Global Surgery

From the program’s early days working on the World Health Organization Surgical Safety Checklist, which helped to reduce surgery-related deaths and complications around the globe, the Center for Surgery and Public Health has been a leader in advocating for the indispensable role surgery plays in global health. According to The Lancet’s Global Surgery 2030 report, more than five billion people lack access to safe, affordable surgical and anesthesia care when needed. Meeting the actual global surgical disease burden would require adding a minimum of 143 million operations every year, primarily in the poorest regions of the world where there is a severe deficit in healthcare workforce and infrastructure. Moreover, of those who can access surgical care, 33 million individuals face catastrophic health expenditure each year as a result of costs incurred.

The Global Surgery Program at CSPH is building capacity across multiple sectors of professional development of the surgical workforce, including surgical care deliverymedical education, and research, accompanying the next generation of global surgery leaders across every point in their journey.


Of the estimated 143 million additional surgical procedures necessary annually to save lives and prevent disability, the greatest need is in lower- and middle-income countries (LMICs). However, an estimated 2.4 million people in LMICs die within 30 days of surgery each year with postoperative deaths accounting for 7.7% of all deaths globally. While scaling up surgical workforce and access, it is critical to simultaneously prioritize the development of novel strategies for improving surgical education, performance, and safety. These efforts must emphasize contemporary challenges, one of which is how to optimize surgical teamwork and reduce the half of adverse events attributable to failures in non-technical skills. While there are a growing number of surgical safety initiatives and courses, none are designed as multiprofessional and include a guide to facilitate implementation in different contexts and facility types, especially in resource variable settings.  

The Non-Technical Skills for Surgery (NOTSS) system is a behavioural assessment tool that describes the main observable non-technical skills associated with good surgical practice. Although originally developed, piloted, validated, and implemented in high-income countries, it has been shown to be highly adaptable to a wide spectrum of contexts, including resource-variable settings. NOTSS was first adapted to the Rwandan context in 2015, with the creation of a locally generated curriculum – NOTSS for the Variable Resource Context (NOTSS-VRC), incorporating locally produced videos of simulated operating room cases for group critique and discussion and integrating contextual factors impacting operative non-technical skills, such as variability in workforce, equipment, supplies, and infrastructure. Although originally intended for surgery residents and attendings, the NOTSS-VRC course has been taught annually to a diverse cohort of surgery, anesthesia, and obstetric consultants and trainees as well as trainees in nursing and non-physician anesthesia programs at the University of Rwanda since 2015. 

Since the majority of surgical care in LMICs is delivered by non-specialist providers at the district hospital level, these providers are key for expanding access to quality surgical care delivery, especially in rural areas. In response to this need, in 2019 a version of the NOTSS-VRC course was integrated as part of a Ministry of Health essential surgical skills workshop for non-specialist operating room teams (primarily general practitioners, non-physician anesthesia providers, and non-specialist nurses) from 18 Rwandan provincial and district hospitals. These workshops were led by a multiprofessional team of Rwandan instructors, with training and support from the NOTSS project team.  

PI: Robert Riviello, MD, MPH & Steve Yule, PhD

Millions die of hemorrhage from trauma each year in settings without access to sufficient blood for transfusion.  The United States military has leveraged recent advances in the use of whole blood for trauma and in blood  testing technology to design a process of emergent blood transfusion in austere settings without a blood bank.  This innovative strategy is known as a “Walking Blood Bank” (WBB), and its application to the civilian sector  could save millions of lives each year, especially in chronically blood-deficient settings in low-and-middle  income countries (LMICs). However, very little is known about WBBs outside of the military context. There are  questions about the appropriate facility in which to activate a civilian WBB, its feasibility, and the safety of its testing process. Funded by a Stepping Strong innovator grant, this study seeks to close these knowledge gaps and explore need, feasibility, and design  of a civilian WBB in rural Kenya, a low-resource civilian environment with very little banked blood. If successful,  the findings from this research could facilitate civilian WBB trials.

PI: Nakul Raykar, MD, MPH

Hemorrhage is the most common preventable cause of death in trauma in the majority of patients who do not reach a hospital and up to half of those who do reach a hospital. In many low-and-middle income countries (LMICs), prehospital systems are underfunded and prehospital providers lack the skillsets necessary to stop life-threatening hemorrhage. Our team is developing a low-cost, comprehensive, open-source simulator uses augmented reality and physical simulation to teach paramedics in Guatemala hemorrhage control techniques (wound pressure, packing, tourniquet application, and foley catheter insertion) as part of initial trauma triage in the pre-hospital environment. We used the $200,000 initial grant from the initial phase of the contest to develop a prototype physical tourniquet simulator to teach proper tourniquet application along with an augmented reality platform to teach decision-making.  Our aims with the $500,000 finalist phase award are two-fold: (1) expand on the virtual and physical simulation elements to encompass the full range of hemorrhage control techniques (pressure, packing, and foley catheter application) and (2) evaluate the program efficacy using rigorous simulation study design.

PI(s): Sabrina Asturias MD (Chief of Trauma, Roosevelt Hospital, Guatemala City, Guatemala); Nakul Raykar, MD, MPH 

Funding Source: MIT Solve – Intuitive Surgical – Nesta Challenges

In this series of studies, we are examining the incidence and impact of financial hardship among patients that receive surgery after presenting for management of trauma. This study is taking place at the All India Institute of Medical Sciences in New Delhi, India. Given the broad-based impact of impoverishing expenditures, we are also examining the impact of surgical expenses in the United States among other groups of marginalized patients.

PI: Kavitha Ranganathan, MD

Funding Source: Burke Global Health Fellowship, Global Women’s Health Research Fellowship Award, Mary Horrigan Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital

The Center for Surgery and Public Health (CSPH) has partnered with the University of Global Health Equity (UGHE) under a Memorandum of Understanding to develop and implement an essential surgery and anesthesia curriculum for UGHE medical students, and to support the development of the UGHE Center for Equity in Global Surgery (CEGS). Under this partnership, Brigham and Women’s Hospital faculty, research fellows, and trainees participate in giving lectures remotely as well as serving as clinical faculty on-site during UGHE’s clinical rotations for clinical students. Clinical rotations are hosted at Butaro District Hospital, which is operated by the Rwanda Ministry of Health with support from Partners in Health/Inshuti Mu Buzima. Additionally, the above listed BWH cadres will support the research, education, and advocacy efforts of the UGHE CEGS. UGHE is an accredited medical school in Butaro, Rwanda, focused on pioneering new ways of training with an emphasis on health equity and preparing graduates to deliver care in rural and neglected communities. Recent medical graduates are expected to serve as general practitioners in district community hospitals, providing a wide range of clinical services, include essential surgical care. A key element of the UGHE curriculum is the inclusion of essential surgery and anesthesia to better prepare graduates and to support safe surgical care delivery for rural communities. Robert Riviello, MD, MPH, an associate professor in the Division of Trauma, Burn and Surgical Critical Care at Brigham and Women’s Hospital, serves as the inaugural chair of the UGHE Department of Surgery and program director for the UGHE-BWH Essential Surgery Program. 

Through a Delphi process involving surgical practitioners throughout East Africa, we developed an essential surgery curriculum covering knowledge areas deemed priorities by practitioners throughout the region. The students participating in the junior and senior surgical clerkships are assessed based upon case reports, log book reviews, OSCEs, 360 evaluations from Butaro District Hospital clinical staff, and knowledge-based examinations. 

PI: Robert Riviello, MD, MPH

As part of the University of Global Health Equity (UGHE) junior and senior surgical clerkships, our team developed multiple high-fidelity, low-cost models for breast biopsy, suprapubic catherization, pericardiocentesis, and thoracentesis. This project is partnership with UGHE Simulation Lab, BWH STRATUS lab, and Boston Children’s Hospital Simulation Lab. 

PI: Geoff Anderson, MD, MPH