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Speaker: [00:00:00] Welcome, Behind the Knife listeners. My name is Mike Malla, and I'm your host for this Global Surgery Series episode of Behind the Knife. I'm a trauma surgeon and acute care surgeon here in Charleston, South Carolina, and I also do a lot of humanitarian and global surgery work with the program that I run.

If you missed the first episode, head on over to Behind the Knife website or app and search for "A Practical Approach to Understanding Global Surgery." It's a great primer. In this episode, we will explore the real-world complexity of global surgery partnerships between high-income institutions and partners in the Global South.

We move beyond broad language about equity and bidirectionality to examine what these partnerships actually look like on the ground. We focus on three major themes. First, how global surgery partnerships can create real educational, clinical, and professional value for both sides. Second, how power imbalances around money, mobility, research, publication [00:01:00] access can make these partnerships unequal even when the intent is good.

And lastly, how we can approach global surgery more responsibly by centering local needs, avoiding exploitation, and remembering that the ultimate goal is better surgical care for patients. It's really important to note the subject is too large to cover in a single episode, and while I tried to be thoughtful about our guest choice, I fully acknowledge that there are many voices not represented in this podcast.

This is not intended to be a holistic conversation, but rather a spark to a much larger and much-needed conversation. With that, allow me to introduce my two guests. First, we have Dr. Hugo Stark. He is the chair of surgery at George Hospital, a hospital in the Western Cape in George, South Africa. He is also head of surgical services for the entire catchment area of the Central Karoo region, and he did his undergraduate and graduate [00:02:00]

Speaker 2: medical training at the University of Stellenbosch.

Welcome, Dr. Stark.

Speaker 3: Thank you. I appreciate it, Mike.

Speaker: We also have Dr. Sydney Bertram. She is a general surgery resident at Emory, and despite being early in her career, has already spent time in Togo, West Africa, as well as George, South Africa, working with Dr. Stark. She has published several papers and won numerous global health awards.

She's also on the Trainee Advisory Council for the Consortium of Universities for Global Health. Welcome, Dr. Bertram.

Speaker 2: Happy to be a part of this

Speaker: I want to briefly frame this conversation. In full disclosure, Dr. Stark and I have known each other for several years through our global surgery partnership. That relationship is part of why this conversation is even possible. These topics require a lot of trust because we're talking about power, inequity, money, opportunity, and the uncomfortable realities that exist even in well-intentioned relationships and partnerships.[00:03:00]

What prompted this episode was a conversation I was part of with Dr. Stark and others about opportunities and cross-Atlantic collaboration. That conversation became a little heated, and it became clear to me that there's often a gap between the language we use in global surgery and the reality on the ground.

We use words like equity, bidirectionality, partnership, decolon- decolonialization. Um, those words are important, but they often become, uh, abstract. The harder question is, what do we actually mean when one institution controls the funding, one side has more mobility, one side has easier access to publication and academic recognition, but yet both sides are still trying to pursue and build something meaningful together?

So I want to start with the benefit before we get into the tension. For each of you, how have you personally or professionally benefited [00:04:00] from the global surgery work and specifically these kinds of partnerships?

Speaker 2: I've benefited hugely as a student and as a trainee from the specific partnership between where I went to medical school in Charleston and George in South Africa.

And then once I got abroad, it was six weeks of a fourth-year medical student rotation that I did with Dr. Stark. There's a lot of opportunities that most medical students simply don't get. Mainly the opportunity to work with one attending for a long period of time under almost an apprenticeship model.

But getting the chance to learn from one surgeon's experience and understand his perspective on taking care of patients, both from a general surgical sense and from more of the global health perspective where we did outreach, went out to a variety of different hospitals throughout the region, was formative coming into intern year and my confidence and my ability to work effectively on the wards and in the operating room, as well as in my perspective of how I wanna approach global health in the future.

Speaker 3: Obviously, there are multiple [00:05:00] components to look at here, and I will start with just the engagement with someone from different country. Every opportunity that I think we get as human beings to engage with people who come from a space that is not the same has the potential to teach you something. The other aspect is realizing that how healthcare looks might be different across the Atlantic or in different places.

But ultimately, in that context, we're all trying to achieve the same thing. Our tool sets are smaller or bigger, but we are trying to accomplish the same thing. And then from a practical perspective, to have willing hands who want to be trained and taught and see and develop the skills that will also be useful when they go back to where they come from Those willing hands in a resource-limited environment becomes valuable hands, not just willing.

They become extremely valuable because the premise for them to come here is to learn. And when you can capitalize on the energy of [00:06:00] people learning, it gives you that space to breathe a little bit more because suddenly there's someone who can help, who wants to help that's being blessed. Surgical blessing right there.

Speaker: So it's really heartwarming to hear that both of you have experienced both personal and professional benefit from the partnership. But I do want to delve into the challenge and the problem. And some of our listeners may have not had the opportunity to engage in global health or global surgery, and so I do want you all to take the moment to define what are those inequities in the dynamic of the partnership, and if you could touch on some of the historical roots in where those inequities exist.

Speaker 3: I think one of the important things with regards to a South African context, and it's just important that I voice my opinion. I'm talking as a South African surgeon working in a South African context, being part of a country with a history, a history that has led people to question humanity in a big way.

And over the [00:07:00] last 30 years have brought a different understanding and a different hope as we try and repair and continuously try to repair. But one of the things that has been difficult to repair has been health equity. It has been difficult. Even though it might seem like it's easier for people to access care, it's still really difficult given the anatomy of our country.

In South Africa, those rural spaces are very far away from healthcare. And so that inequity has been a big part of the drive of what we've done at our unit is to try and address that by saying, "I'm going to be sensitive to the fact that you are going through a lot of discomfort to come to me as a specialist.

So what I can do is this, let me come to you because my discomfort does not even remotely come close to what you have to deal with." And so even though the inequity of access Still exists. There are platforms on which we are trying to address it because we are aware of it. And unfortunately, money will always [00:08:00] have an unfair advantage in the equations of health.

Having money offers the opportunity to have access to a different type of care. It's just there is a different access which makes it sometimes seem unfair that a waiting list for MRI scans in my environment is one and a half years for an elective MRI, whereas that is not the case where if you have private insurance.

So there's this constant awareness that the inequities exist, but then there are real platforms on which we are trying to address it.

Speaker 2: Yeah, for me as someone from the US, the roots of inequity and global health partnerships, the history runs deep in the-- in Africa and South America. It's like 600 years' worth of history that we'd have to cover to talk about why global health inequity exists.

The root of most of this is in the fact that at one point and still now, part of the world decided to dominate the rest of the world, and that was an extractive process, and most resources for wealth building and building a more stable society were removed from a lot of [00:09:00] countries across Africa and South America and the Global South.

So there's a long history of extraction, and I think it's something that we're trying not to repeat as global surgery comes into vogue. We have a little bit of an advantage. I think we have a little bit more knowledge, hopefully, among the wider acad-academia to consider how to not be so extractive as we build global surgery into a bigger field.

Speaker: You both sparked a lot of thoughts and reactions. I don't mean this to be per-provocative. I myself am a high-income country. I was not a colonizer personally. I don't have a personal history of slave ownership or resource extraction. Yet I sit in a academic medical center that's reasonably well-funded compared to a lot of centers in the Global South.

What is my responsibility? I have agendas and I have students and residents that want to go to places, and I have administrators that want me to do certain things. [00:10:00] But when I compare that to Dr. Stark's context, what is my responsibility now walking that line as a surgeon in the high-income context?

Speaker 3: I think your voice Just by default carries weight.

And so the ability to acknowledge that there are discrepancies actually goes against the grain of being a person in a profession that has a humanitarian undertone. It's there. We wanna help people. I think what gets interesting is when we decide to selectively help people, and what happens is the global surgery echoes are, "We must help everyone.

Look at those poor people who don't have access to care." And so if it has been given such a voice, then do I dare say that we become hypocritical when we say things but we don't do things after we've said [00:11:00] them? Because then it becomes just noise,

Speaker: surgical noise. My question is, why does my voice have a weight?

Speaker 2: Your voice has money behind it, right? I know because I've watched. It's not easy to get global health funding in the US right now, both from a governmental standpoint and from a institutional standpoint, especially those of us who are operating on state budgets that are less friendly towards international initiatives.

But your voice still has money behind it. Your voice has access to money, whether that's grant funding or federal funding or state funding. The things that you say you would like to do, you have a way of getting the funding to do them. Someone in another place could want to do those same things and have all the same great ideas, um, and have no access to talk to someone that could get them money or to apply for money, and I think that's a root of inequities that we see in general.

The majority of world wealth is amassed in just a few hands, and it has been for a long time, and [00:12:00] most global health funding hasn't changed much. The money is still in the same hands. We've changed our paradigm, or at least we like to think we have, but the money is still in the same hands, and so there's certainly still a lot of control in the hands of people with money.

Speaker 3: Sorry, I just-- There's one thing that maybe is-- I wanna add to what Sydney has said about the money. Currency and what it allows people to do changes the way that you can see your potential and your impact. So the fact that you are able to travel means you can go and explore places where you have an interest, but once you phrase that afterwards, you have a better voice to phrase this because you have had access to different voices, whereas those different voices can't come to you necessarily or go actually and visit each other on the same planet like Africa.

It's almost why is it that other people are worried about surgery in Africa? And because they're able to get here, and they're able to see the problems and then go back to where they come from, [00:13:00] and dare I say, a position of comfort, and then it becomes a conversation about other poor places where they just don't have this.

And so your voice is very different than mine. The problem with me as a white South African is I don't necessarily represent the current medium of South Africa. So that changes already my voice. Even in amongst our own people, as a white person, my voice doesn't sound the same and might represent something that has already had a bad history.

It's not difficult to understand why your voice is heavier than mine. But I think the problem is when people don't understand the responsibility that comes with having a heavy voice.

Speaker: I believe creating this podcast and trying to amplify voices is at least what I'm doing with that, and I know that Sydney feels the same way.

For the listeners who are hearing this podcast, Dr. Stark, as he mentioned, is a white South African but has chosen to work in the government sector in [00:14:00] treating a lot of folks who otherwise wouldn't have access. And so for that, I think humanity owes you a debt of gratitude. It feels to me because I am in a position of privilege where the funding is coming from my center, my center is setting the agenda.

We are setting the agenda, we're setting the priorities, we're choosing the partners, and we are in control. Are we really being respectful of those voices? Are we being mindful of the other partners' agenda because we control the money? I

Speaker 2: think the other half of colonization and decolonization when used in the context of global health and global surgery is extraction.

The control is for the purpose of extraction and of wealth and resources and making the colonizing organization or country stronger and more powerful. And so I think part of it that goes into is are high-income institutions and high-income countries benefiting more from global health partnerships than their partners in low- and middle-income [00:15:00] countries?

Speaker: This is true. Very recently when I was conducting an international site visit with one of our neurosurgeons, we were discussing potential partnership, and one of the Global South surgeons looked us in the face and said, "Hey, you can send your people here. They can operate, they can do research, they can publish, and we can't even access those same journals that you're publishing in, and we can't come and operate with you in your context."

Both myself and my friend, we felt completely naked and exposed 'cause it's true. We do get extraction of opportunity that we cannot reciprocate. In fairness to our context, there are legals and credentialing challenges that we are trying to overcome, and people are working on this. But in the current state, it's not equal.

Do you all see opportunities to continue to push towards true equality?

Speaker 3: So first and foremost, if there's an initiative from a [00:16:00] high-income country to invest in some partnership, some experience that would enrich the high-income individuals who arrive, I think there's a strange stubbornness in low-income countries before they will receive support.

And when someone wants to invest in our space to help us, to say, "Yeah, but what's in it? What's gonna be in it in both directions?" I think that defies the purpose of where healthcare makes the biggest impact, and that's where people require assistance. I might get criticisms for that, but we are always on the receiving end of having to manage resources that if someone willingly says, "Let's go and invest there," there's gonna be benefit for us.

I would be naive to think that you can do a singular direction benefit, and that would purely be the low-income country's benefit. That's naive. [00:17:00]

Speaker 2: My question for you, Dr. Stark, when I was there as a medical student with you, very busy surgical service at George Hospital. It was me, there were two German medical students, and also two South African medical students, and I was there hopefully with the goal of supplying my skills and being helpful, and also mainly as a student, of course, learning.

But did me coming and benefiting from your excellent teaching take away from the human resource building of your South African medical students? When we have people from multiple countries, high income and low income at the same level working together, for example, when a medical student from the US comes abroad and works with medical students from their home country, how do we decrease the risk of taking away from their learning experiences?

Speaker 3: So if you are a learner, that title is international. There's no, "Oh, you're an American learner. [00:18:00] Oh, that is just far more superior than an African learner." No, you're a learner. And so there's no, "Oh, we're only selecting out the really important learners because they are bringing potential capital to our unit."

That's nonsense. So if you are a learner and there's a space to be taught in, you make sure you get into that space. Now, that experience isn't necessarily the same for everyone, but the opportunity is exactly the same. So I will not steal from the one to pay the other one. That's not the point. You're a learner, and I'm a teacher, and if you're close enough, I will try my best to teach.

Speaker: Sydney, how would you guide us about ethically approaching global surgery as a trainee, and how do you avoid medical voluntourism?

Speaker 2: It's hard, and this is something that I spend a lot of time thinking about and carefully choosing what I'm doing, where I'm going, who I'm doing it with. I definitely do a lot of research before I go [00:19:00] anywhere or do anything abroad 'cause I wanna make sure I'm doing it responsibly and in a way that feels like it's building a system up instead of just doing work and then leaving with no lasting effect.

I think there's a lot of organizations out there, most of which are trying to do the right thing and ethically send students abroad and take students from abroad for clinical learning. For me, the principles that I abide by are, one, is there a lasting partnership with the community and the local community that works where I'm going with the organization that I'm going with?

But for me, it's important to go with a group that wants to help humanity, wants to work in places that truly need it, and is more about doing the work than being seen for doing the work. And you can actually tell that about an organization, I think, pretty well based on, A, the work that they're doing, and B, how they talk about the work that they're doing.

Speaker: Really, really great answer. So what unites us as surgeons from China to the United States to South Africa to Russia and everywhere in between, it, it is ultimately all about you and the patient on the [00:20:00] table. So why is this conversation important for my patient or our patients?

Speaker 3: I'll throw a spanner in the works there in the way that you phrased it, Mike, for the patient on the table.

So over the years, I've had to obviously appreciate that There's an understanding that doing surgery means whatever you do in the OR. Being a surgeon does not just mean that. The big part of my approach to surgery is this: yes, I can work in my regional hospital, but some of the best surgical work I can do is to expand my surgical footprint in the decision-making about surgery.

And so I think that's where a lot of people are falling short. They're not getting access to surgical decision-making. I'm not too fussed about highlighting the surgical OR component, even though that's sometimes the most exciting part. Sure, I get that. But to make [00:21:00] sure that there isn't significant delays in just getting to the decision about surgical care, and then trying to prioritize where the care is necessary or not.

I sometimes think we just bulldoze in because it's about surgery. Get the patient on the table. Next one on the table. I don't subscribe to that. And so I think a lot of the problems that we have in the low-income countries is giving people in front of us access to surgical decision-making that will lead to or not to an intervention that's in the OR, the sexy part of it.

But the point is that before I get to the knife, behind that knife was a long decision and a clear, informed conversation about surgical care, and I value that as much as what's gonna happen on the table.

Speaker 2: You graciously introduced me as a resident, Dr. Mahla, but I am in fact a rising PGY2. And that's what this year has been all about, is about learning how to make decisions in surgical care.

It's a treat if I get to the OR, and I love getting to the OR, but there's so much to learn about surgical decision-making. And I think it could be a whole other [00:22:00] can of worms to talk about decolonization of surgical training, who is taught how to make surgical decisions, and which patients have access to those people before we even get to the table.

Speaker: Yeah, I heard a quote very recently that hit me like a ton of bricks, that trauma is a political disease. Who gets shot? Who is close and not close to a hospital? And where are those decisions being made? But as surgeons trying to take care of patients, those decisions matter, and all of that is the context swirling around the operating room above you, your patient, and the headlight where you're operating.

For the last question, I want to take all that down and ask each of you if in our partnership, if we could redesign all of our partnerships from scratch today, if we could remove all of the historical baggage, if there was no funding asymmetries, if there was no institutional agendas and hierarchies, what would it look like?

How would it be different from what we have today?

Speaker 2: None of [00:23:00] this would exist, right? If we could remove all of the historical baggage and all the damage done by global colonization over the last six hundred years, I don't even think we'd be having this conversation. But all the damage has been done and the policies are in place, and although this isn't the optimistic, sunny answer, we're working within the systems that exist.

I think the individual choices that we make to call up whatever your equivalent representative is to talk about how you want policy to change. As a group, we can change policy and make our ideal partnership possible, but as individuals, I think we still have a lot of power to say, "Hey, I want more money allocated here.

I want my salary split this way so I have more time to work on this." If you're a resident and don't have any say over your salary, "I want to use my research time to do this." There's a lot of individual small decisions we can make to make our partnerships more ideal and more equitable since we're living in an unideal world.

Speaker 3: I would love to see The movement of, of people in and out of spaces [00:24:00] that lead to character growth, that promotes whether it's a, an American voice with a background as yourself being able to have an equal voice in one that I would be able to voice as a white South African man. We have a camaraderie, and we want to just learn from each other because I have a different skill set than yours maybe.

But I can bring it, and you can bring yours, and we can share. That's the whole point of sharing experiences and not just one person talking all the way and the other one just listens because he's got nothing to offer. That's not sharing experiences and strengthening a partnership because the experience is met on either side of the-- It's participating in dialogue about these things with which both of us, all three of us talk about this topic and is listened to with the same intensity.

That would be my ideal, to arrive in Charleston not as a South African surgeon but [00:25:00] as a colleague of surgery irrespective of whatever my heritage is. And you arrive here as a colleague of surgery, and we participate together in what it means to care for the health of people. My goodness, before I start tearing up here because we often feel like we fail in doing that.

So but yeah, that's-- I think that would be amazing if we could get to that point.

Speaker: Yeah. It's such a massive disservice to our field, our patients, our colleagues, and to our students and residents across all of humanity that we are not able to so freely exchange ideas, techniques, experiences, pathologies as a result of this history, this legacy that has kept us separated.

With that, what departing words do you have for our listeners?

Speaker 3: I'm just very grateful for the fact that there are platforms on which conversations like this can exist, and that with a click of a button an audience can be involved in this. And that the hope is that surgery challenges [00:26:00] and resolves more issues than the political climate would want to solve because we understand each other, and this academic concept of global surgery comes to, to look in, in human form.

Speaker 2: I would close with if we keep talking so much about it being perfect instead of doing it, we'll never get it done. So some of this conversation can be discouraging when people think about how am I ever going to be a part of global surgery if it's so complicated to get it right? Just start. But also, if we don't talk about it and just do it, we're likely to do harm.

Speaker: Truly amazing final words. Thank you so much to our guests, Dr. Cindy Bertram and Dr. Hugo Stark. I really appreciate you all taking the time to share your thoughts and experiences. For our listeners, thank you so much for your time and attention to this episode and this topic. If you enjoyed this episode, be sure to keep an eye out for future Behind the Knife Global Surgery Series episodes coming soon.

We'll be exploring various additional topics, including potentially [00:27:00] surgery in active conflict zones and ethics around global surgery research. If you have interest in other topics or suggestions, please feel free to reach out to me. My information can be found in the show notes. You can also contact Behind the Knife at the email address hello@behindtheknife.org or on X.

We really appreciate you listening. Until next time, dominate the day