ACS Training Hubs Help Build Surgical Capacity in Africa

In sub-Saharan Africa, ACS Operation Giving Back (OGB) is transforming how ACS members—in collaboration with their African colleagues—provide services to populations with limited access to surgical care.

Christopher M. Dodgion, MD, MSPH, MBA, a trauma surgeon and assistant professor of surgery in the Division of Trauma/Critical Care at the Medical College of Wisconsin in Milwaukee, is one of many surgeons working in Africa via OGB, the College’s volunteerism initiative.

What he does on his visits to Hawassa University Hospital in Ethiopia, though, is not what surgeons have traditionally done in volunteer work. “Most of the time, when I go to Hawassa, I am not providing clinical care,” Dr. Dodgion said.

Instead, his work contributes to a larger-scale, sustainable shift in the way African surgeons gain skills, manage resource constraints, and improve patient care.

Worldwide, the need for more surgery is vast. Roughly one-third of the global disease burden can be addressed by surgical means. But per Global Surgery 2030, a report by The Lancet Commission on Global Surgery, 5 billion people worldwide lack access to safe, affordable surgical and anesthesia care.

Overall, the poorest one-third of the world population receives just 3.5% of all surgical procedures,^* and fully meeting the need in low- and middle-income countries would require an additional 143 million procedures per year.^† In many parts of Africa and Asia, the absence of access to surgery is nearly total.^†

Originally established to connect willing surgeons to volunteer opportunities in the US and abroad, OGB is part of a long tradition of volunteerism in surgery.

“Previously, Operation Giving Back tried to find opportunities for our Fellows to provide clinical service or teaching by identifying nongovernmental organizations that work in low-resource settings,” said OGB Medical Director, Girma Tefera, MD, FACS, letting interested surgeons initiate the volunteer work on their own.

Many of these opportunities involved long-standing models of surgical volunteerism, including surgeons traveling to address surging needs caused by disaster or war, or making short visits to underserved communities to complete as many procedures as possible.

Those approaches may seem intuitive, given the intensity of need in sub-Saharan Africa. But while such work remains helpful, Dr. Tefera explained that around 2017, “We started thinking: why can’t we create the programs and develop partnerships that allow our Fellows to provide, in a meaningful manner, whatever contribution they want, instead of seeking these one-off opportunities? And if we do that, we could come up with a much more solid and sustainable, longitudinal program.”

Six years later, that effort has resulted in emerging surgical training hubs designed to link US institutions with hospitals in Ethiopia, Rwanda, and Zambia, and provide US and African surgeons opportunities to collaborate on mutually beneficial education, workforce development, and quality improvement programs. Through these hubs, OGB is focused on building surgical capacity and improving patient care.

Hawassa, Ethiopia

The insufficiency of access to surgery is a reality that Belay Mellese, MD, knows well. He is a general surgeon and assistant professor of surgery at Hawassa University Hospital, the first surgical teaching hub established by OGB. An OGB committee selected the hospital as the site of the first hub after it applied to OGB via an open call in 2017.

Surgery accounts for more than 200 of the tertiary facility’s 500 beds. According to Dr. Belay, the hospital serves a catchment area of more than 20 million people, and the surgical team carries out more than 10,000 operations annually in six operating rooms.

In this environment, it would be understandable if local physicians wanted someone to simply tackle some of the caseload. Yet when Dr. Belay brings up Dr. Dodgion—the volunteer surgeon whose four trips to Hawassa have included little clinical work—he smiles broadly. “He has an extremely important role,” Dr. Belay said.

Dr. Dodgion was part of providing recent Advanced Trauma Life Support (ATLS™) training, which Dr. Belay and his colleague, emergency physician Emnet Tesfaye, MD, ECCP, said is the first ATLS course ever presented in Ethiopia. The training included teaching the Hawassa surgeons how to train others, so that additional Ethiopian physicians can receive ATLS training.

“They never had a clear and systematic way to care for the injured patient,” Dr. Tefera explained. “There was no overarching, structured approach. Now, it’s become the place where others will go and get trained on how to care for trauma patients.”

According to Dr. Emnet, Hawassa physicians also may travel to Addis Ababa next year to lead ATLS courses there. “We want to expand. There is obviously demand all over the country,” Dr. Belay added.

The ATLS training is just one of many things the hub has been able to accomplish since its start in Hawassa 3 years ago. During the COVID-19 pandemic, when travel was infeasible, the consortium virtually connected Hawassa surgeons to journal clubs, grand rounds, and a Trauma Evaluation and Management (TEAM™) course.

In addition, Dr. Dodgion and others led a course in research methods, which he said yielded 10 institutional review board-ready protocols, numerous case reports published in East and Central African Journal of Surgery (a journal affiliated with the College of Surgeons of East, Central, and Southern Africa—an ACS collaborator), and personalized support for the Ethiopian surgeons.

Hawassa University Hospital’s chief executive director Anteneh Gadisa Belachew, MD, FCS-ECSA, FACS, who is a colorectal surgeon, summarized the impact of these educational opportunities. “The training hub has been instrumental in standardizing our service, our education, and bringing culture change in the department. In a sense, the faculty were not interested and had no opportunity to do research, conduct quality improvement programs, or update skills in certain areas. The hub helped to generate appetite, provide the training, and provide mentorship in doing those things.”

All 13 US institutions remain committed to collaboration with the hub, including about a month of in-person work per institution per year. This means the project is poised to expand training into additional surgical and quality improvement initiatives.

“The ACS collaboration with our university has been beneficial in so many ways,” Dr. Emnet said.

Lusaka, Zambia

While initiating the surgical training hub in Hawassa, OGB also has worked to create a second hub in Lusaka, Zambia. Situated between the Democratic Republic of Congo and Zimbabwe, Zambia, like Ethiopia and Rwanda, has insufficient healthcare infrastructure. Although as distant from Hawassa as Cincinnati is from San Francisco, this hub is nonetheless quite like the pilot site.

“The work that is being done has similarities,” said Dr. Tefera. “Both are focused right now on what we would call general surgery.”

To that end, the hub is in the middle of a post-pandemic scale-up in on-the-ground interactions between US and Zambian physicians, with a strong focus on “specific tasks that are geared toward transferring skills,” including a recent course on research methods, noted Dr. Tefera.

As with Hawassa, the collaboration began with a 2017 application from the University Teaching Hospital in Lusaka to become an OGB hub site. Following its acceptance, a consortium of 11 academic departments of surgery in the US was formed, all of which have multiyear commitments to the program, including at least 2 weeks of work in Zambia per year. In Lusaka, the consortium is working to establish a simulation laboratory, a nascent educational approach in sub-Saharan Africa. In addition, in the past 6 months, multiple groups have traveled to Lusaka to deliver workshops on research methodology, laparoscopic surgery, and pediatric surgery.

Dr. Tefera notes that the shift from laparotomy to laparoscopy is likely to reduce pressure on crowded surgical wards. “Imagine what that means for people who always have open gallbladder surgery,” said Dr. Tefera. “They stay in the hospital 5 days to 1 week. This way, they go home the next day.”

The hub is poised to build on previous successes. “From the pilot phase in Hawassa, we learned a lot of things. So, the Lusaka piece can be run a little bit smoother,” Dr. Tefera commented.

Kigali, Rwanda

While the Lusaka and Hawassa surgical training hubs focus on general surgery, OGB’s collaborations in Rwanda are focused on cardiothoracic, vascular, and plastic surgery subspecialties and trauma system development.

In March 2023, trauma surgeons Jeffrey D. Kerby, MD, PhD, FACS, ACS Committee on Trauma (COT) Chair, Eileen M. Bulger, MD, FACS, Medical Director of the COT, and Barclay T. Stewart, MD, PhD, MPH, a COT Future Trauma Leader, visited Rwanda with OGB, on a trip also attended by Patricia L. Turner, MD, MBA, FACS, Executive Director and CEO of the ACS.

The primary purpose of the visit was to generate a report and action plan for building the nation’s capacity for trauma care. “We do a lot of trauma system development work in the US,” Dr. Bulger said about the COT. “But we haven’t done that as routinely in the global space, and there’s such a need for systems development.”

Indeed, 77% of preventable deaths from unmet surgical need worldwide arise from injuries*—and at present, Rwanda has insufficient access to trauma surgery. “They don’t have any trauma or surgical critical care-trained surgeons in the country,” Dr. Kerby noted.

Trauma educational sessions will be among the initial steps to aid Rwanda. “I think there’s an opportunity for us to at least do a demonstration course and then try to promulgate ATLS,” Dr. Kerby stated, building off the OGB experience training surgeons in ATLS in Hawassa. The course can offer a meaningful starting point for further work.

“What ATLS brings is a common language that everyone learns. Everyone has the same priorities and is talking the same language because they’ve all taken ATLS, and the priorities are very clearly outlined,” he said.

The longer-term plan is full-scale systematic change in the way Rwanda serves the trauma patient. “When we talk about trauma systems, we’re talking about everything from the point of entry to rehabilitation,” Dr. Bulger said.

To that end, the group visited the three largest hospitals in Kigali, toured four of five levels of care in facilities outside the capital, and met with Rwandan Ministry of Health officials and local surgical champions, capping a year of online meetings. “You obviously need to have buy-in at a high level for systematic change, and this trip helped cement those relationships,” Dr. Bulger explained.

In many ways, Rwandan health officials need no convincing. Unlike the surgical training hubs in Ethiopia and Zambia, which began via an open call for applications, OGB’s work in Rwanda started with the Rwandan Human Resources for Health (HRH) Program reaching out directly to OGB to request specific help. “Before our visit, surgical champions in the country who we met with had already done a fair amount of legwork toward building standards for trauma centers and working on prehospital care coordination,” said Dr. Kerby.

In addition, the visiting surgeons were enthusiastic about the country’s fastidious traffic safety initiatives. “Helmets are mandated across the country for all motorcycle riders, and it’s well enforced, with the uptake approaching 100%,” explained Dr. Stewart, in describing the laws that apply to motorcycles, the dominant vehicles on many roadways in Kigali.

“There are hundreds of automated speed enforcement cameras that really limit people’s inclination to overspeed. The cameras are connected to a system that distributes traffic tickets via people’s cell phones. The tickets are US$25 and increase to US$35 if they are not promptly paid; that’s a lot of money for a lot of people, which further limits the inclination to speed,” he said, adding that vehicles also are required to have speed governors, cell phones are locked in boxes installed on motorcycles while moving, and pedestrians respect crosswalks due to the strategic placement of walkways, curbs, and vegetation.

In addition to training and education, the COT will support a trauma task force centered in the Rwandan Ministry of Health. After noting that eliminating death and disability from trauma across the globe is part of the COT’s vision statement, Dr. Bulger stated, “We expect it to be a long-standing relationship.”

Trauma alone is not the extent of OGB’s collaborations within the country. Rwandan HRH Program’s initial request also aligned with OGB’s interest in engaging specific kinds of subspecialist surgeon volunteers.

“What we are doing in Rwanda is more subspecialty-focused, so it is cardiac surgery, thoracic surgery, plastic surgery, and vascular surgery,” said Dr. Tefera, who is a vascular surgeon at the University of Wisconsin-Madison.

Toward that end, OGB has collaborated closely with King Faisal Hospital in Kigali on a plan to enhance supply chains, protocols, and workforce development plans in cardiothoracic surgery. OGB has also worked to engage US plastic surgeons to develop and conduct several workshops in plastic surgery for Rwandan resident physicians.

Dr. Tefera said the impact of this work is emerging. “Because of our presence, some changes are also happening with local general surgeons wanting to be subspecialists. For example, the very first vascular surgeon is finishing up now to go back and work in Hawassa. A cancer surgeon who was inspired by some of our volunteers has also completed his subspeciality training.”

A Clear Perspective

In the end, OGB’s perspective is clear: the best way to improve global surgery is not just to do it but to teach it.

Dr. Tefera noted that ACS member surgeons do operate in Africa, and “inspiring others by actually being elbow to elbow in the operating room with them” is part of what the US surgeons can offer their African colleagues.

But, he added, “We don’t want the US surgeons going because they want to do tons of cases. We want them to go because they want to teach. The teaching happens in the classroom, the teaching happens in the simulation lab, and the teaching happens in the operating room as well.”

Many of the surgeons working with OGB also note that the surgical training hubs emphasize respect and mutual learning. Echoing remarks from Drs. Belay and Emnet on the presence in Africa of highly experienced surgeons with skills in rare disease management, laparotomic techniques, and creative workarounds for resource constraints, Dr. Tefera noted, “We learn from them as well.”

M. Sophia Newman is the Medical Writer and Speechwriter in the ACS Division of Integrated Communications in Chicago, IL.

^*Debas HT, Donkor P, Gawande A, Jamison DT, et al. Disease Control Priorities: Essential Surgery, Third Edition. World Bank. 2015.
^†Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993): 569-624.