Neurosurgeon Michael Haglund, founder of Duke Global Neurosurgery and Neurology, has one word to describe the initial effect of COVID-19 on his organization's global health initiatives.
"Terrible."
Since 2007, his group has performed hundreds of life-saving neurosurgical procedures. They've repaired traumatic brain injuries and removed brain tumors. They've sent neurosurgeons, nurses, bioengineers and physical therapists to train local health care providers. When they started, Uganda had five neurosurgeons for 30 million people; now it has 14, in addition to lots of newly trained nurses and others.
But no members of the Duke group have set foot in Africa since the pandemic began. "This was just so frustrating," Haglund says.
The 25-year-old Himalayan Cataract Project was on track to do 75,000 eye surgeries in Ghana, Ethiopia and Nepal in what turned out to be the first year of the pandemic. They did only about a third of those planned cases, says Dr. Matt Oliva, an ophthalmologist with the project. "My worst fear is that by helping someone see, we unexpectedly expose them to COVID. We had to hit the pause button and reconsider our strategy."
For many decades, medical missions have flown doctors and nurses from wealthy countries into poorer nations, set up temporary clinics, treated as many patients as they could in a week or two, then flown their staff back home. These visits may have helped those who were in the front of the line for care — but don't help those who can't be seen during a limited visit or need follow-up care — until and unless the mission returns.
In recent years, there's been a shift in focus in medical missions – a recognition that training in-country medical staff to do surgeries or provide routine medical care is a better path than parachuting in for a round of procedures.
Since the pandemic began, both types of programs have been kayoed by travel restrictions, lockdowns and the influx of COVID patients. Judith Lasker, a medical sociologist who has been studying medical missions for decades, estimates that 90% of the fly-in missions shut down. But many of the training missions have found ways to work around COVID's travel restrictions.
And while the training missions were figuring out work-arounds, the pandemic provided time for debate over the effectiveness of medical missions, which pleases Lasker: "It's shifted to what's the right thing to do and who should be doing it and how should they be doing it, and not taking for granted that sending a bunch of people somewhere that's poor is somehow automatically going to benefit those folks."
"The pandemic has provided the opportunity to rethink," says Dr. Lawrence Loh, an adjunct professor at Dalla Lana School of Public Health at the University of Toronto.
To get a sense of the new reality for medical missions, we talked to representatives of a half-dozen organizations whose volunteers provide surgical and medical care while training local health professionals.
Learning how to do things differently
All have found ways to stay involved. The initial "terrible" situation for the Duke group, for example, has turned out not so badly. Duke's pre-COVID missions were based on "twinning"-- pairing up its doctors, nurses and biomedical engineers with local health professionals. And those local people have been able to carry on the work even though most in-person missions have stopped.
For example, Duke doctors are working on research papers with counterparts in Uganda, bioengineers there are checking with their North Carolina counterparts for help in fixing equipment, Haglund zooms every other week with the neurosurgery trainees, and his group has just sent neurosurgical equipment to a recently remodeled hospital in Kampala.
Like Duke, Bridge to Health, which forms partnerships with local communities in poor countries to provide medical care and training, stopped sending people out. It took a deep dive into digital training.
"Sometimes it takes a pandemic to force you to do things differently," says William Cherniak, co-founder of the organization. Bridge to Health had planned to send portable ultrasound machines each about the size of an electric razor and 3 or 4 trainers to Yemen in 2020 to teach doctors there how to use ultrasound for diagnosis. When COVID made the trip a no-go, the organization started to work on a solution they've already beta-tested in Kenya.
It's basically a digital version of teamwork that pairs the camera on an i-Pad or i-Phone with the image from the portable ultrasound probe. Trainers in the U.S. and Canada can see the trainee's hands, the patient and the ultrasound image in real time.
Getting the ultrasound probes into Yemen without sending people along with them took some time. The shipping logistics finally came together last week, and the devices should be in Yemen soon.
"It's really opened our eyes to go, oh, wow, there is really fantastic technology available to us and we can do things in a more innovative way," Cherniak says. "We're in Toronto, but we're essentially there in Yemen too."
With the money saved from eliminating travel, Bridge to Health is considering supporting more on-the-ground staffers, purchasing more ultrasound devices and paying to treat patients in Yemen with medical conditions identified by the ultrasound images. That might mean covering the cost of antibiotics for pneumonia or surgery for abdominal trauma.
Sometimes the trips do go on — but not exactly the same way as before
Some of the training missions managed to continue some travel during the pandemic. That meant taking new precautions. The Himalayan Cataract Project maintained physical distancing in clinics and used PPE to make sure health workers from the U.S. weren't unintentionally exposing patients in other countries to SARS-CoV-2.
All the revamping and travel restrictions cut into how much they could do on these pandemic trips. "Instead of seeing 200 people a day we'd see 30 people," says ophthalmologist Matt Oliva. "We'd work out of one room instead of several, with one surgeon doing surgery."
Still, the organization made progress toward its ultimate goal of creating local eye surgery programs that can work without Western doctors present. With less travel on their 2020 schedule, project staff had time to develop online training modules that could reach more doctors and nurses. The cataract project used to send African doctors to Nepal for training under the guidance of visiting Western experts; now the African doctors could stay home and still learn.
And there's one benefit that has nothing to do with health-care but everything to do with earth care, notes Judith Lasker – fewer plane trips. She got together with the Catholic Health Association a few years ago and determined that half the budget of the medical missions they surveyed went to airfare. Now, she says, "We're not polluting the air as much. These trips are hugely carbon footprint heavy."
Ramping up virtual training, yearning for visits to return
ReSurge, one of the first medical missions to focus on training local health workers rather than having Westerners do it all, worked in 17 countries in the year before COVID, then cancelled all training and surgical trips in spring of 2020. That could have meant calling a halt to training on reconstructive surgeries like cleft palate repair and burn repair for surgeons in Latin America, Africa, and south Asia.
"We realized that to remain relevant, we would need to really ramp up our virtual training," says Jeff Whisenant, president and CEO of ReSurge. And they did. Where 636 young surgeons attended lectures and virtual training in the year before COVID, 2,803 surgeons did so in the first year of the pandemic. And instead of working in 17 countries, ReSurge was able to work in 31.
When ReSurge first started with virtual lectures in Uganda, they saw a really big uptake. "And then we saw it decline," says Whisenant. It turned out the surgical trainees couldn't afford the data costs for web access on their own, so ReSurge tried a new approach – funding the local hospital to create an e-learning center for not only reconstructive surgeons but for other doctors as well. "It's been a blessing in disguise for us," says Whisenant. Overall, he says, the tragic pandemic had not a silver lining but a golden one — more care being provided by local providers.
But there's also a longing for a return to in-person training among in-country medical staff. "None of our visiting educators could come to Nepal since January 2020," says Shankar Rai, a reconstructive surgeon in Nepal who was instrumental in getting medical missions to focus on educating local health professionals and who works with ReSurge. "We have tried to compensate with webinars and other virtual educational activities. Still, we miss the opportunity to socially interact, care for patients together and learn so many things from visiting educators." In Nepal, reconstructive surgery stopped with the onset of the pandemic. With vaccines trickling in, some surgeries are starting up again, and Rai is eagerly awaiting the return of visiting educators.
Joanne Silberner is a freelance journalist and former health policy correspondent for NPR. She has covered global health issues since the outbreak of HIV.
Dr. Adela Wu was the AAAS intern at NPR this summer.
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