American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Making Health More Equitable Across the Globe

Kevin Blair, MDIn 2019, Dr. Madhukar Pai wrote, “Global health is still struggling to shed its colonial past. This is reflected in who drives the research agenda, who dominates the authorship, and who edits the research.”1 I have been reflecting on this recently, and how I can approach global surgery work in a better, more equitable way. It has been encouraging to see many fellow researchers confronting the topic in recent years.2-5 It is one thing, though, to critique global health research; it’s another for me (us) to actually put those critiques into practice. Through this post, I want to share what it looks like to work through the topic of global health equity as a research resident.

I am a PGY-4 General Surgery resident at University of California Los Angeles (UCLA) in my second year of research time. I have two funded global surgery projects. In Colombia, my work is funded through UCLA’s South American Program in HIV Prevention Research (SAPHIR), and we are working to introduce Colombia’s first high-resolution anoscopy program as a part of an anal cancer screening protocol. My other project in El Salvador focuses on risk factors for violent injury in low- and middle-income countries (LMICs) and the implementation of a hospital-based violence intervention program (HVIP). Our work in El Salvador has been particularly relevant to the topic of striving for equitable partnerships in global health.

My first trip to El Salvador was in 2010 as a volunteer with an organization working with former juvenile gang members. I made lasting connections and have since been back more than ten times. As I prepared for my research years, I learned a non-governmental organization (NGO) in El Salvador with which I already had a connection had begun implementing an HVIP. Given my mentors’ (Dr. Rochelle Dicker and Dr. Catherine Juillard) experience with HVIPs and my interest in violence prevention, we began developing a project in partnership with that NGO to further develop the first HVIP in Latin America.

In designing the project, I made a mistake common in global health work: I let my own ideas drive the early planning process, rather than learning from and designing the project based on the needs and interests of the Salvadoran stakeholders. This could have been avoided (at least in part) if I had waited to write our proposal until I moved to El Salvador; however, the process of preparing for research time and applying for grants often forces us to develop plans before we are on the ground. In contrast, my project through SAPHIR allowed me to wait to develop our project proposal until after I had arrived in Colombia, which made it easier to learn the priorities of our colleagues and write a protocol accordingly.

Kevin with his co-resident, Dennis Zheng, at ACS Clinical Congress in 2019

Once I moved to El Salvador (I split time between El Salvador and Colombia), I quickly recognized I had made some incorrect assumptions about the priorities and interests of my research partners. This was a wakeup call for me to spend some time (a few months, actually) observing, learning, and asking questions before re-initiating the planning conversations. I have heard a number of well-respected global health experts say it can take years before we (from high-income countries) understand the cultural, political, societal, and healthcare norms in a given LMIC well enough to make recommendations about changing a system or program; it is essential for us to approach our global surgery projects with this understanding.

Kevin with one of his mentors, Dr. Rochelle Dicker, at ACS Clinical Congress in 2019After taking a step back and re-examining my goals alongside those of my local collaborators, we developed an interesting project in which we will examine their HVIP through an implementation science framework, with the hypothesis that the HVIP framework we use in the US cannot work in a LMIC setting without adaptations. Developing this proposal took time, and I had to submit a mid-year update to the grant committee stating the project was still in the development phase. It can be scary and feel unproductive to spend so much of our precious research time planning and engaging stakeholders, but with global health projects it is imperative and well worth the time spent.

As we finalized our plan, another important question came up: How will the local stakeholders benefit from the results of this project? In the case the project in El Salvador, the hope is to further strengthen the HVIP program, with the larger aim of reducing violent injury and death in El Salvador. I truly believe in this goal, but I also recognize I have personal motivations to publish, to report progress to the grant committee, and to establish a reputation in the violence prevention world. As trainees, these career-oriented desires are not inherently bad, but we must recognize when they begin to overshadow the benefits of the project as they relate to the LMIC stakeholders.

Kevin on a waterfall hike in El Salvador with one of his Salvadoran colleagues and friends, Wilfredo GonzalezIn thinking about research impact, authorship,6 journal choice,7 and target audience8 are also key considerations. I love how Dr. Seye Abimbola discusses this in his BMJ Global Health article.8 Many of our colleagues in LMICs speak English as a second or third language, or don’t speak English at all. In El Salvador, none of the local NGO employees speak English fluently, nor do the HVIP interventionists who are the ones implementing the program. As with many of you, I hope to eventually publish in a well-known journal, but that is likely not the best way to disseminate the findings to those to whom the research pertains. I am exploring alternative options, such as publishing a summary in Spanish in a non-peer reviewed local paper, or publishing in a journal that allows a second abstract in Spanish.

Unfortunately, this particular project in El Salvador is on hold because of COVID-19, but the lessons hold true, nonetheless. I, like many of you, am eager to continue learning how to approach global surgery research in a more equitable way. I have made mistakes, but I have some fantastic mentors who have helped educate me along the way. There is so much potential in global health partnerships. I encourage anyone taking the time to read this to make note of my references; they do a much better job of discussing the nuances of global health work and can serve as discussion starters for you and your colleagues.

References

  1. Pai M. Global Health Research Needs More Than A Makeover. Forbes. www.forbes.com/sites/madhukarpai/2019/11/10/global-health-research-needs-more-than-a-makeover/#50297fb57e34. Published 2019. Accessed September 17, 2020.
  2. Crane JT. Unequal ‘Partners’. AIDS, Academia, and the Rise of Global Health. Behemoth. 2010;3(3).
  3. Jumbam DT. How (not) to write about global health. BMJ Glob Health. 2020;5(7).
  4. Scheiner A, Rickard JL, Nwomeh B, et al. Global Surgery Pro–Con Debate: A Pathway to Bilateral Academic Success or the Bold New Face of Colonialism? Journal of Surgical Research. 2020;252:272-280.
  5. Crane JT. Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science. Ithaca, United States: Cornell University Press; 2013.
  6. Iyer AR. Authorship trends in The Lancet Global Health. The Lancet Global Health. 2018;6(2).
  7. Nafade V, Sen P, Pai M. Global health journals need to address equity, diversity and inclusion. BMJ Global Health. 2019;4(5).
  8. Abimbola S. The foreign gaze: authorship in academic global health. BMJ Global Health. 2019;4(5).

    Kevin Blair, MD, is a PGY-4 general surgery resident at University of California Los Angeles (UCLA) and an MSc Candidate at the London School of Hygiene and Tropical Medicine. Follow him on twitter @KJBlairMD.