Association for Academic Surgery (AAS)

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Exploring “Global Surgery” through a Neocolonialist Lens

One of the most personally and professionally rewarding opportunities I have had over the past several years is to serve as an examiner for the College of Surgeons of East Central and Southern Africa (COSECSA), both for FCS (fellows) in pediatric surgery and MCS (members) in general surgery. I have been incredibly impressed by the organization’s ability to scale up training, examine across training programs, languages, and health system resources, and adapt to the changing global environment that is COVID. In 2020, for example, while the American Board of Surgery struggled to transition its certifying exams to online, COSECSA successfully conducted hybrid exams of 234 candidates and exceeded their goal of training 500 surgeons by 2020. This past month, I traveled to Malawi to again serve as a COSECSA examiner for pediatric surgery. I joined colleagues from across the region in examining 11 talented pediatric surgery fellows. After 18 months of COVID-restrictions and canceled in-person conferences, networking with fellow pediatric surgeons outside my own workplace was refreshing. As we sat chatting, however, one of my African colleagues asked me (the only American examiner), “What is global surgery?”

I’m certainly accustomed to that question from American colleagues—from chairs of surgery trying to understand how this new wave of global surgery interest fits into an academic surgical model to a growing number of eager students aspiring to a surgical career in order to be “global surgeons”.  I am very proud of the fact that “academic global surgery” is finding its foothold in the echelons of American surgery.  However, it reinforced when my African colleague asked “What is global surgery?” that global surgery is an “us” field. It is a specialty born out of privilege, and as such, should perhaps be examined through a neocolonialist lens.

When I search “neocolonialism” or “decolonizing” and “global health” or “global surgery” on PubMed, there are scant results, and the few results are often by authors all from the global North (also a confusing term).  The term “neocolonialism” was popularized by Kwame Nkrumah, the first president of Ghana, in 1965 and illustrates a complicated global history of development aid and political gain. Fundamentally used to describe the economic dependence of nations and indirect control and exploitation through imperialism/capitalism rather than direct colonial rule, the use of the term in global health partnerships focuses on exploring inequality in partnerships as well as ongoing exploitation and inequitable gain for the global North partner.1-2

Increasing calls to “decolonize global health” urge us to look at the geopolitical history of global health and international aid and the inherent hegemony of better-resourced partners.2-3 For example, despite all of the resources for global health, why are so few clinical trials conducted in Africa?4 A particularly poignant article by researchers in Ethiopia points to the inherent inequity in global research partnerships due to diminished mobility in the visa system (i.e., global North partners can have wide entry whereas reciprocal programs are limited due to barriers to travel and visas).5

So, what is global surgery and how does this realization that the term depicts those of us in high-resource settings impact our global interactions? Does global surgery mean international missions, development aid, research fellows helping governments to develop National Surgical Obstetric and Anesthesia Plans? All of these have some play in global surgery and as such, contribute to the power dynamics inherent in the definition.

I’ve been engaged in Rwanda and surgical education in sub-Saharan Africa for the past 12 years. My path has been interesting because my early engagement was as a surgical trainee myself. And so, as surgery in the region has evolved, adapted, and grown (exponentially), I also feel that my understanding of my role in global health has changed as well. Now, I see a focus in developing sustainable global partnerships that include bidirectional global health education and equitable research authorship. I have come to the realization that these partnerships are never truly equal, but I believe the key is communication. My priority may not be my partner’s priority, and this requires careful finesse and renegotiation to identify definable priorities and deliverables that are mutually acceptable.

In trying to look at my own engagement in global surgery through a neocolonialist lens, I found the article “Anti-Racism and Anti-Colonialism Praxis in Global Health—Reflection and Action for Practitioners in US Academic Medical Centers” very useful for my own introspection and call to do better. 3 I encourage my fellow (and aspiring) academic global surgeons and global surgery advocates to do the same. For me, I see global surgery as a discipline inexplicably linked with health equity, with exploring how poverty, health disparities, rurality, culture, migration, health systems, development aid, and education contribute to surgical disease and outcomes. It may take some effort to re-define how we do “global surgery”, but maybe it can be more than just an “us” field.

References:

  1. Halperin, Sandra. “neocolonialism”. Encyclopedia Britannica, 6 May. 2020, https://www.britannica.com/topic/neocolonialism. Accessed 30 November 2021.
  2. Garba DL, Stankey MC, Jayaram A, Hedt-Gauthier BL. How Do We Decolonize Global Health in Medical Education? Ann Glob Health. 2021 Mar 24;87(1):29. doi: 10.5334/aogh.3220. PMID: 33816134; PMCID: PMC7996454.
  3. Daffé ZN, Guillaume Y, Ivers LC. Anti-Racism and Anti-Colonialism Praxis in Global Health-Reflection and Action for Practitioners in US Academic Medical Centers. Am J Trop Med Hyg. 2021 Jul 19;105(3):557-560. doi: 10.4269/ajtmh.21-0187. PMID: 34280137; PMCID: PMC8592354.
  4. Wondimagegn, Dawit MA, MD1; Ragab, Lamis MD2; Yifter, Helen MD3; Wassim, Monica MD4; Rashid, Mohammed A. MBChB, MSc, MRCGP5; Whitehead, Cynthia R MScCH, MD, PhD6; Gill, Deborah MBBS, EdD7; Soklaridis, Sophie MA, PhD8 Breaking Borders, Academic Medicine: July 27, 2021 – Volume – Issue -doi: 10.1097/ACM.0000000000004257
  5. Taylor-Robinson SD, Spearman CW, Suliman AAA. Why is there a paucity of clinical trials in Africa? QJM. 2021 Oct 7;114(6):357-358. doi: 10.1093/qjmed/hcab010. PMID: 33486529; PMCID: PMC7928546.
Robin T. Petroze, MD, MPH, FACS, FAAP

Robin T. Petroze, MD, MPH, FACS, FAAP

Robin Petroze, MD MPH FACS FAAP: Dr. Petroze is an Associate Professor and Pediatric Surgeon at the University of Florida. She is the inaugural Assistant Chair of Global Surgery and founded the University of Florida Global Surgery and Health Equity Program. She completed her general surgery training at the University of Virginia and pediatric surgery at McGill University. A former Fogarty International Clinical Research Fellow, she currently serves as a co-mentor in the Fogarty program with her partner in Rwanda. Dr. Petroze is the recipient of the 2012 American College of Surgeons/Pfizer Surgical Volunteerism Award and the 2015 Association of Women Surgeons Resident of the Year for her global health research and advocacy in Rwanda. @robinpetroze @UFglobalsurg
Robin T. Petroze, MD, MPH, FACS, FAAP

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