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Surgical digest

Ten lessons for global surgery researchers   


Dhananjaya Sharma, MBBS, MS, PhD, DSc, FRCS, FCLS (Hon), FRCST (Hon)

Honorary Member Académie Nationale de Chirurgie France
Head, Department of Surgery, Government NSCB Medical College, Jabalpur (MP) India

https://doi.org/10.58974/bjss/azbc033

Global surgery is an area of study, research; practice and advocacy that seeks to improve health outcomes and achieve health equity for all people who require surgical care, with a special emphasis on underserved populations. Researchers and institutions in LMICs (Low and Middle Income Countries) are the major stakeholders in this and have to provide the academic leadership in this emerging field.   

I am a lifelong activist and campaigner for appropriate technology and affordable low-cost surgical solutions to achieve equitable surgical care for underserved populations. It gives me great pleasure to share our successful ideas which made a difference and which become our vade mecum over the years, as lessons for global surgery researchers from LMICs.

   

1. Follow the roadmap for meaningful research in LMICs:   

A huge amount of clinical material is available in LMICs; however, global surgery researchers working in resource-constrained settings (suboptimal human resources, limited research facilities, lack of reserved time for research, etc.) struggle to perform research.  It is, however, possible to conduct meaningful research by following a simple roadmap which may assist clinicians facing hitherto insuperable hurdles (Table 1)1

Table 1 

Seven steps for conducting problem-solving research in resource-constrained settings 

#Step
1Identify a specific problem which needs solution 
2Study and master all the basics of the problem 
3Hold brain-storming sessions; thinking imaginatively, differently and deliberately. Keeping an open mind will ensure recognition of a good idea to find the simple, most cost-effective solution to a complex problem 
4Examine safety and ethics of the new idea 
5If necessary, perform a pilot study before clinical study 
6Perform a robust study to find necessary rigorous evidence 
7If necessary, perform a pilot study before clinical study 
Adapted from Sharma et al1 

One can start by remembering inspirational advice from scientific heroes to help overcome initial doubts and pessimism. The first step is to see difficulties as opportunities and perform research on what is important rather than what is interesting. One basic tenet of our philosophy “modify-simplify-apply” exemplifies Occam’s razor and can be used for validation of indigenous traditional simple ideas, simplifying the surgical techniques, developing simple new surgical techniques and low-cost instruments; development and validation of simple prognostic scores and easy decision making algorithms and surgical training2-4. It is important to innovate and develop appropriate technology (Table 2), because innovations can lead to quantum change and help in devising an operation for every purse and purpose. For this, it is crucial to be curious about new ideas; but also to recognize a new idea, it is equally important to keep an open mind and be well-versed with basic and clinical sciences as the opportunity favours a prepared mind. A combination of global wisdom and local resources can allow optimization of limited resources. Similarly, knowing the difference between knowledge and wisdom helps. Last but not the least, permission from the institutional ethics committee must be obtained before any research; because as the old adage mentions ‘if the passionate do the surgery, then the skeptics have to assess the ethics’.   

Table 2 

Pre-requisites for appropriate technology for resource-constrained settings 

#Pre-requisite
1It should be need based for locals 
2It should be available at grass root level 
3It should be affordable (cost effective) 
4It should be easy to maintain at local level 
5It should be ‘transparent’ (understood by locals) 
6It should involve locals in its ‘co-creation’ (skills transfer) 
Adapted from Sharma et al1 

In addition, this roadmap allows global surgery researchers in LMICs to develop their local transformative leadership; and provide local-evidence-based decision-making and solutions for their patients’ local surgical problems – a win-win situation for everyone.  

2. Evaluate the innovation/ idea scientifically:  

Rigorous and scientific evaluation is needed so that introduction and adoption of new ideas are governed by evidence-based principles rather than a serendipitous trial and error process5. Affordable low cost surgical ideas/innovations face unique challenges in evaluation due to factors like limited funding, lack of regulation or patenting, and challenges in gaining clinical buy-in6. A better understanding of local practices; infrastructure limitations and resource availability can help. Even then a low-cost idea which has undergone all 5 stages of evaluation is a rarity7.  

One of the earlier limitations of surgical research was the myth that only a randomized controlled trial (RCT) can provide strong evidence. But now we know that an RCT is not the only building block for Evidence Based Medicine. A prospective observational study with a registered research protocol, proforma-directed data collection and necessary statistical rigour is equally effective for evidence evaluation when an RCT is not feasible or necessary8,9

3. Publication is a must for peer review and peer acceptance:  

Publication of research is of paramount important for peer review and peer acceptance – the two cornerstones of science. Earlier publications of ideas originating from LMIC global surgery researchers faced many challenges due to the lack of a structured template, and were, therefore frequently reported as informal anecdotal communications. Moreover, lack of command over the English language and structured scientific writing prevent their entitled scientific evaluation and recognition by reviewers, editors and readers. A formal unambiguous, unequivocal and transparent ‘structured’ checklist enumerating a standard reporting format is now available which will go a long way in overcoming these hurdles10

4. Reforms are needed in the process of publication of papers and guidelines:  

LMIC global surgery researchers are its major stakeholders, yet they find themselves marginalized as authors in major journals, under-represented within editorial workforces and are recipients of unconscious bias that affects editorial decision-making processes at major journals11. Moreover, the colonial mindset of LMIC researchers compels them to seek peer approval from a foreign gaze by trying to publish their work in high impact journals as trophy publications, only to face the 10:90 paradox. Once they receive a nicely worded rejection mentioning that space constraints mean that fewer than 10% of articles can be published, they submit the same manuscript to their national journal where they stand a 90% chance of acceptance. Major reforms are required for the correction of such disproportionate imbalance of power. This must also include strengthening of national journals by submitting LMIC’s best manuscripts here rather than in the elite journals so that fellow stakeholders in global surgery can access their published work more easily12. Ideally, the local authors should write about the local issues from a local perspective for local readers in local journals.   

Best evidence from Clinical Practice Guidelines (CPGs) often struggles to actual translation in LMICs due to their inherent practical and logistical constraints. Incorporation of input from end users and stakeholders while formulating a guideline can make it more effective and acceptable. Such a glocal philosophy, i.e. global wisdom tailored to local resources, can ensure that patients and the CPGs get the best of both the worlds13

5. Ensure dissemination and adoption of successful ideas:  

Output of global surgery researchers from LMICs leads to affordable surgical innovations (ASIs) which provide simple, safe and equitable solutions in resource-limited settings. However, they face challenges with their dissemination and adoption even after supporting evidence is published. Our surgery-specific ‘DISSEMINATE’ roadmap provides structure for effective dissemination and adoption to overcome this know-do gaps in the use of ASIs in LMICs. It showcases the actions needed to achieve this goal (Table 3)14

Table 3 

Domains and definitions of the proposed DISSEMINATE roadmap 

LetterDomainDefinition
D Design Innovation must be relevant, useful, and feasible: must have advantage (of cost, effectiveness, simplicity, compatibility) over current practice(s); must be experimentable on a trial basis; outcomes must be evaluable, must be adaptable by stakeholders and applicable to local context(s).    
I Innovate Combine IDEAL framework with evidence synthesis, stakeholder involvement (local contexts, environmental and cultural factors) and health economics modelling 
S  Substantiate  Validation from peer review and publication; further validation from impact in scale-up, practice and long-term results.  
Scale up Get relevant evidence published as book chapter/  textbooks/evidence-based guidelines/policy 
Share     Facilitate widespread use of the innovation by reaching and educating target audiences at conferences, meeting and workshops at health facilities and policymaking forums and in communities. Organizers can provide a platform for innovator-industry interaction for further development. 
Sustainability  Innovation implementers and implementation climate must champion the innovation and be flexible to adapt and further develop it to withstand the test of time and competing needs. 
E Endorsement  Seek endorsements of the innovation by catalysts of spread and scale in the local implementation environment, e.g. opinion makers, leaders in the field, national organizations, government and healthcare policy makers, patient groups, researchers and developers of support materials or instruments. Academic societies need to step up and promote ASIs.  Awards validating/supporting the use of ASIs 
M Media Strategically promote and popularize use of the innovation through mass, social and other appropriate media  
I Identify early adopters Early engagement with early adopters and supporting them to address issues with adoption, implementation, and sustainability 
Improve Take stakeholders’ feedback to improve and refine the innovation 
Improvise Be prepared to improvise/ repurpose quickly in face of a crisis 
Implementation Science methods Use implementation science methods to bridge the research-practice know-do gap 
N Navigate through barriers Identify and address barriers to adoption at multiple levels of delivery and recipient systems   
A Aspirational Affordability Replace scarcity terms like “low-cost” or “frugal” with “cost-effective” or “affordable” to fulfill target’s social aspirations 
Advocacy  Strong advocacy to demonstrate the value of ASIs, influence industry and lobby global organizations 
T Tools for assessing scalability and adoption Use/refine/improve upon available tools for assessing use and impact, such as citations, altmetrics, patient/service outcomes and implementation practice analysis 
E Evaluate impact of dissemination  Is the innovation having the desired impact? If not, why not? 
Extend  Extend the use of innovation as a “reverse innovation” in resource-rich settings 
ASI = affordable surgical innovation  
IDEAL = Idea, Development, Exploration, Assessment and Long-term follow-up 
From Sharma et al14 

6. Break the glass ceiling for global ideas/innovations:  

The term ‘reverse innovation’ (RI) refers to an innovation from a LMIC for its unmet needs, which has later been found of use in a high-income country (HIC). In line with the political correctness of the times, these ideas are now called global innovations. These have the potential to offer efficient cost-effective alternatives to global surgical care; however, in HICs, their acceptance is suboptimal, and their uptake remains grossly under-utilised15. Barriers to embracing RIs such as quality concerns, regulations, access, technical feasibility and alignment with public policy are not insurmountable. RIs are much more than solutions to problems of the underprivileged, and a more receptive attitude can ensure that such knowledge and wisdom are lost.   

7. Take lead/active part in global surgery’s coming of age:  

The current vociferous call to ‘decolonise’ global health and global surgery has been prompted by many inherent flaws of their outreach programmes. Roadmaps are now available for 50-50 bi-directional partnerships between the global north and global south to correct the present imbalance which favours the north. We suggest the phrase ‘coming of age’ for the new transformed sensitised global health and global surgery. All health care workers, regardless of their geographical location, must fully embrace the change so they truly become the two sides of the same coin, and complement each other to work together towards the same objective — accessible healthcare for all16. It is not a zero sum game in which the global south gains and the global north loses.  

The global south is the biggest stakeholder in this process and with achievement of decolonisation, we stand to benefit the most. Therefore, we have to take the responsibility of shifting the centre of gravity to the south17

8. Develop simple affordable learning systems for surgical training/teaching:  

Surgical capacity building is a crucial part of global surgery. Surgical skills, like any other motor skills, can only be acquired by repetitive practice, i.e. simulation, which provides the much needed bridge between theoretical learning and real-life operating experience for a trainee and has become the foundation of modern surgical training. Training opportunities in modern surgical skills centres were and are limited due to cost and availability. However, simple innovative ideas can develop low-cost, low maintenance, locally made simulators with self-assembly of components that are available locally or online and even with used, discarded or expired disposable instruments. These may be accessible to trainees worldwide18,19. More importantly, skills acquired through these low-cost simulations translate into improvements in operating room performance by reducing the initial learning curve, and their efficacy is on par with expensive systems20,21. These low-cost systems can result in significant savings in costs of resident training, as well as in annual running costs of skills laboratories.   

9. Invest in and promote youngsters:  

Noblesse oblige, the desire and responsibility to help those who are less privileged, is attracting more and more students and trainees to the discipline of global surgery and have made it a force majeure in recent years.   

Young minds are the most fertile ones. If challenged with a problem and appropriately mentored in a problem-solving ecosystem without silos, and cross pollination of ideas from different disciplines, they can work wonders in finding solutions22. Their mentoring must also include teaching the importance of teamwork, since teamwork makes the dream work. Moreover, the academic world has several rewards like authorships, patents, and promotions to offer as positive reinforcements for successful ideas/solutions3

Several academic global surgery teaching and training programmes are already being run by HIC institutions. Motivated students and trainees have formed networks of future global surgery providers in the U.S. (Global Surgery Student Alliance, GSSA) as well as all over the world (International Student Surgical Network, InciSioN). These networks provide inspirational leadership for advocacy, education, and research towards the future of global surgery23. Their special capacity to act as change agents should not be left untapped.   

10. Walk the talk:  

Guidelines and checklists for how to plan, what to do, what not to do, how to do it, how to deal with the extra layer of ethical complexity of global surgery, how to measure impact and even how to write about it have been comprehensively documented.  All that is now needed is to ‘walk the talk’ with forbearance and kindness, instead of patronizing or condescending airs24

Global means together – like a team game – and in this ecosystem of global surgery everyone brings something to the table. While significant progress has been made, sustainable changes require a long-term commitment and the journey toward achieving equitable access to surgical care is far from over. It is well known that resource constraints drive innovation. Quality of surgical care in LMICs can be improved with the help of locally developed low-cost affordable surgical solutions/innovations, in response to their unique challenges3,25. These evidence-based solutions can easily replace those with disproportionately high cost and can be incorporated into standard surgical pathways26,27. To paraphrase U.S. President Abraham Lincoln’s Gettysburg Address these global surgery solutions are ‘of the people, by the people, for the people’.   

To sum up, global surgery researchers from LMICs offer a unique perspective, having overcome substantial challenges and made significant contributions to the field. Hopefully these 10 lessons can provide valuable insights for researchers from all backgrounds in achieving equitable access to surgical care.   

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