Global Engagement Spotlight: Nichole Starr

By Mohammed Al Kadhim

When Dr. Nichole Starr was in her third year of surgical residency at UCSF and preparing for several years of dedicated research time, she dreamed of returning to Ethiopia where she had been a Peace Corps volunteer. She had lived outside Addis Ababa for two years, spoke the language, loved the culture, and had many personal relationships.

She shared her ambitions with colleagues and was soon connected to Dr. Jared Forrester, who was himself working in Ethiopia under the direction of Dr. Tom Weiser and the charity organization Lifebox, a nonprofit dedicated to improving surgical and anesthetic safety globally. She met with Jared and Tom and learned about the Clean Cut program to improve surgical quality and safety through teambuilding and improved compliance with standards. This initiative was just being launched by Lifebox and matched her personal desire for deep, collaborative work. Nichole spent three years living in Ethiopia and working with the Lifebox team based there. While Jared established the framework and launched Clean Cut at five hospitals, Nichole expanded the program, refined the educational materials, and led the launch in multiple hospitals throughout the country, thus promoting its wide implementation and sustainability.

We caught up with Nichole recently to ask about her experience. “Working across cultures is always challenging, every resident doing research time abroad should expect it” says Nichole. “There are definitely differences in availability of resources that we don’t always face in the US. In Ethiopia as in many places, healthcare professionals are stretched really thin as there’s a smaller number of them and a lot of disease.” She emphasized, “Healthcare professionals in Ethiopia are expected to take on much broader roles and a lot more responsibility compared with the US”.

She gave an example of one of her colleagues who is a relatively young surgeon but also functions as the operating room manager for the hospital, leads educational initiatives for the Federal Ministry of Health, and held several other leadership roles with little training or support. Nichole continued: “We have no exposure to such challenges as physicians in the US. One of the positive aspects that I have learned from my experience is the creativity and innovation needed by these providers. There are so many solutions and ideas that come from colleagues to improve the available resources, to make surgery safer and more sustainable. That is also something we are rarely asked to do in the US, I learned a lot from that perspective”.

Nichole believes that motivations to engage in global health work may be different from one person another: the challenge of working in a different environment, the desire to promote equity not only in the US but around the globe, the desire to share lessons and cross cultures in a variety of environments. She would recommend such an experience to residents and fellows as it is life changing.

Working in such a setting was beneficial in other ways as well, such as working together with diverse groups from all over the world on topics that included policy, humanitarian initiatives, innovations in biodesign, material conservation, and novel educational programs. One particular experience Nichole valued was the open conversations she had with different teams and the truly bidirectional nature of her partnerships. Her work with others was always focused on implementation, listening to partners, and delivering results based on what partners say is needed. “I felt the impact of my presence to deliver thoughtful, meaningful and helpful work there. We don’t always have the proper perspective on how to have the most impact before going, it was a very special experience to have” she said.

During the COVID-19 pandemic, Dr. Starr and Lifebox pivoted their work to focus on protecting surgical and anesthesia providers and their patients from COVID infection. She led the creation of educational materials and videos on personal protective equipment and led a study to understand the safety concerns and priorities of surgical providers during the first wave of the pandemic. Through a collaborative effort with engineers and physicist from and clinical teams around the globe, Nichole and her partners designed, tested and implemented locally-built UV-C cabinets to decontaminate and reuse N95 respirators, a tool that could expand the PPE supply five-fold during times of critical PPE shortages. The cabinets were implemented in a total of 21 hospitals in seven countries during the pandemic and estimated to decontaminate nearly 1 million masks to date. The experience has been fully described in a New England Journal of Medicine Catalyst article ( The use of sterile processing workflows and existing personnel was a critical aspect of the project’s success – something Dr. Starr had become familiar with through Clean Cut program implementation at hospitals across Ethiopia.

Part of Clean Cut involved proper implementation of the WHO Surgical Safety Checklist created by many of the leaders who founded Lifebox. “The checklist is all about patient safety and avoiding mistakes that can happen in the operating room. It helps us avoid many possible complications and even improves perioperative mortality, it’s a low-cost tool and it engages all members of the surgical team”. It was studied in many income-variable environments and has become a standard process to be used in the operating room. “We use it at UCSF and it’s required prior to any procedure, it’s a global thing now,” Nichole added. There are five other standards addressed by Clean Cut, which was designed to reduce infections after surgery. “There are many interventions that are pretty cheap and relatively easy to perform in operating rooms in low-income environments, but we chose six interventions that we considered effective in reducing infections. They are basic things that you would think are done prior to every operation, but there are many gaps that needed to be addressed which point to where the failure is in implementation. It’s a matter of communication, standard procedures and the surgical ecosystem,” she noted.

Dr. Starr ended her interview with us by stating: “We’ve been doing Clean Cut for six years now, and some of the studies that we either published or still working on showed significant improvements. We saw a 46% reduction in infections when we looked at the first five pilot hospital sites where Clean Cut was implemented, and in the next five sites (and this is not yet published) where we refined our implementation and made some programmatic changes, we saw a 50% absolute reduction in surgical infections”.

Opportunities for engagement in global surgery has grown, with more opportunities around the world. Global Engagement at Stanford Surgery is a proud partner in this effort.