Global surgery has received sorely needed attention in more recent years. Given the limited surgical capacity of low and middle income countries (LMICs), it is estimated that 5 billion people lack access to safe and affordable surgical care and that 143 million additional surgeries are needed to save lives and prevent disability due to surgical disease.¹ In 2015, the Lancet Commission on Global Surgery (LCGS) was purposed to promote widespread access to safe and high-quality surgical care.¹ As part of its efforts, the LCGS forwarded a group of 6 core indicators and related goals to be used for assessment of efforts to improve worldwide surgical and anesthetic care access by 2030. Such metrics, including specialist surgical workforce density, were widely supported by global health leaders given the lack of established indicators for progress and the need to rapidly introduce a framework for surgical care expansion.²

Despite these actions, research assessing these global surgery indicators shows that we remain far from the 2030 goals set by the LCGS.^3–5 The implications of this surgical void are profound. In addition to resultant mortality, morbidity and quality of life impacts, the lack of surgical care has equally deleterious impacts on the financial well-being of both individuals with surgical disease and, on a larger scale, LMICs themselves.

Unfortunately, the COVID-19 pandemic has further impacted global surgery efforts, presenting both barriers to established programs as well as new challenges. Global Surgical Expedition (GSE) is a medical charity that provides surgical care internationally to populations in need. Since 2012, GSE has provided nearly 400 urological and urogynecologic surgeries in Belize and Rwanda to help treat surgical disease. Similar to most international global surgery organizations, GSE has largely suspended its on-site global surgery trips as a result of the pandemic. Although necessary, the impact of this suspension to the urological infrastructure developed over the last decade has been significant.

While this impact has been disappointing, GSE has also approached this period as an opportunity to place focus on numerous other programs critical to the global surgery effort. Accordingly, GSE has advanced its research initiatives to help better understand the financial impact of urological disorders in LMICs. As part of this, our recently completed data now demonstrate that, in a cohort of urological patients in Belize, their urological disorder results in a loss of over 10% of their annual income potential. This finding suggests that a routine surgery for benign prostatic hyperplasia or pelvic organ prolapse not only can positively impact quality of life, but also can have an enormous positive impact on the financial health of urological patients and their dependents.

Another area of focus has been GSE’s advocacy efforts. Certainly, advocacy remains the cornerstone of generating the worldwide support needed to provide safe and affordable surgical care to all. On a larger scale, GSE is a committed member of the G4 Alliance. This organization is a group of more than 70 academic institutions, professional societies, nonprofit organizations and other organizations working in over 160 countries with the mission to advocate for increased access to safe, essential and timely surgical, obstetric, trauma and anesthesia care. Advocacy opportunities have also been present with GSE’s individual international partners. GSE recently visited numerous health care leaders across Belize not only to discuss needs related to the COVID-19 pandemic, but also to reinforce awareness regarding the urological need and necessary program support.

Further, GSE has placed focus on its educational efforts. A founding vision of GSE was to foster the next generation of global surgery leaders. In addition to providing international global surgery experiences for residents and students, GSE has also sought to provide more formal educational opportunities and curricula. In conjunction with the University of Virginia Global Health Leadership Track, GSE was proud to support the development of a formal certificate program in global surgery/urology and recently celebrated its first resident graduate, Dr. Clint Yeaman (see figure 1). These experiences have reinforced GSE’s strong belief in the value of formal global surgery training programs and the need for support from the urological community and leadership.

Figure 1. Dr. Clint Yeaman (University of Virginia Global Health Leadership Tract Resident) during research and advocacy trip to Belize, September 2021.

Finally, much like many international surgery organizations, GSE has transitioned much of its in-person surgical activity to alternate models of assistance. This transition includes virtual activities focused foremost on clinical care or education. Indeed, virtual lectures to health care providers in Rwanda have been very successful and well received. This transition also includes focus on developing strategies to prevent or treat surgical illness such that surgery may not be necessary. In November 2021, GSE traveled to Belize to begin an exciting 2-year program to develop a pelvic floor therapy initiative in an effort to treat patients with pelvic floor disorders and train local providers to deliver this care independently.

Nonetheless, in-country efforts remain important. Determining the optimal way and time to reinstitute on-site surgical trips is complex but critical.^6,7 In November 2021, GSE was fortunate to complete our first in-country surgical trip to Belize since the pandemic began and provided 31 urological surgeries to treat benign prostatic hyperplasia, urethral stricture, urolithiasis, pelvic organ prolapse and urinary incontinence (see figures 2 and 3). This trip took place following a careful and longitudinal assessment of risks and benefits. As part of this, a separate visit to Belize was performed 2 months prior to meet with health care leaders across the country and assess numerous considerations, including balancing unmet surgical need with potential deleterious impacts to hospital bed capacity, COVID transmission and use of hospital resources. Our experience demonstrates the careful assessment that must take place as we seek to begin international trips once again.

Figure 2. Vesicovaginal fistula repair during November 2021 surgical trip to Belize. Pictured: Dr. Jacqueline Zillioux (left), Dr. David Rapp (middle), Dr. Jonathan Starkman (right).

Figure 3. Surgical team during November 2021 surgical trip to Belize.

While the pandemic has negatively impacted many important and long-standing in-country efforts, our experience underscores the many new and exciting global surgery opportunities across research, advocacy, education and clinical care. Not only are these efforts important during this period of widespread international trip suspension, they are also critical long-term approaches to help augment our global surgery efforts. Indeed, the lessons learned throughout the pandemic can help the surgery community to develop approaches that may better achieve the sustainable and scalable global surgery efforts that are needed to truly provide surgical care to all.

Acknowledgments

GSE would like to thank many individuals and organizations for their support of GSE’s research and clinical programs. This includes the Urology Care Foundation™ and Fox Family, the University of Virginia Center for Global Inquiry and Innovation, as well as numerous individual donors.