Leading from the South: 10 commandments for global surgery leadership

The first step in leadership is the most private one, it begins in the mirror, begins with serious introspection. Before we challenge global hierarchies, we must interrogate the ones within us. Too often, we unconsciously measure ourselves by Western metrics — citation counts, impact factors, or the accent of authority. True decolonization begins when we stop seeking validation through such borrowed mirrors. But beware the opposite trap — of becoming a local colonizer, reproducing the same hierarchies we once resisted: urban over rural, senior over junior, English-speaking over vernacular voices2-4. Liberation without empathy becomes imitation. True leadership is not about hoarding the power; it is about democratizing and diffusing it to empower others.

True leadership means serving not ruling. Titles and fellowships are transient; service is enduring. Some of the most transformative leaders never held grand offices; they taught quietly, operated tirelessly, and built systems that outlasted them. Leadership in the South has its ethical centre — to serve, and to serve better. When your students, patients, and colleagues sense that your motivation is service, not spotlight, they will follow your example long after they forget your words.

The true frontier of surgical science is not in high-tech labs, but in low-resource wards where need meets ingenuity5. Leadership in Global Surgery is built not on publication counts but on purpose. Ask questions that emerge from the bedside, not the bibliography; a good question born out of local realities will always be more important than a borrowed hypothesis. Let relevance, not prestige be your compass. Research from the South must be relevant to local needs—contextual, cost-aware, and community-informed6. The Global South holds an advantage the North cannot replicate — proximity to the real need. Each study that emerges from that proximity is a piece of intellectual sovereignty; and its impact should be measured not by its journal’s impact factor but by its ability to inform better care, guide policy, or inspire frugal innovation. Impactful research does not chase citation counts; it answers local urgent questions. The most meaningful science often begins with the sentence: “We saw this problem every day, and we decided to understand it better.” Leading from the South means shifting from “publish or perish” to “publish and progress.” When your work improves outcomes for your people, you are already influencing the world — whether or not the world yet notices.

Leadership requires intellectual independence; it cannot flourish in dependency. Independence of thought—protected from donor or political capture—is the first infrastructure of leadership; and once institutionalized, becomes a generational gift. We must build multidisciplinary think tanks, research groups, innovation labs, journals, and open-access platforms that belong to the South — in spirit, not merely in location; where surgeons collaborate with engineers, economists, public health experts, and ethicists—can question, critique, and innovate freely to generate locally viable solutions. These are not just physical institutions; they are scientific ecosystems where inquiry is free, questioning is safe, and young minds can imagine without fear of funding strings or foreign validation. Such hubs must be insulated from political patronage and donor influence to remain credible. These can offer grounded perspectives on affordability, appropriateness, and sustainability that are often missing in global debates. The world listens to those who speak from their own foundation.

Some successful initiatives such as International Student Surgical Network (InciSioN, https://www.incisionetwork.org/) illustrate feasibility, but their scarcity underscores how exceptional—rather than representative—such spaces remain. The need here is therefore not aspirational, but structural: the field requires many more independently anchored ecosystems to normalize Global South leadership.

We cannot lead tomorrow if we silence today’s youth. Many youngsters in the South navigate systems that reward obedience more than originality. A true leader must invert that paradigm—create a space where curiosity is celebrated, dissent is safe, and collaboration is natural. Give them the freedom to ask, to err, to dream7. A young researcher who feels safe to disagree with you today may one day save your system from stagnation. And make the workplace a happy one — not performatively, but genuinely. Laughter, kindness, and fairness are not distractions from productivity; they are its preconditions. Nurture young minds; give them the space where laughter coexists with learning, the freedom to fail and wings to fly. Happiness is not a luxury in leadership; it is its oxygen. The aim is not only to nurture competence but to ensure joy in the pursuit of excellence. A “happy academic ecosystem” nurtures not just competence but creativity, ensuring that leadership renewal becomes self-sustaining.

6. Provide inclusive leadership as “we,” not “I”

Own the mantle of leadership with pride—not arrogance. Pride in one’s identity, traditions, and innovations must coexist with openness to learn from others. In surgery, success is never solitary. The anaesthetist, the scrub nurse, the resident — each holds the patient’s safety in their hands. Leadership is no different.Share funding, credit and authorship liberally. Listen before you instruct.Inclusive leadership with shared credit is not weakness; it is wisdom. Remember, there is no “I” in team — but there is “we” in victory. An inclusive team is like a well-sutured wound: each stitch matters, but only when connected. Mentor through equity, not hierarchy; leadership divorced from equity is merely authority. Embed equity and inclusion at every level. Women, early-career professionals, and marginalized voices must be integral—not peripheral—to leadership structures. This inclusivity must extend across gender, discipline, and background. Leadership that excludes, even unintentionally, repeats the very hierarchies it claims to replace. And representation should not be tokenistic; it must shape decision-making. Equity must also extend to patients and communities, whose lived experiences should guide research priorities and service delivery models. The most authentic form of leadership is one that reflects the diversity it serves. Legacy is not what you accumulate — it is what you enable. Inclusive team leadership means recognizing that success in Global Surgery will never be the triumph of one individual, institution, or nation—but a shared victory for humanity. Remember, pride is the quiet dignity of saying, “We did this together.”

Perhaps the truest measure of leadership is what happens after you step aside. Sustainable leadership demands succession planning—identifying the next line of leaders early, celebrating their growth without insecurity, and continuously mentoring and empowering them. The Global South’s greatest resource is its people; investing in their growth ensures that leadership becomes a movement, not a moment. The old adage “the true measure of success lies in the cultivation of capable successors” remains as relevant today as ever. Mentorship is the most potent legacy of leadership. The key is to build a legacy, not an empire; true leadership is a relay, not a throne. In the continuity of others’ success lies the immortality of your effort.

Global surgical leadership is incomplete without advocacy8. Evidence provides the analytical rigor, while patience enables sustained progress. Data must travel beyond conferences and publications to corridors of power. Leaders must translate evidence into narratives that resonate with policymakers and the public alike. Advocacy is not activism—it is disciplined persuasion - built on evidence to align national priorities with human needs. Whether it is surgical safety, workforce distribution, or financing, the voice of the surgeon/ gynecologist/ anaesthetist/ nurse-scientist must be heard in ministries as clearly as in journals. Policy change in the South can be slow, uneven, and often discouraging. But advocacy grounded in data — and repeated with calm persistence — can shift systems as shown by The Pan African Surgical Health Forum (https://www.pashef.org/) which brings together policymakers, clinicians, researchers, and advocates. Transform your evidence into stories policymakers can feel. Present it not as complaint, but as contribution. Each small success — a new training post, a supply chain reform, a safer referral system — can be a quiet revolution and creates ripples outward. Advocacy done right is corrective surgery on the system itself.

The path to global leadership begins locally. The next revolution in Global Surgery will not be led by aid, but by alliance. When the South collaborates with the South, it creates authenticity. Shared geographies, resource constraints, and cultural similarities foster empathy and practical problem-solving. South–South partnerships are not acts of defiance; they are acts of self-respect. Let us tell our own stories to one another first — for in that dialogue, we find both solidarity and amplify our collective strength. We must institutionalize regional platforms for joint research, technology exchange, and training. When the South speaks to itself, it gains coherence; when it speaks together, it gains power and we become a chorus which then sets the agenda. However, care must be taken to address power asymmetries which can exist even within South–South collaborations.

This emphasis on South–South collaboration is not meant to preclude equitable, reciprocal partnerships with the Global North, which can be deeply valuable when grounded in mutual learning and respect.

Frugal innovation is the soul of Global Surgery9, 10. It is not about doing less—it is about doing more with less. Across the Global South, surgeons have learned to do this — not only because they must, but also because they can. At the same time, framing scarcity or frugality carries a risk of romanticisation if detached from systemic challenges. The Global South has produced countless low-cost, high-impact solutions born out of necessity and ingenuity. [11] It reflects the brilliance of surgeons and engineers who innovate to meet real needs, not market trends12. A repurposed instrument, a simplified protocol, a simulation model built from recycled material — each is an act of ingenuity under constraint. The world often calls it improvisation; it should be called design thinking in its purest form13. Frugal innovation is the South’s intellectual gift to the world; let frugality become not our limitation, but our leadership language. Let us publish it, patent it, and be proud of it. For too long, the South’s successes have remained footnotes in others’ stories. Change that. Write, publish, and speak in ways that carry your context forward14. It is vital for leaders from the South to own, articulate and champion their narratives and guidelines—through their own journals and publications, conferences and digital storytelling15, 16. If your work improves surgical care in a district hospital, document it. If your innovation saves a limb, tell the world how. Our best ideas should not be locked in conference abstracts; they should be published, disseminated and circulated like lifeblood. This knowledge economy must be recognized and formalized; converting local improvisations into globally scalable models. By owning frugal innovation as intellectual leadership, the South can redefine what progress in surgery means: not more expensive, but more equitable.

Leadership means not only doing the work but also ensuring that the world recognises its value, replicates its lessons and inspires others to act. It is important to create open repositories for frugal innovations, allowing others across similar settings to replicate, adapt, and scale them. When the world learns from your constraints, you have already begun to lead it.

If leadership is a scalpel, integrity is its edge. Once dulled, it cuts neither cleanly nor safely. Be transparent in authorship, fair in mentorship, honest in results.Do not let competition corrode collegiality. Our credibility — as individuals and as a region — will rest not on brilliance, but on trust. Leadership in Global Surgery is not about being first; it is about being accountable — to the patient, to the truth, and to the next generation. Resist the temptation to overstate, over-claim, or overlook. In resource-limited settings, ethical dilemmas are frequent and complex—balancing patient care, training needs, and institutional pressures. Ethical leadership means setting the standard even when it is inconvenient. The moral compass of the leader is the invisible infrastructure of Global Surgery.

If there is one thread that runs through all these commandments, it is this:Leadership from the South is not about geography; it is about the fact that the South has something the world now urgently needs — the wisdom of adversity, the creativity of constraint, the empathy of proximity. To lead from the South is not to invert the hierarchy; it is not to replace one story with another, but to make the story whole and complete. Leadership begins in the mind, matures in action, and endures in collective legacy. The world needs that leadership—authentic, inclusive, and transformative—now more than ever. Global Surgery, as it is known today, was born in the North but must mature in the South. It is time for the Global South to move from being asked what it brings to the table to affirming its ownership of the house where the table stands.

The time for waiting is over. The operating table is ready. The patient is global surgery itself. The scalpel of leadership is already in our hands, let us steady it with wisdom, guide it with empathy, and use it to shape the future we have long imagined. And may the incision we make today — into old systems and tired hierarchies — heal into something wiser, fairer, and whole.

This manuscript reflects the author’s long-standing professional engagement in surgical practice, education, and leadership within resource-constrained settings of the Global South. The views expressed are intentionally reflective and normative, offered as a personal perspective rather than a comprehensive or universal account, with the aim of encouraging thoughtful dialogue in the field.