Important and Often Forgotten Aspects of Surgical GHE: A Response to “Gynecologic SURGRETE, New Horizons Guyana 2019: An Experience of a Lifetime for Global Health Engagement and Medical Readiness”

To the editor, We recently read “Gynecologic SURGRETE, New Horizons Guyana 2019: An Experience of a Lifetime for Global Health Engagement and Medical Readiness” by Charron et al. It is clear that the authors had a very rewarding experience that not only contributed to graduate medical education but also provided the opportunity to operate in a resource-constrained environment. Military surgical missions such as this have faced harsh criticism by the civilian global surgical community and even some partner nation (PN) providers, due to the lack of consideration of PN benefit (affordability or sustainability) and evaluation of effectiveness via surgical outcome data audits. Because of these and other concerns, we believe it is important to draw attention to a few additional considerations for future surgical global health engagement (GHE) missions. In the Department of Defense Instruction (DoDI) 2000.30 for Global Health Engagement (GHE) activities, we read that GHE might be used to “enhance the readiness” of military personnel and also should “sustainably improve the operational skills of PN personnel”, engaging in bidirectional activities. Successful GHE planning needs to consider the health context analysis of the region to include political, educational, economic, and social factors. The authors clearly state that the objective of this mission was focused solely on acquisition of skills for U.S. military personnel; however, the discussion of capacity building is still crucial. The authors discuss the missing equipment that made the surgeries more challenging, but there was no discussion of how future engagements could be focused on building this capacity so that the local hospital is not dependent on excess military equipment, nongovernmental organizations, or the United States Agency for International Development. When considering the local health care providers, the authors state that they “gained sustainable knowledge”. Ideally, this would have involved some formal teaching or exchange and subsequently validated by assessment, monitoring, and evaluation, which is a critical component of GHE. While the SURGRETE team did attempt to include more PN providers, we advocate for formal exchanges or teaching in addition to intraoperative teaching. Sustainability is a key attribute of effective GHE and as such an analysis of any unintended consequences. The mission itself spanned just more than 2 weeks; so, it is certainly possible that a complication could have occurred after the U.S. team has left. Although not discussed in the manuscript, the local Guyanese physician did provide longer-term information back to the operating team about outcomes. The failure to perform long-term outcome measurements has been, and continues to be, a severe defect in GHE execution since they began, decades ago. From personal communication with the authors, we determined that the postoperative specimens were sent to Georgetown for pathologic evaluation, an important fact for discovery of unexpected disease. Is there a need for local pathology capacity? How could future GHE missions facilitate this? A short-term surgical mission can help provide clinical care in regions where there is lack of access to surgery, but failure to build sustainable local surgical capability in the region may also create problems for local providers. The authors note that a medium-sized public hospital with 2 operating rooms only has surgical capability performed by general practitioners without formal surgical training. Are local surgeons not able to build a practice in an area where humanitarian groups offer free services frequently? Has this mission and others hurt the ability of local women to receive consistent gynecologic surgery because there is not enough economic incentive for PN providers to build a practice there? Surgical missions can work within the local healthcare system to create capacity in the absence of subspecialty surgical care. We are aware that surgeons from Uniformed Services University have built a sustainable kidney and corneal transplant program in Guyana in recent years. The authors mention that their success was dependent on a single Guyanese doctor, but this doctor was not involved in the creation of this manuscript. We believe it is important to acknowledge the contributions of a PN colleague and to include her perspective of the mission. Such activity is a powerful way to affirm the hardworking PN provider and reduces the academic and professional development inequity between physicians in high-income countries and low- to middle-income countries. Finally, we believe these missions are more effective learning tools for all when a dedicated effort is made to address long-term outcomes. This is best done face-to-face at the site of the mission, 6 months or more after re-deployment. The surgical complications will be evident, and any displacement of local providers due to the mission should also be known. The Department of Defense does a fine job of ensuring pre-mission “site surveys”, but the failure to likewise evaluate the mission afterward is a missed opportunity. The lessons learned from such an evaluation could be great. The goals of improving readiness for U.S. military personnel and building PN capacity should not be mutually exclusive. GHE mission planning should always consider how we can build upon past engagements and work toward sustainable security cooperation lines of effort. We believe that with a focus on the needs of the PN, short-term surgical missions such as SURGRETE and U.S. hospital ship missions can be a PN capacity-building engagement, while also strengthening a Department of Defense readiness platform and benefiting the health and security needs of both the USA and its partners. References available from the authors. None. None declared. The authors have no conflict of interest of funding for this paper. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DoD), the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the US Government.