Constance S. Harrell Shreckengost, MD, PhD
General Surgery Resident and Global Surgery Research Fellow, Emory University
As a resident embarking on a "global surgery" research sabbatical in July 2020, I was disappointed by the travel ban that prevented me from traveling to Santa Cruz de la Sierra, Bolivia. I'd been excited to continue work on a trauma registry and educational initiatives started by previous residents in collaboration with the Clínica Foianini, other Bolivian hospitals, and the regional health department. However, travel wasn't safe for me or my Bolivian colleagues, and we had to change tracks quickly. Little did I know that hitting the brakes on my plans due to COVID would end up having a silver lining.
I thus Zoomed into the first few months of my research sabbatical, getting to know my Bolivian surgical colleagues remotely. I realized that some of the projects I'd anticipated were understandably no longer a priority for local health officials or surgeons. However, other priorities became apparent. I met passionate Bolivian educators and the pediatric surgical residents at Santa Cruz's main children's hospital, who were eager to develop virtual laparoscopic surgery courses to continue learning despite COVID's impact on surgical practice and traditional education. Through these virtual courses, I met surgeons and residents from a variety of Bolivian hospitals who shared their different experiences and broadened my understanding of their interests and needs.
Talking with my principal Bolivian mentor, Dr. Esteban Foianini, in fall 2020 when COVID hit the country hard, I learned about issues at his hospital regarding tracheostomies in COVID-19-positive individuals. Moonlighting in COVID ICUs in the US, I'd been aware of the concerns about aerosolization and tracheostomy delays. Finding the balance of optimizing patient care, ensuring provider safety, and maximizing scarce resources such as ventilators and oxygen has been a holy grail for this pandemic. Achieving this delicate balance becomes even more tenuous as resources get scarcer. Thus, we embarked on a study of both patient and provider outcomes after undergoing or performing tracheostomies during the pandemic. This effort blossomed into a multi-institute, multi-national study that became my biggest project for my first research year. I learned more about the pandemic's impact on healthcare not only in Bolivia and the US, but also Brazil, Spain, India, and elsewhere.
After I described a project to develop a low-cost digital pathology tool with colleagues at Emory and Georgia Tech, Dr. Foianini virtually introduced me to physicians at Santa Cruz's Oncologic Institute, the largest public cancer hospital in eastern Bolivia. While the pathologist at the Oncologic Institute was interested in the tool, she explained that the Institute had a much bigger problem—the hospital didn't have the capacity to perform immunohistochemistry. Given that this basic technique is so essential to cancer diagnostics, my Bolivian and US colleagues and I sought a path to build that capacity while simultaneously using the information obtained to better understand issues in Bolivian cancer care. These conversations led me to submit a Fogarty Global Health Fellowship application, now funded by the VECD Fogarty Consortium. Moreover, we established a new Fogarty site in Bolivia through this application, which I hope provides opportunities not just for US global health researchers, but for Bolivian researchers as well.
Before the pieces came together for this cancer pathology project, I was fortunate to make other virtual contacts. I had been awarded an associate fellowship with the safe surgery and anesthesia organization Lifebox for the 2020–2021 year, and in that position I attended weekly team meetings. I watched the organization grow, undertaking incredible projects such as their COVID-19-specific safe surgery checklist and Clean Cut programs championed not only by UCSF general surgery resident Dr. Nichole Starr, but also by numerous colleagues from the UK, Ethiopia, Liberia, Madagascar, India, and elsewhere. I learned a lot about global surgery at my computer instead of in the OR, listening to surgeons, anesthesiologists, and others from around the world instead of talking about my beliefs and my needs.
I’m extremely thankful that vaccines and other public health measures, in addition to my own privilege as a well-educated, white, and well-to-do surgeon-in-training from the US, have allowed me to come to Santa Cruz, Bolivia, where I am currently living and working. I have the chance to meet with healthcare workers and patients in person and to further develop the partnerships and collaborations that started virtually. Here, in person, the work that sometimes felt intangible from afar takes shape.
The COVID-19 pandemic continues its devastation worldwide, and that can never be a good thing; however, the pandemic forced me—and potentially others from the Global North working in “global surgery”—to reconsider priorities. Moreover, the shift to virtual communication not only lowers the financial barriers to being heard, but it also changes the dynamic. No longer is one person the wealthy traveler and another the local host. Instead, we become people who happen to be in different geographies talking about what matters to us, our patients, and our communities. The system is far from perfect, but it has nonetheless allowed me to grow in unexpected ways on this path in academic global surgery.
About the Author
Dr. Constance Harrell Shreckengost is a general surgery resident and global surgery research fellow at Emory University, where she also earned her MD and PhD in neuroscience. Dr. Harrell Shreckengost is currently on a research sabbatical after completing two years of clinical residency. She is based in Santa Cruz de la Sierra, Bolivia, as a VECD Fogarty Global Health Fellow, working on several global surgery and global surgical oncology research and quality improvement initiatives.