fellows combined have participated in 13 international missions in countries including China, Vietnam, Mexico, India, and the Philippines, and operated on 684 patients. The procedures performed included primary cleft lip repair, primary cleft palate repair, alveolar cleft repair, and ear reconstruction.
As the landscape of plastic surgery and global health continues to grow, it has become increasingly critical to exchange information across institutions. The partnership model described here offers opportunities for information sharing and resource pooling in the field of global health surgery.
As the GSP is still in its infancy, no formal evaluation has yet been conducted. Nev ertheless, we recognize that an evaluation process will be essential in assessing institutional roles and iden tifying areas of success and improvement.6 For example, as with any partnership, funding and competing priorities can impede progress.6 Institutions should enter multi-institutional collaborations based on common goals, shared visions, and equal contributions from all partners. In developing the GSP, the three participating institutions faced differences in assessing joint priorities, largely due to their varying missions and primary functions. For example, the preference of USC for the publication of peer-reviewed journal articles can be at odds with the desires of Operation Smile and CHLA for frequent news features that provide publicity and fundraising support. Compromise on such core issues is a continuing process that involves constant communication and efforts to redefine both short- and long-term expectations.
Over the next several years, the GSP plans to conduct an evaluation and then to expand its educational programs, to pioneer new research initiatives that build on current research, and to further integrate these education and research initiatives with its service activities. For example, the GSP hopes to expand recruitment for the Tsao Fellowship beyond the United States. The GSP also looks forward to exploring additional opportunities, including expanding current efforts in capacity building, incorporating telecommunication and e-health elements as supplemental service provision tools, and identifying new avenues for integrating GSP service initiatives with local health care systems.
We encourage other global health organizations and academic and medical institutions to engage with each other. Even preliminary conversations can help unearth opportunities for collaboration. Similarly, informal alliances can be built upon to develop more formal partnerships. We believe the GSP provides a basic model for interdisciplinary and international partnerships in the global health arena.
Acknowledgments: The authors would like to acknowledge the following individuals for their support and contributions to this project. University of Southern California: Jane Figueiredo, PhD, Pedro Sanchez, MD, Jonathan Samet, MD, Graham Casey, PhD, Ugonna Ihenacho, Melinda Costa, MD, Justin Gillenwater, MD. Operation Smile, Inc.: Operation Smile Philippines, Operation Smile Honduras, Operation Smile Vietnam, Operation Smile South Africa, Operation Smile Morocco, Operation Smile Mexico, Sue Tsao, Richard Vanderburg, Ruben Ayala, Melissa Dibona, Haley Raimondi, Melissa Medel. Children’s Hospital Los Angeles: Mark Urata, MD, Dalia E. Rosales, Rosa Castaneda, Monica Delgado, Monique Menke.
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