Lee Errett named Professor of Global Surgery

Lee Errett and his wife Mitze Mourinho

For more than 20 years, Lee Errett has spent part of the year performing surgeries in underserviced parts of the world. He has operated on every continent (he removed a foreign body from a man’s foot in Antarctica). In July 2015 he was appointed the first Professor of Global Surgery at the University of Toronto.

“My goal, is to learn from all the talented surgeons here who have done work across the globe and do what I can to help in further developing the program.”

“The most compelling demographic for health - and your ability to access surgical care - is where you were born” says Lee. It is true that health outcomes are really a lottery of birth place. This applies to the simplest of surgical procedures. Prolonged and unsafe labour can be dealt with only by incremental improvements. Congenital deformities like cleft lip can have a transformative effect on the patients and families when addressed early. Morbidity from hernias and common abdominal issues like appendicitis can be reduced dramatically when treated appropriately. Basic fracture therapy can decide whether someone returns to work or never works again. All of these sorts of conditions can be effected in the poorest of countries with resource limited environments.

Indeed, even more complex surgeries can be performed in under-resourced settings.”

Sir Magdi Yacoub commenting when he visited the heart surgical unit at St. Michaels stated that “heart surgery raises all the boats: anesthesia, ICU, hospital hygiene… everyone benefits”.

Despite the work of committed individuals and organizations, the urgent need for surgical care in the world’s poorest regions has been widely under-recognized as a broader global health issue over the past few decades. Most people when asked to name global health challenges cite HIV/AIDS, maternal and child health and infectious diseases. Surgery has not featured on the agenda of major international health agencies, global health funders or national governments. Yet, approximately one third of the global burden of disease is due to surgical conditions, and contrary to common assumption, this burden falls predominantly on people living in low- and middleincome – developing – countries (LMICs).

Recent data from the Lancet Commission on Global Surgery (a two year global collaborative effort established by the Lancet journal to generate research, metrics and recommendations for improving surgical care in LMICs) shows that worldwide 5 billion people cannot access safe, timely and affordable surgical care, should they need it. As a result, common surgical conditions such as appendicitis are still diseases with high case fatality rates in many parts of the world. High-income countries have ten times as many operating rooms and one hundred times as many surgical providers as low- and middle-income countries. Not only do untreated surgical conditions have major health impacts in the world’s poorest regions, they also have significant social and economic impacts; failure to improve access to surgical care is likely to knock 2% off GDP in LMICs over the next 15 years as a result of lost labour and productivity.

However, after much inattention, surgery is now gaining recognition as a legitimate component of global health. This has led to the emergence of the discipline of ‘global surgery’, a field that aims to improve health and health equity for all who are affected by surgical conditions, or have a need for surgical care, with a particular focus on underserved populations. There is growing interest in how high-income countries can partner with LMICs to improve surgical capacity through education, training, research, policy and implementation. There is also interest in how the principles of global surgery can be used to improve inequity in surgical care at home, including for minority and indigenous populations.

In years past, the modus operandi of surgeons looking to engage in global health was the surgical mission model. These short-term outreach programs temporarily brought surgeons to where help was needed most, allowing patients access to essential surgical care where they would otherwise have gone without. While there is still a role for these programs, the potential for impact is far greater when high-income country actors work together with low-income country partners to build local surgical capacity over a prolonged period of time. Programs like Rwanda’s Human Resources for Health program, which aims to train hundreds of specialist physicians in the landlocked African nation over a seven-year period, leverages high-income country clinical expertise to assist local health leaders in training and growing a local health workforce far beyond what is possible in a two-week mission trip. These kinds of programs are only as strong as the partnerships they are based on: to develop them, buy-in is required from surgeons, hospitals, national governments and funding agencies in low-income countries, high-income country hospitals and clinicians, national governments, and funding agencies. This is the model of partnership Lee Errett seeks to generate with the countries the University becomes involved with. “In these partnerships, the learning goes both ways” he says.

Global surgery programs across North America and Europe are blossoming. Established global surgery programs at Harvard University, UCSF, Oxford University, King’s College London, McGill, and the University of British Columbia demonstrate that the field has been accepted as an academic surgical discipline. Many of these programs have been driven by an overwhelming demand from medical students and surgical residents to develop skill sets at the interface of clinical surgery, health research and policy and global health practice, and to study, train and work in a global context. The University of Toronto in particular has enormous potential to contribute to the growing movement for global surgery. As the largest academic surgical institution in North America, the community of surgeons that can contribute both research and clinical capacity building is vast. At present, over 40 surgeons are engaged in global health work, and there is great potential for further collaboration and growth. Collaborations with institutions in China, Ukraine, Ethiopia, Botswana and South Africa already exist and Lee Errett is in the process of further strengthening these existing partnerships and forging new ones, including in Jamaica and Cuba. Lee says: “Toronto surgeons are globally minded, are committed to health equity, and have Canadian sensibilities for global health work. They value an ethos of partnership, and have world-class surgical skills and research expertise to bring to the table.” The goal of the program is to become leaders in the education, training and clinical care. Documenting successes and failures with the view that these observations can translate into valuable research projects is another objective. In order to accomplish this, the following are the intents:

1. Define the burden of surgical disease along with the obstacles that prevent optimal care,
2. Maintain communication through tele-medicine for care and education.
3. Collaborate with ministries of health and local health providers to enhance and develop surgical and anesthesia care.
4. Support faculty from low and middle income counties (LMICs) and the University of Toronto to excel in Global Surgery.

Doing all this requires funding. “The need is great and the task daunting. Nonetheless we have the people with the knowledge, expertise and the will to make significant strides. The most important issue will never be independent of where you are born but we can get the great satisfaction of making it less important to some than it has always been” says Lee.

Martin McKneally & Lee Errett