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Global Surgery Perspective: The Long and Winding Road That Leads to Global Surgery

Youmna Sherif

Each person chooses global surgery for his or her own reasons. Each person comes to global surgery through his or her own unique path. My story isn’t really mine, it is my mother’s. My mom was from a small town in the Egyptian countryside where she lived in a three-story, pink concrete building along the Nile. Growing up she took every opportunity to go fishing with her uncle, and she often snuck out of her home to go to school. I don’t know much else about her childhood because she found it difficult to discuss. Even these bits of information I gleaned from eavesdropping on her late-night conversations with her younger sister in Egypt.

I do know, however, that her childhood drove her to provide me with the opportunities she didn’t have. She encouraged me to pursue higher education, explore the world, and live a life of service. Unfortunately, she passed away three days before my college graduation, one year before my whitecoat ceremony, and five years before my match day.

She died from a metastatic hepatocellular carcinoma, the sequelae of a hepatitis C infection. At the time I didn’t really understand the meaning of her disease, let alone that it was rooted in deep inequities related to socioeconomic and structural factors. In fact, I only began to understand the story of her death in my first year of medical school during our microbiology block.

I was flipping through the parasite section of a textbook drawing picture mnemonics in the margins when I eventually landed on Schistosoma. Schistosomiasis is a parasitic infection that tends to be particularly prevalent in resource-limited countries lacking the infrastructure for proper water sanitation. I lingered on this pathogen because there was a stated history intimately relating Egypt to the disease.1 Thirty percent of the Egyptian population was infected with Schistosoma in the 1960s and, in response, the Egyptian government pursued a nation-wide vaccination campaign in an attempt to treat schistosomiasis. Unfortunately, these vaccines did not provide much clinical benefit. Moreover, it was later discovered that individuals who received the anti-Schistosomal therapy were at a much higher risk of being infected with hepatitis C, as proper needle sterilization techniques were not practiced.2

I read this history and remembered the scar on my mom’s left arm, the one she got from her vaccinations in Egypt. I read this after the height of the Egyptian revolution where the weary but resilient citizens of Egypt took to the streets protesting miserable economic conditions and the consistent political devaluation of the Egyptian body. I read this when the Egyptian body continued to be leveraged as political candidates platformed on facilitating a solution to the hepatitis C epidemic in Egypt. The contraction of hepatitis C in Egypt, its sequela, and the disparity in access to quality care could only be explained as a direct product of Egypt’s larger political, social, and economic situation. My mother’s death felt like an unintended consequence of a struggling health care system.

My parents, Kariman and Ashraf Sherif. The first photo was taken shortly after their engagement. The second was taken one year before my mother passed away.

This realization bred questions: How did such high-risk practices go on for so long? Why were politicians allowed to use this epidemic for political gain when these individuals likely contracted the illness due to governmental interventions? Could her death have been prevented? The more I sat with the information, the more information I needed.

So, the summer after my first year of medical school, I traveled to Egypt to study the biopolitics of hepatitis C in Egypt. I found an appropriate community partner, I obtained IRB approval in the U.S. and Egypt, and I partnered with an anthropologist who worked in the region.

My global surgery experience in Egypt (July 2019). Part of the experience included assisting in the opening of a minor procedure room.

After paying homage to the revolution in Tahrir Square, I made my way to the public hospital where our community partner was based. There, I spent a month interviewing patients in the hepatology wing of the internal medicine building. It was through my conversations with these patients that I realized, in a sea of hurt and feelings of loss, that I was hoping to unload some of my grief by finding a community that shared my pain. I didn’t find relief. Rather, I found an absence of medical resources, infrastructure, and capacity. I found that I had no skills to assist the population, no power to affect change, and no knowledge to share. I had simply opened a wound the Egyptian people had long learned how to manage. I realized then that if I was going to participate in any form of global clinical care or research, I had to take a more nuanced approach. One that tailored to community needs, the region’s history, and the existent medical capacity. That month spent in Egypt made me realize that global health interventions required methodical, thoughtful, community-centered, well-researched, and infrastructure-based approaches.

I progressed through medical school, gaining knowledge, experience, and clinical skills. I eventually found my passion in surgery. I was then fortunate enough to match into a global surgery track after medical school, where I delved into global surgery literature and sought mentorship from surgeons who were experts in the field. I developed an interest in capacity building, task shifting, bioethics, and global surgery education. In July 2019 I started the first of two global surgery fellowship years. I began in a town in the Egyptian countryside. The country had changed. A new government was in place, a large percentage of hepatitis C-infected Egyptians were now receiving treatment, and the epidemic was slowly coming to an end. I had changed. This time I stepped on Egyptian sand as part of a team intended to build surgical infrastructure.

I spent my first of two global surgery fellowship years attempting to accomplish specific goals to correct my previous approach to global medicine. I dedicated my time to (1) gaining the technical skills to competently operate in resource-limited settings through rotations with the Baylor orthopaedics, urology, anesthesia, and emergency department; (2) educating myself on the ethics of trainees engaging in global surgery efforts; and (3) working toward developing global surgery efforts that are focused primarily on capacity building and development of local workforces.

I was able to travel to Uganda, the Philippines, Prague, and Poland to learn from experts in the field and gain an understanding of what meaningful, sustainable global surgery efforts look like. I was fortunate enough to have wonderful mentors provide guidance and advice on developing an ethical, conscientious practice as an academic global surgeon.

I write this on the last day of my first of two global surgery years. As I return to my responsibilities as a general surgery resident, I am especially thankful for being part of a surgical program that has afforded me the opportunity to pursue my passions. Opportunities my mother only dreamed of for me. With time and experience I’ve realized anything meaningful I strive to do is a direct product of the values she instilled in me, the behaviors she encouraged, and the attitudes she fostered. Everything I have done and everything I will do will always be for her.

References

  1. World Health Organization. International Strategies for Tropical Disease Treatments Experiences with Praziquantel. Edna McConnell Clark Foundation, 1998.
  2. Frank C, Mohamed MK, Strickland GT, Lavanchy D, Arthur RR, Magder LS, Khoby T, Abdel-Wahab Y, Aly Ohn ES, Anwar W, Sallam W. The Role of Parenteral Antischistosomal Therapy in the Spread of Hepatitis C Virus in Egypt. Lancet. March 11, 2000;355(9207):887-891.

About the Author

Youmna Sherif is a resident in the global surgery track at the Baylor College of Medicine. Her interests include global surgery education, ethics of global surgery, surgical capacity building, and surgical infrastructure. In pursuit of these interests, she has engaged in global surgery work in Egypt, Malawi, Turkey, and Uganda. She has worked with community partners in these nations and performed research on the structure of global surgery education in high-income countries, the professional development of non-physician clinicians in Sub-Saharan Africa, global surgery scale-up models, the use of guidelines and surgical standards in low-middle income countries, humanism in medicine, and Islamic bioethics as it relates to care of the female. She is also a member of the Gold Humanism Society and the Texas Children’s Clinical Ethics Committee.