Behind the Knife-Global Surgery Series Episode 1-esv2-50p-bg-10p
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[00:00:00] All right. Welcome behind the Knife listeners. My name is Mike Mah. I'm really excited about this episode in this series. I'm a trauma surgeon, acute care surgeon in Charleston, South Carolina. I run the global surgery program here along with some amazing co-faculty, residents, students, and staff. I'm also a humanitarian surgeon and global surgeon.

I've traveled to about 60 countries of operate on five continents. Most recently in an active war zone with the un, WHO. This work is very, very exciting to me and is kinda just in my bones, and so I'm really excited that here behind the knife we are doing a. Global Surgery Series. This is the first episode.

We'll be doing about five or six episodes just talking about all things global surgery as it is a hot topic for this first episode. I'm really excited and I can't believe we landed my guest, Dr. Juan Carlos Pana. He is originally a Columbian and currently the O'Brien Chair of Global Surgery at RCSI, the Royal College of Surgeons Ireland.

He [00:01:00] leads the Royal College of Surgeons Ireland Institute of Global Surgery. He's also the director of Global Health and Surgery at uh, university of Pittsburgh, where he is still on faculty. He's the past president of the Pan-American Trauma Society. Number of the. National Academy of Sciences on Global Health.

He's got 165 peer reviewed publications, eight NIH funded grants, and just a living legend in the space. So I am so excited to have you both as a mentor and as my friend, if I can call you that and as a guest on this episode. So thank you so much for joining us. Thank you, Mike. Appreciate it. I'm delighted about the invitation and looking forward to have a.

Interesting and dynamic conversation with you. Thank you for your kind introduction as well. So let's get right into it. When I, I've given many talks on global surgery and I think when I just bring up that term, global surgery, I think people have very different definitions [00:02:00] of what that means and most.

Historical is people think that it means that we just travel to a country and do some operating and fly back and high five each other for all the amazing surgery that has been done. So I guess from your standpoint, how do you define global surgery in your own words? And I think it's also important to recognize that definition has changed as the field has evolved.

And so how do you feel that definition has changed? Yeah, I think the term global surgery. It's a term that we use because it's comfortable to say two simple words to refer to a major, major global health problem by large. And by that I mean when we say global surgery, what we really are talking about is the tremendous disparity that exists in the world between those places who have high resources and have access to surgical care.

And what happens. The [00:03:00] majority part of the world where surgical care is not part of the health services that one can't receive. And when you say global surgery to people who are not into medicine or surgery, they don't even know what that is. When you talk to a lawyer or when you talk to a CEO of a company, they think global surgery has to do with everything except the fact.

There are 5 billion people who have no access to surgery. The world global surgery actually is short. It is not the right term. We, the people dedicated to try to improve on this problem ought to come up with a better way of saying what we like to do is improve access to surgical care and comparative care in all parts of the world where there is low resource.

'cause the world Global health means a lot, and that is what [00:04:00] WHO and the United Nations have sort of used as a term to refer to everything that has to do with international health and the provision of care around the world. We think that simply changing global health for global surgery will signify that people understand what we're talking about.

Bottom line is that is not the case. 30% of the global burden of disease will require that some surgeon at some point do something for you. So when people don't get what global surgery means, just ask them. Imagine yourself needing an operation, not being able to get it. That's global surgery. I have struggled, even though I feel like I know, like in my, in my heart, what it is, I've struggled to define it, and I think that's the best way is if you need an operation.

And you can't get it. That's what this work is about. And it's interesting, you know, you say global surgery, but in, for [00:05:00] example, I have a partner in South Africa that I work with frequently, and he said here we just call it surgery. It's like, here we call it Thai food, but in Thailand they just call it food.

That that is another very important point. Global surgery was a term coined by the academicians who were writing about these tremendous problem. And when you talk to people who. Are in places where surgery is not readily available. They say, what are you talking about? Global surgery is a term. Created a little bit by complying with some of the academic definitions required from those who in the north felt that that was a term to refer to the problem with the fine before, but in the global south.

Global surgery does not mean what we were just talking about, right? Because that term doesn't exist for them. So that is absolutely true. Your, your buddy from South Africa [00:06:00] is very real and very truth about that problem. We have lots of listeners all around the world, but a good portion of our listeners are in high income countries, and so for surgeons or surgical trainees or medical students who are in high income countries.

High resourced countries, why should they care about global surgery? Well, I think that understanding that we're not alone in this world and that when we are confined by the four walls that surround us that we missed. Everything else that happens in these rich and very wide planet that we lived in and not being aware and not being knowledgeable of these crisis will give you the most narrow and obtuse vision of the great medical challenges in front of us.

Traveling is the best way of avoiding [00:07:00] racism and prejudism and everything else because then you realize that the world you live in is such a tiny little piece of the world we all lived in. Why is it important for a medical student or a resident to understand this? Because this is the only way that you have a broader vision of the practice of surgery.

This is the way that you will realize that. There are many ways of providing care in that, despite the fact that many surgeons in the world do not have all the resources that you and I have here in the United States or in Europe, people can provide very good care, very good quality. So to think that the only way we can provide the best care is only with the resources that are.

American medical system is able to provide is a terrible misunderstanding and it's a terrible mistake, and I think it lacks humility and it lacks awareness [00:08:00] that we can exercise good medicine and be more capable of using your own instincts to operate and make decisions without depending on the technology that we get so much.

We have gotten so much used to it today.

I was gonna say it's, it's interesting because I'm glad that we behind and I were having this conversation because it's so obvious to people who engage in the work. I think you and I are sitting here doing this interview trying to explain something that when people go and engage in this activity, whether you followed global surgery or humanitarian surgery, whatever it is, it becomes very obvious, especially in a world where.

We have increasingly become feeling like disconnected at my global surgery events, I had somebody comment. They said, I've never seen so many young people not on their phones, and it's because it's a very humanizing experience. I'll ask you, what first drew you to the [00:09:00] field of quote unquote global surgery, and are you able to share either a personal story or a patient story that has shaped your perspective in the work?

We all have a personal story. I think in my case, when I had the opportunity of leaving Columbia after finishing medical school and I was lucky enough to be offered a position to do basic science research at a major academic hospital in in Montreal, in Canada, I always felt that I wanted to go back to my home country and do something.

For the people that I grew up with, and then I realized that, that I wasn't going to go back to Columbia, that I did my fellowship, that I stay in the United States after being trained in Canada. I don't like the term giving back. I think that term is short of what we actually [00:10:00] do when we engage in improving access to surgical care.

A global health challenge, but in my personal case, it's that I always felt that I could do something more at any level from the place that I was born in. In my case, in Columbia, I saw. Over many years during medical school, great deal of suffering in many places where there was not enough resources, where there was not enough blood to take care of the trauma patients when there was not of surgeons to take care of a lot of injuries that were characteristics at those times.

Working with my classmates from Columbia, we began to create. Collaborations. We began to, to travel together, to share experiences, to learn from each other. And I think that's how it started because we both as trauma surgeons, the people in Columbia that I work with and myself [00:11:00] had things in common that would allow us to learn from each other.

It never started, oh, I wanna be a global surgeon. No, that came later. It was the fact that we were working together to solve problems and learning from each other that then allow us to create the training programs that we get funded for some of the research projects that we then ended up writing grants about it, but the basic need of collaborating and learning.

What actually gave the origin of me being here saying that I'm an expert in global surgery. I'm not expert. I just felt that at that time there was a tremendous need to do that sort of collaborative effort among friends, really among personal friends. That's how we started. A lot of, a lot of the things that you said there.

We had a journal club last week where we talked about re oa. You know, everybody loves to talk about re oa and the series that we reviewed had 19 cases over five years. And I remember [00:12:00] thinking, okay, who would be great at Lap Coley if we did only 19 in five years? But there are a group of surgeons in Cali that have, I saw a guy named Jose who is.

Phenomenal surgeon, phenomenal speaker at the Pan American Trauma Society, and he has extensive experience in the Rebo, and so his outcomes are actually much better than what is published in the literature. And so you then go, kind of going back to what you were saying about. You know, not just giving back.

I also hate that term, giving back. You learn so much from going to some of these places where people have experiences that you do not have. And so he's on stage teaching the rest of us about his experience with the rebo A and it's pretty amazing. Although even. I still would never use it here in the us but that's another, that's another, uh, another episode.

So we're behind the knife Is G giving back and getting it and getting back too? I mean, it should be a, it should be a 50 50 both ways that, uh, actually no, go ahead. No one [00:13:00] is giving everybody's receiving. Yeah. It actually kind of is a nice segue into. Another topic around the ethics of this work, and I feel this personally as someone who runs a, you know, fairly nascent global surgery program where we've done a lot of great things, but there does exist this tension between what I'll say, like what I need, and that may be my students, that might be my residents, that might be me as a, you know, assistant professor trying to make associate in the publication pressures.

There's what I need, right? Then there is what the population needs in the countries that we partner with. And so that could be what the surgeon there needs or what their students and trainees need or what their actual population needs in terms of patient care. And so there is this tension, right? My residents, they want to go and operate in another place and learn.

And so how do you think about navigating that tension responsibly? Both around research, around [00:14:00] education, around patient care. How do you think about that? It's an easy question. There are many ways to answer these, and perhaps one easy way to do it is to just give you a few examples. We just said between you and I that we are committed to.

Be part of this world where we are open, where we have no barriers for culture, and that we are willing to listen to everyone and learn from these experiences by doing so. And when you do that, you knowingly, you actually express and understand what may be the best way of collaborating. Collaboration is simply working together on a common goal That's as simple as it is for me, and when the [00:15:00] goal is very clearly delineated by that collaboration, it's actually no tension at all.

When the Royal College of Surgeons in 2000 and in Ireland in 2008 or 2009. Contemplated the possibility of collaborating with the College of Surgeons of Africa coa it. This interaction happened also at a personal level. The president of the college in Africa was this, uh, person originally from Armenia who grew up in Zambia, who was the president of the college, who actually was trained at the Royal College with Professor O Sullivan, who were classmates.

In the sixties when they were both being trained in surgery. 40 years later they meet and they say, let's collaborate again, a personal connection, a true and genuine [00:16:00] interest on helping each other and understanding where the needs were and when The Royal College of Surgeons in Ireland proposed a set of ideas.

To the members of the College of African Surgeons, the solutions and the implementation of what to do next came out of that conversation. What is it that you need and how we have a common goal, and I like to bring this example as a perfect collaboration because when you do that, there is no such attention at that time.

The African college surgeons wanted to improve the way they will examine and certify their graduates. And I said, let me show you what we do in Ireland. You look at it, modify to your needs and we'll help you implement. So it was not [00:17:00] a, this is the will be the Irish do it. Therefore you need to do it the same way.

This is how we do it. Let's work together and figure out a way how. What we do here can be modified and adapted to what you need. And that's how the Irish surgeons began to participate in the exams. And guess what? The African surgeons came to Dublin and they actually participated in the exams. They were examining graduates from the Royal College here as they were examining them in some of the countries in Africa.

And that evolved. Until another need search. Oh, let's now do the log book. Okay, now let's do the administration part of the college. Let's now see how we do the accounting. Let's make sure how we do the postgraduate education. Every need gave this origin to a new collaboration where there was this very specific effort and understanding what the needs were and how those needs can be.[00:18:00]

Responded to in a collaborative fashion. So for the listeners, I will highlight that if they're not aware, they should look up the relationship that exists between the Royal College of Surgeons, Ireland, and koa, the College of Surgeons of East Central and Southern Africa. It was actually highlighted at the American College Surgeons last year.

I think the keynote lecture was a Tale of Two Colleges, but it's such a beautiful connection between these two organizations. In my program, I stress to my trainees the importance of relationship building. It's a lesson that I learned in business. I say businesses don't do business with businesses.

People do business with people. The example that you gave really struck home to me, the two medical school classmates. There's a lot of trust there. When you cross over borders, geographies, cultures, languages, every interaction becomes that much more, having a potential to go sideways. And so if you have that trust initially.[00:19:00]

It's really important, and I think that's what you know, at least with my South African partner, Hugo Stark. We sat down at the very beginning, three years ago and said, Hey, what, how will you benefit from this? How will I benefit from this? And how can we work to a common vision? I think that is a micro example of what RCSI and COSSA have done.

Switching gears a little bit, I will ask you globally. Countries and nations are turning more inward, we're becoming more insular. I mean, the prime example of this is like the complete gutting of U-S-A-I-D. What concerns do you have? Do you have major concerns or what concerns do you have in terms of how this is gonna impact global surgery, do you think will have a negative impact?

And is there, is there a way that we, in the well-resourced world. Can mitigate that impact and still help improve access to care for vulnerable populations at home and abroad? To be honest with you, only until the appointment of Atul [00:20:00] Gawande as head of the U-S-A-I-D International program, uh, I don't think that before that time, U-S-A-I-D was that must invested in helping global surgery as the way we define it at the beginning.

When we saw all the cuts that U-S-A-I-D was suffering through, we call our partners in Africa and other places, is this going to affect you? And they said no, because we never depended on U-S-A-I-D in the first place. When you look at some of the places that I visited in the last few months in Mozambique, for example, we went to a hospital with every box.

The hospital was labeled, donated by U-S-A-I-D. Every box, meaning all the antibiotics, all the IV fluids, a bunch of nutritional supplements, all the vaccines, every little car, cardboard box that was sitting in [00:21:00] the warehouses of the hospital, if not all of them, 80% of them were labeled U-S-A-I-D. So even though.

Training programs or surgical services provision programs were not funded or dependent on U-S-A-I-D, the hospitals in which these surgeons work became in a much vulnerable position after all these cuts to place. There is no question that the impact in that paper that was written in the New Yorker. UL Gowane who says people will die.

It's a paper that everybody needs to read because people are dying, not will die. People are dying today because of what is happening. Clearly suspending U-S-A-I-D aid overnight in a way that these current [00:22:00] administration has done was not the right way of doing it. I think that many places, many nations have all of the sudden realized that they can no longer depend on these A programs.

I think it's a very high price to pay because a lot of people will die. But at the same time, those countries who have the capability of begun to looking beyond these and say, okay, we no longer have these eight. What are we going to do? To help ourselves doing that. So I guess what I'm trying to say is that aid was needed.

Aid had a tremendous value. Aid was cut in a way that should not have been cut aid should not be the only way that help care systems need to be developed. And this is going to force everyone, people in the south and people [00:23:00] in the north. Dedicated to this challenge to identify new ways of financing, new ways of moving forward, and learn not to depend on these eight because I don't think this is gonna change right away.

I don't think that we're gonna go back to the way things were. It's hard to tell what's gonna happen in the next 3, 4, 8 years, but whatever happens, I think, uh, it will be a new order of how we deal with these problems. So kind of, I'm starting to wrap up here, as you said, the new order or how things are panning themselves out over the next eight to 10 years.

As you look into the horizon of, again, what we're calling global surgery, what do you find to be the most exciting and what do you find to be the most scary in this? In this field, the, the most exciting thing is that we are going to have great deal of innovation. Because of the changes [00:24:00] we just referred to in our previous conversation, and the innovation has to be on everything.

Innovation on financing, innovation on training, not just innovation on medical devices or frugal innovations for providing solutions that are low cost. All that we're now forced to accelerate. I think people like you and every young surgeon who wants to be dedicated to improving access to surgical care and, and poor regions of the world, IE global surgery, need to think outside the box.

What do I need to do to accelerate? How do we do that? I don't know the answer to that. I can give you an example just to to finish, but I'm tremendously excited. We are collaborating with an NGO in Mozambique that is called the Gorongoza Restoration Project. This is an American billionaire who created a foundation that restore the park, [00:25:00] and this park is now back to what it used to be before the Civil War wasn't big.

All the animals are back. It is the greatest return of a conservation project ever done in Africa. And now he wants to develop a health system that is supported by the economical growth of the region. Why can't we do this in every park? Why can't we do this in every, uh, why cannot we find ways of developing the economical.

Infrastructure of the region while we help the health system, maybe we ought to all go back to school and do an MBA, but maybe we ought to simply partner with people who can help us do both at the same time. You're speaking my language As somebody who paused medical school for three years and did business consulting, you are taking the words outta my mouth, so, so I wanna just thank you so much again, Dr.

Pana. I know you have an incredibly busy schedule as I tried to get you scheduled for this interview, so appreciate your time. The [00:26:00] incredible discussion, how you defined global surgery for the audience and gave great. Context and numerous efforts going on around the world today. For the listeners, if you guys enjoyed this episode, be sure to keep an eye out for Future Behind the Knife Global Surgery Series.

Episodes that are coming soon. We are exploring various topics like surgery and active conflict zones, ethics around global surgery research. If you are interested in more topics or have suggestions, reach out to me or behind the knife. You can contact us at hello@behindtheknife.org or on X. There's also gonna be some show notes that you can find contact information for Dr.

Pana and myself. Um, that concludes this episode. We, we hope you're much more familiar with how the field of global surgery has grown so rapidly over the years and has become so influential. We appreciate you listening, and until next time, dominate the day. Okay.