Global Surgery: Reaching the Unreachable

This article was written by Nicole Feldman and republished from the Spring 2024 Harvard Otolaryngology Magazine.

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In 2015, the Lancet Commission on Global Surgery established six indicators to measure surgical access, marking a pivotal turning point in better understanding worldwide disparities in surgical accessibility. The indicators include geographic accessibility, density of surgical providers, number of procedures performed, perioperative mortality, impoverishing expenditure, and catastrophic expenditure.

To further understand the scope of measuring surgical access in otolaryngology–head and neck surgery, Blake C. Alkire, MD, MPH, a comprehensive otolaryngologist at Mass Eye and Ear and assistant professor of Otolaryngology–Head and Neck Surgery at Harvard Medical School, co-founded the Global Otolaryngology–Head and Neck Surgery Initiative, a research collaborative with a focus on identifying and prioritizing gaps in otolaryngology–head and neck surgical care worldwide. The collaborative recruited globally, resulting in a membership of more than 350 otolaryngologists, with representation from every World Bank region and 50% from low- and middle-income countries.

"We are investigating several different facets, including essential procedures and conditions, workforce population, training and education, infrastructure and equipment, and barriers to care," explained Dr. Alkire. "The goal of our investigations is to benefit countries and regions interested in expanding access to high-quality surgical care."

The initiative launched a major survey sent to ministries of health and professional societies around the world, with a goal of learning the number of otolaryngology–head and neck surgery care clinicians per capita worldwide. Responses came from 114 countries or territories, representing 84% of the world's population.

The survey results, published in August 2023 in JAMA Otolaryngology–Head & Neck Surgery, revealed variations in clinician density based on income and region. Higher-income countries generally had more clinicians per capita, with Europe having the highest density and low-income countries in Africa and Southeast Asia having the lowest. These findings can steer focused investments in training and policy-making to address inequalities in the availability of otolaryngology–head and neck surgery clinicians.

Global Surgery Scholars Program

The surgical workforce is in crisis across low-to middle-income countries. For over a decade, David A. Shaye, MD, MPH, FACS, facial plastic and reconstructive surgeon at Mass Eye and Ear and assistant professor of Otolaryngology–Head and Neck Surgery at Harvard Medical School, has traveled to countries in Africa, Asia, and South America to teach facial reconstructive surgery for treating trauma, head and neck cancer, and congenital anomalies.

"The shortage of surgeons across Africa has reached a critical state, such that a billion people on the continent do not have access to surgical care," said Dr. Shaye, who serves as director of Global Surgery, Otolaryngology–Head and Neck Surgery. "The intention of our international surgical work is to bring what academic surgery does best—teaching—to places that need it most. Teaching surgery is a winning investment every time."

Dr. Shaye spends many months each year working directly with surgeons in countries affected by the surgical workforce crisis. Through firsthand experience, he has identified a critical need for further educational and training opportunities outside of what he can offer.

Since joining Mass Eye and Ear in 2014, Dr. Shaye has seen the organization's unique position as a hub of subspecialty surgical activity. With up to 15 operative rooms in action daily, and a multitude of talented surgeons, visiting surgeons have a unique opportunity to experience in just a few weeks what would amount to years' worth of surgeries in their home countries.

In 2023, Dr. Shaye founded the Global Surgery Scholars Program at Mass Eye and Ear. The program offers educational opportunities for junior surgeons from Africa, Asia, and South America to spend one month at Mass Eye and Ear, observing surgeries, attending lectures, and immersing themselves in a subspecialty head and neck hospital. The program is fully funded by philanthropy, from visa fees to flights to meals. Visiting surgeons are hosted by hospital faculty and other generous volunteers to create a welcoming and educational experience.

"For surgeons already armed with foundational skills from their residency training, this program offers a unique opportunity to see the vast array of surgeries performed at Mass Eye and Ear. Surgical skills, safety systems, and other ideas can then be tailored and replicated at university hospitals in Africa, Asia, and South America," said Dr. Shaye. "From novel surgical techniques to new equipment to building lifelong relationships, we are excited to see this program have a global reach."

Inaugural Program Launch

In the summer of 2023, the Department of Otolaryngology–Head and Neck Surgery hosted three surgeons: Pramila Shakya, MD, an oral and maxillofacial surgeon from Kirtipur Hospital in Nepal; Wayne Manana, MD, a maxillofacial and cleft surgeon from Parirenyatwa Hospital in Zimbabwe; and Perla Villamor, MD, a pediatric otolaryngologist from Children's Hospital "La Casa del Niño" in Colombia.

Dr. Shakya is the leading cleft and craniofacial surgeon in Nepal with vast experience in her field; however, she identified a gap for her Nepalese patients in nasal reconstruction and rhinoplasty. In Boston, Dr. Shakya was able to observe dozens of nasal reconstruction surgeries. She also trained under Caroline A. Banks, MD, a facial plastic and reconstructive surgeon at Mass Eye and Ear and instructor in Otolaryngology–Head and Neck Surgery at Harvard Medical School, which helped Dr. Shakya recognize the unmet need for facial paralysis care in Nepal.

"I feel more confident than I ever have, and I believe that I can better help and serve people of my country with the knowledge and experience gathered from Mass Eye and Ear," said Dr. Shakya.

Following Dr. Shakya's visit, Dr. Wayne Manana arrived from Zimbabwe. Dr. Manana is a lead facial reconstructive surgeon; one of the few in the entire country of 16 million people. During his month-long visit at Mass Eye and Ear, Dr. Manana relished the opportunity to learn techniques in free tissue transfer, skin cancer reconstruction, nasal reconstruction, facial reanimation surgery, hypoglossal nerve stimulators, and periocular surgery.

"This experience was arguably the biggest turning point in my career," said Dr. Manana. "It has challenged and redefined my scope of practice. I believe that this could mark the birth of facial plastic and reconstructive surgery in Zimbabwe." He added that the biggest winner in the Global Surgery Scholars Program are the patients that they save and serve.

"It was such a privilege to be a mentor in the Global Surgery Scholars Program and work with incredibly talented surgeons like Drs. Manana and Shakya," said Dr. Banks. "Exchanging ideas and learning about each other's practices has been a very rewarding experience."

The third surgeon, Dr. Villamor, trained under Christopher J. Hartnick, MD, MS, and division director of Pediatric Otolaryngology at Mass Eye and Ear and professor of Otolaryngology–Head and Neck Surgery at Harvard Medical School, to expand her learning in pediatric airway reconstruction.

She shared that her experience at Mass Eye and Ear was transformative. "The opportunity to observe cutting-edge medical and surgical practices, as well as advanced technologies, fills me with enthusiasm to replicate these advances as much as possible at our hospital," said Dr. Villamor.

Dr. Hartnick remarked, "The Global Surgery Scholars Program allowed a wonderful pediatric otolaryngology surgeon to learn and experience our team culture of care and bring what she saw in Boston back home with her to Colombia. She is building her own program and creating a true multidisciplinary effort to help children in need."

In addition to returning home with new knowledge and fresh skillsets, the scholars were given much needed surgical instruments to perform the surgeries they observed at Mass Eye and Ear. For example, Dr. Manana returned to Zimbabwe with a new battery powered surgical headlight, enabling him to perform surgeries of the head and neck even when the electricity goes out, which is a common occurrence. "We want our visiting surgeons to not only leave with knowledge, but also with the equipment to perform and teach these surgeries at home," said Dr. Shaye.

The Global Surgery Scholars Program is now approaching year two of hosting global surgeons, with the intention to expand the program with each year. "Every surgeon in this program has a shared goal to improve surgical care through teaching. I am extremely proud that Mass Eye and Ear has a program with global reach where it matters most," emphasized Dr. Shaye.

Learn more about the Department of Otolaryngology–Head and Neck Surgery at Mass Eye and Ear

Refer a patient to Mass Eye and Ear/Mass General Brigham