The field of global surgery has evolved beyond its roots in both humanitarian surgery and public health to become a richly interdisciplinary endeavor including fields outside of medicine. The Consortium of Universities for Global Health defines global health as “the field of study, research, and practice that places a priority on achieving equity in health for all people.”¹ It is different from international health in that it is not specifically international, but retains a core emphasis on low resource areas within countries and regions. As a surgical specialty, urology lives within the general area of global surgery.

It was not long ago that generalists and specialists including urologists ventured alone or with smaller groups—sometimes faith-based, sometimes professional or with multispecialty nonprofit organizations to serve in resource-limited settings, and, where possible, to teach. “Parachute medicine” got a bad name. The intent was laudable, the outcomes hard to measure, and the scalability difficult. Rarely were conditions optimal or even good for supporting quality surgery as we know it. Many operating rooms had limited electricity, and frequent power surges, humidity, and lack of biomedical engineering meant that even excellent instruments/equipment had a short life span. Most scopes, the “eyes” of the urologist, were doomed. Safe anesthesia, especially regional anesthesia, has been a critical component of the development of surgery. And even infrastructure has needed to be rethought and hospitals redesigned since hospitals built during colonial times, and even after, often lacked dedicated recovery areas with trained staff. When patients are taken directly from the operating room to crowded wards with limited nursing, all manner of complications can arise.

We urologists have been in good company; surgeons of all specialties experienced the same troubles when trying to create conditions for equitable surgical care globally. But the efforts and relationships nurtured through the early efforts have borne fruit as the training programs have matured and professional societies developed around the world. Younger generations of students, trainees, faculty, and practicing surgeons are now actively engaged. Many universities now offer academic programs in global surgery, and consortia have emerged that bring together a broad community of groups including industry, the United Nations through UNITAR (United Nations Institute for Training and Research), and the Global Surgery Foundation, advocates, entrepreneurs, and others.

One area that has brought about this transformation has been technology outside the domain of medicine. Mobile phones and apps such as WhatsApp revolutionized our ability to talk to/text/email individuals and groups in real time, and networks like Starlink make communications access possible even in remote areas. Computing power has improved in poor countries to the point that newer areas of research are expanding our understanding of surgical disease and capacity through geospatial mapping. Better understanding can lead to more effective use of both financial and human resources. Artificial intelligence promises to make access to information even more equitable, especially in diagnostics, where lab data, image capture, and shared global resources can reach rural areas and regions like the Pacific archipelagos with great geographical challenges. Technical surgery, on the other hand, will still be hands on, even as robotics companies begin to innovate streamlined minimally invasive surgery and to market it to low resource settings.

Another area of transformation is advocacy, backed by modeling and data, and coming from the Global South. Groups such as the G4 Alliance have successfully advocated for funds for surgical development through USAID (US Agency for International Development) and other international development agencies, which until recently, did not see surgical care as a priority for development. Low- and middle-income countries (LMICs) themselves proposed and achieved a resolution through the World Health Assembly to declare surgical care an essential, indispensable component of health.² This has set the stage for additional funding and engagement through multiple collaborations.

At the LMIC level, surgical care is being strengthened by the collaborative efforts of academics, country ministries of health, and multilateral organizations through the development of National Surgical, Obstetric, and Anesthesia Plans which support all types of surgery, including urology.³ Multilateral international collaborations have proven effective for surgical correction of obstetric fistula and lymphatic filariasis. But these disease-focused programs are adjusting to support the surgical systems that enable them. The COVID pandemic has demonstrated that healthy surgical ecosystems can also support public health.

One of the biggest hurdles facing practicing urologists engaging in humanitarian or global surgical work is time—time away from home and their primary practice. Research time is still difficult for academic urologists because it is rarely supported by the types of grants that cover institutional indirect overhead. This is changing, as surgeons become more creative in partnering with others to innovate and reimagine their roles in health care. Clinical outreach and teaching are largely self-funded, and because individual surgeons can rarely commit to long stays, the work of many individuals has been harnessed by groups and organizations like IVU (International Volunteers in Urology) to sustain programs through rotating teams working with partner sites. Organizations like the Societies for Pediatric Urology and the Society of Genitourinary Reconstructive Surgeons are also developing task forces and programs to strengthen engagement and bilateral training in LMICs.

Students and trainees, with their enthusiasm and fewer external commitments, sometimes have more opportunities for travel, and their research can contribute in valuable ways to ongoing programs. IVU has supported mentored traveling scholarships for North American trainees for over 25 years, and research grants through the Fogarty International program at NIH have recently supported surgical specialty trainees. The student and trainee networks Global Surgery Student Alliance and affiliated International Student Surgical Network (“InciSioN”) create bridges across the world and often nurture new collaborations. Through the COVID pandemic these organizations were particularly active sustaining lectures and research projects around the world by leveraging social and other media platforms.

Opportunities for engagement with colleagues around the world are expanding in many forms. From distance mentorship to partnership and case conferences, and from on-site service delivery to local, country, and regional program development, we have many structures and levels through which to build equity in urological health for people globally. Urologists have always had the hearts of humanitarians. Now we also are developing the tools of global surgeons.