Cooperating Towards Surgical Equity:
Dr. Johanna Riesel on The Role of Partnerships in Global Surgery
By Miriam Gladstone
Living in a township near Port Elizabeth, South Africa during an undergraduate study abroad program, Dr. Johanna Riesel saw firsthand how decreased access to health care can impact a population. A village over, one nurse was responsible for caring for the entire community of people – with no physician support, no time off, and no replacement if she fell sick. Moved by what she saw, Dr. Riesel was inspired to go to medical school to try to make a difference in such systems. Now, as a Pediatric Reconstructive Surgeon at the Hospital for Sick Children in Toronto and a respected expert on global surgery, she works to advance surgical training and surgical capacity in under-resourced settings. Here, Dr. Riesel discusses the role of surgery in global health, how she magnifies her impact by situating her work within a network of partners, and the importance of listening to others when determining global health priorities.
The Role of Surgery in Global Health
Since the formation of the World Health Organization in 1948 in response to the global cholera epidemic, global health has almost exclusively focused on the prevention and treatment of infectious diseases. In comparison, global surgery, a relatively emerging field, has at times struggled to gain support on the world stage. Dr. Riesel reports facing pushback from major stakeholders in global health during her work co-authoring the 2015 landmark publication, ‘Lancet Commission for Global Surgery’. She explains, “Nobody wanted to hear about it. They said, ‘It’s too much, it’s too complicated, it’s too expensive. The biggest bang for our buck is going to be on preventing disease”.
However, Dr. Riesel maintains that surgery is essential to every health system, not a second priority to communicable diseases, “The reality is until we eliminate accidents, road traffic accidents - one of the highest causes of morbidity and mortality for young people - until we can eliminate cancer, until we can eliminate deep space infections, until we can prevent all maternal hemorrhage, and until we [can] prevent obstructed labor, you must have surgery in a complete health system.”
Investing in surgical capacity in global health settings will also strengthen entire health systems. Dr. Riesel explains, “If you create a health system that can withstand surgical care that means that you have electricity, running water, oxygen, and access to intravenous lines. You might not cure Ebola with surgery, but you cure it with supportive care that requires resources that you need to have in place in a surgical system. If we want to achieve any of the sustainable development goals, we have to consider a more holistic approach to health care, which includes surgical and anesthesia care.”
In the past, notions of surgery in global health typically entailed mission trips of well-intentioned surgeons travelling to under-served settings to operate intensely for weeks at a time. Some of these mission trips or surgical camps continue today and, although they can provide essential surgical care to individuals in need, they are limited in their ability to make sustainable change. Further, they may have unintended consequences on the availability of resources throughout the public health system.
In Uganda, supplies for the public health care system are allocated monthly by the government based on the previous years’ trends in surgical activity. During her time working in Uganda, Riesel observed that hospitals were sometimes left more fragile after a surgical camp had finished than before it had started. Dr. Riesel says, “[While the visiting surgical team would be operating], there would be women sometimes waiting for days in obstructed labor to have a C-section [because the operating rooms were all being used by the visiting surgical camps]. Hospitals would run out of [the monthly supply of] propofol, which is sedative used for anesthesia. The trips might consume all the [monthly] resources [in one week] and then operating rooms might be shut down for the rest of the month”.
Decolonizing Global Surgery
Nowadays, the ‘decolonization’ movement is reshaping approaches to global health worldwide. Mirroring this change, global surgery is emphasizing collaboration and listening in lieu of prioritizing the agendas of foreign entities. At the start of her global surgery fellowship at the Harvard Medical School Program in Global Surgery and Social Change, Dr. Riesel realized her responsibility to respond to the lived experiences of the people she was working with, rather than pursue her academic objectives.
She describes, “I was in Liberia to do research. However, it became very clear to me as soon as I was there that they have much bigger fish to fry. They had so many patients to look after and they had very few surgeons there at the time. Doing research was not a priority for them, so I switched gears.”
Dr. Riesel assessed how she, a resident in general surgery at the time, could support the local health care team in their work. “There were a number of medical students who were on their surgery rotation but didn’t have any surgeons to follow because the practicing surgeons were too busy with clinical care to teach.”
Taking the initiative to participate in the student’s clinical duties and to give them lectures on surgical techniques, Dr. Riesel says, “I rooted my priorities in the needs of others in order to stay well aligned with my partner’s goals”.
The decolonization of global surgery also recognizes a dynamic of “bi-directionality” and “mutually beneficial exchanges” between all stakeholders, reports Dr. Riesel. “There are a lot of things that we can learn from limited resource settings, like learning how to re-sterilize equipment. We go through so much waste in the operating room in high income settings.”
Even within institutions, she explains, there is room to increase communication to maximize impact. “Everyone is reinventing the wheel every time they go somewhere or partner with someone new. It would be really great to centralize and streamline a lot of those efforts so that we can maximize impact, connection, and collaboration.”
Strengthening Partnerships
On how she maintains optimism in the face of sometimes overwhelming global need, Dr. Riesel says that it is her partnerships with students, collaborators, and mentees around the globe that fuel her motivation: “Staying engaged with people is always what energizes me. When you’re tired or you’re burnt out, it’s really helpful to have someone who shares a similar vision to you to reinvigorate why you’re doing the work.”
Dr. Riesel multiplies the impact of her work by mentoring residents and junior surgeons in regions with limited numbers of plastic surgeons through programs like Surgeons in Humanitarian Alliance for Reconstructive Research and Education. She says, “I can’t change the whole world but if I can change one person’s world then maybe that has a ripple effect to people around them and their worlds.”
Although the road to achieving comprehensive surgical care worldwide can seem long and challenging, Dr. Riesel reminds us that strong partnerships are our greatest assets. “There’s a saying that goes, ‘if you want to go far, go together’, which I believe is true. It’s time we harness that power and use it for good.”
Dr Johanna Riesel is a pediatric reconstructive surgeon at the Hospital for Sick Children in Toronto.
Check back on the blog in two weeks for an interview with her SHARE program mentee, Dr. Zenebe Teklu, a plastic surgeon in Ethiopia.