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Re-Imagining a Global Surgical Organization: A View during and beyond the Pandemic

INTERNATIONAL Volunteers in Urology (IVU) recently marked its 25th anniversary as a global nonprofit organization providing urological services in resourcepoor settings. The motto of “Teach One, Reach Many” emphasizes IVU’s core mission: surgical education. IVU’s model is based on short-term surgical missions but has expanded beyond this standard by developing regional centers (hubs) of urological training. In this model, regularly scheduled weeklong workshops provide hands-on training in countries that meet basic infrastructure requirements. This strategy has worked well, training 3,021 surgeons in over 40 countries and serving nearly 12,000 patients. Despite the ever increasing demand for training, the question exists of whether our efforts and mission have been effective. Outcome data have been difficult to obtain. The COVID-19 pandemic has begun to change that. Since March of 2020, the nature of global surgery has changed. Repercussions due to the COVID-19 pandemic have impacted every country’s health care infrastructure, with far-reaching consequences on individuals, caregivers, health systems and economies. The struggle has been multifold, affecting every level of what the Lancet Commission on Global Surgery has identified as core surgical indicators. Data reviewed even prior to COVID-19 found surgical access worldwide “inequitably distributed” with “near absence of access” in low and/or middle-income countries (LMICs). Limitations in international travel have eliminated the ability of global health organizations largely based in high-income countries (HICs) to support LMICs in person. As a result, many nonprofit global mission programs refocused their educational curriculum during the pandemic. IVU specifically turned to virtual lectures and case conferences. Not only did this reconnect workshop volunteers with global partners, it also enabled pooling of educational experiences amongst LMIC sites. What have been termed virtual visiting professor (VVP) lectures have become, and will be going forward, a more important part of our curriculum. RECALCULATING AND RESPONDING In 2019 (fiscal year April 2018 through March 2019), IVU trained 373 local surgeons and provided surgical services to 902 patients. Based on past workshop volumes, we project a 2-year loss of providing services to approximately 1,700 patients in 24 countries. As the pandemic spread and rapidly altered surgical care worldwide, our first inclination was to better understand our international partners’ fate. In May 2020, an IRB-approved survey was emailed to IVU participant surgeons in LMICs and HICs querying patient care and operating practice during the pandemic, as well as personal response (IRB No. STUDY00001098). We received 40 responses from 103 surveys: 17 from LMICs and 23 from HICs. Despite HICs reporting higher rates of COVID-19 testing (83% vs 6%, p <0.001), both groups similarly reported having hospital guidelines on COVID-19 patient care, operating at normal volume, having cared for or operated on COVID-19 positive patients and having patients die from COVID-19 (p >0.05). Significantly more HIC respondents reported performing telemedicine (87% vs 18%, p[0.0007), but without a difference between groups in working remotely (p[0.24). While a Likert scale of the pandemic (1dunremarkable; 100dworst seen) did not differ between LMICs and HICs (median 72.5 vs 88.0, p[0.11), LMIC respondents expressed stronger concern regarding personal (p[0.0003) and family (p[0.0082) risk of contracting COVID-19, as well as being a possible vector of transmission (p[0.0282). We concluded that early in the pandemic there were clear differences in access to COVID-19 testing and how care was performed but with overall little difference in Abbreviations and Acronyms