ACS HOPE and the Surgical Training Collaborative in Lusaka, Zambia—Part 3

Dr. Anita Mohan is a clinical assistant professor in the Division of Plastic Surgery. She spent eight years at Mayo Clinic in Rochester, Minnesota where she completed her plastic surgery integrated residency and a post-doctoral research fellowship following a PhD at University of Cambridge, U.K. Prior to coming to the U.S., she completed seven years of basic surgery training and plastic surgery residency in England, and a one-year fellowship in Cape Town, South Africa.

Dr Mohan recently returned from Zambia where she followed Drs. Tom Pham and Robin Cisco as part of the ASC HOPE program at the University Teaching Hospital. Here she shares her background and experience:

I had always been inspired by programs and initiatives for establishing services and access to healthcare in less resourced communities. This has been engrained through inspiration of my grandfather, who was a physician, building a hospital and establishing clinics through collaborative efforts for long-term access to resources and healthcare. During medical school, I had initial exposure to the challenges of pediatric burn care in South Africa and later returned as a registrar working in plastic surgery. Following my management studies, I had the opportunity to continue work with my mentor at Imperial College London, who had worked with the World Health Organization, World Bank, and many global health policies and initiatives. I had the opportunities to assist in a variety of different global projects, literature reviews, and reviewing conference proceedings. It was clear then, nearly 20 years ago, that attention to and focus on global surgery was severely lacking. It is exciting to see over the years how that has rapidly changed to improve care and access to safe anesthesia and surgery to millions of people around the world.

During surgical training, I joined several formal mission trips in cleft lip and palate surgeries and breast reconstruction. I also returned to do a one-year fellowship in South Africa where I worked as a registrar in pediatric burns, pediatric plastics, hand and general plastics. A lot of these patients were from underprivileged areas. It highlighted the challenges of education, perioperative cares, communication, community cares, and follow up. These experiences inspired and fueled my passion in global health, not only in performing a surgery, but also in understanding the health systems, the infrastructure, education and the logistics that may ensure the sustainability of developing programs.

 As a new faculty member to Stanford, the ACS-HOPE trip to Lusaka was a perfect opportunity to get involved. I was also keen to meet and get to know other passionate surgeons at Stanford who support global surgery so I can collaborate and contribute more to such programs in the future. 

I did not have any specific agenda for my trip, but it was the first visit of our team here at Stanford to the site at UTH. I knew it was crucially important to plan and prepare in advance to make the most of the limited time there. They had never had a plastic surgeon visit through the ACS program, and we were trying to learn more about their capacity and resources. Communication was an essential  part of the preparation and over several pre-trip meetings we aimed to understand the expectations for our role, the nature of cases I could assist with, and share knowledge and plan activities for the trip. We also discussed some of the equipment and tools that may be impactful for clinical activities and simulation education sessions.  We reviewed cases in advance, and during my week there I had the opportunity to work with their staff in the OR, review clinic patients, provide lunchtime lectures to the department, and deliver a microsurgical skills workshop. We debriefed on the supplies and equipment they have, the nature of the cases, perioperative challenges, and challenges with referrals and coordinating multidisciplinary care. This helped to identify areas for future work, knowledge sharing and improving local resources. I was also grateful for the donations from companies for supporting the skills workshop and planned clinical cases.

The team is motivated and excellent to work with, however there is a great need, no doubt about that. There are currently only two Zambian plastic surgeons at UTH, and the hospital takes referrals for the whole country. Both surgeons have been there less than two years but are building the foundations for growing their division. One key objective is to establish a plastic surgery residency in Zambia.

Prior to the two Zambians, there was one ex-patriot who had been serving the country for the last 35 years, including trips to the remote villages, but he is now semi-retired. There is also a new American surgeon in another hospital nearby focused on cleft and craniofacial cases. There is a lot of need for entire population in Zambia, but the country is under-resourced to meet the high demand.

During the trip we identified areas for program development for the future. We also looked at the specialization and training needs of the current faculty. In the U.S and around the world, surgeons may complete fellowships, observerships, and dedicated training in specialist areas to complement the training we have received. UTH is a large university hospital, and similar to Europe and the U.S., there is a need for reconstructive expertise that overlaps with many other specialties, requiring multidisciplinary care.

Currently cases include burns reconstructive cases and trauma as well as oncologic reconstruction, hand, old injuries, congenital anomalies, breast, lymphedema, etc.  There are interesting patterns of injury, severity, presentation, and congenital pathology that we don’t typically see in the U.S. or Europe.

UTH wants to expand the number of surgeons in Zambia and establish a residency program, which we could support and assist through ongoing collaboration. Although there are a handful of Zambians training abroad who are expected to return, it is still not enough for a population of 20 million. There is an opportunity to help support and shape a formal Plastic Surgery residency curriculum, provide didactics in areas with knowledge or clinical gaps, and consider how to offer opportunities to gain exposure through Stanford’s Global Engagement Visiting Observer program.

They want to set up a microsurgery skills lab, and we could support efforts to establish simulation models, including 3D printing models and running formal workshops that will complement their curriculum. There is scope for assisting in knowledge sharing, training, and support of the current faculty and resident education. We can share perioperative protocols, expand nursing education, formalize multi-disciplinary case conferences, and assist the development of effective referral pathways within UTH. For us visitors, we can learn from challenges in the variety of presentation such as delays or advanced severity that is influenced by socioeconomic circumstances and access limitation. There are also rare congenital anomalies we do not frequently see in the Western world. This forces us to work with the local surgeons to sometimes think outside the box, learn to work within resource limitations, and can provide educational opportunities for our own staff and residents. The visiting observer program can expose colleagues at UTH to see other types of infrastructure, protocols, and workflows that they can draw ideas from and adapt to their system. It’s a valuable opportunity for everyone.