Embracing The “global” In Global Surgery: A Consensus Statement On Conference Equity From The Association Of Academic Global Surgery

Global health, though lacking a single consensus definition, is broadly recognized as an area of research and practice dedicated to applying multidisciplinary, multisectoral, and culturally sensitive approaches to reducing health disparities that cross national borders [1]. Global surgery is a historically neglected subset of global health that focuses specifically on surgical care delivery. Considering a broad definition to ensure inclusivity, “global surgery” can be defined as the multidisciplinary enterprise with the goal to provide improved and equitable surgical, anesthetic, and obstetric care to the world’s population, based on the central pillars of need, access, and quality [2].

A conference is a keystone of academic medicine, serving as a platform for sharing best practices, networking with various researchers and institutions, and developing health policies for implementation. Global health conferences, specifically, seek to achieve these objectives in the context of healthcare in low- and middle-income countries (LMICs). While the focus of these “global” conferences are LMICs, practitioners on the frontlines of global health and surgical care delivery from LMICs are inadequately represented. A systematic review by Velin et al found that a mere 39% of 254,601 attendees across 112 global health conferences were from LMICs [3]. The lack of frontline LMIC representation at these forums not only propagates academic inequity and neo-colonial trends but also leads to a lack of prioritization of the most pressing challenges faced in global health, from the standpoint of those who are tasked with delivering this care [3–6].

Frontline providers are poorly represented in abstract submission, conference research presentations, delegate attendance, and membership on panels. This results in a cascade of secondary issues such as fewer opportunities to network, participate in meaningful collaborations, and engage in impactful dialogues around global surgery. While virtual or hybrid participation is increasingly prevalent, these experiences remain suboptimal compared to in-person attendance [4,6].

This statement intends to provide a summary of the barriers to frontline provider participation in global surgery conferences, and provide actionable recommendations for key stakeholders. The recommendations provided are meant to be helpful guides for conference organizers to ensure equitable involvement of global partners, particularly practitioners from LMICs. In doing so, the statement advocates for and seeks to facilitate the inclusion of LMIC voices in important dialogues on global surgery. The inclusion of LMIC voices at impactful, global congregations is paramount to ensuring progress towards equitable solutions.

The AAGS Advocacy Committee discussed the development of the consensus statement over two consecutive meetings, facilitated virtually in April and May of 2022. Two members of the Advocacy Committee (RS, NR) met with experts in the field of global surgery to guide discussions and refine the scope of the consensus statement. These experts were affiliated with the World Health Organization Collaborating Centre (WHO-CC) for Research in Surgical Care Delivery in low- and middle-income countries in Mumbai, India [7]. A writing group comprising volunteers from LMICs such as India, Rwanda, Egypt, and Malaysia, as well as AAGS Committee members, was assembled.

The authors performed a literature review to identify the available evidence on the topic of conference equity in global surgery and to further develop the scope of this consensus statement. From May-June 2022, we searched scientific (PubMed) and gray literature using terms such as “conference equity”, “conference attendance”, and “barriers” to identify relevant articles. We included articles discussing global health conferences in general because literature specific to global surgery conferences is sparse. We defined global health conferences as those that focus on health care issues with emphasized focus on low- and middle-income countries, feature international participation, and aim to address global health disparities. We defined conference equity according to the systematic review by Velin et al, to encompass “attainment of an equitable level of attendee active engagement, influence and access to a conference regardless of country of origin, location, available funds or affiliation, through the mitigation of known barriers and enhancement of efficacious facilitators” [3].

The core writing group developed a draft of the consensus statement following careful evaluation of the themes identified from the literature following a thematic analysis to identify key barriers and facilitators. We extracted data from included articles, assigned codes, and synthesized coded data. Codes such as “registration cost”, “travel cost” and “accommodation cost” were attributed to the “Financial Barriers” theme. Similarly, “visa refusals”, “difficult visa processes”, “distance” and “time zones” comprised the theme of “Geo-political Barriers”. Finally, “lack of mentorship” and “authorship inequity” coded for “Accessibility Barriers”. The recommendations for “conference equity” were hence accordingly categorized into Financial, Geo-political, and Accessibility Facilitators. A tiered approach to proposed suggestions was agreed; the three tiers were entitled “Basic”, “Standard”, and “Ideal”. Relevant stakeholders for conference organization and attendance were identified, and action points were listed respective to each. The preliminary draft was circulated to collaborators of the consensus statement in July 2022.

Comments from collaborators were incorporated and a further revised draft was then circulated to the AAGS Advocacy Committee faculty, for review, commentary, and feedback through the use of a shared Google document. Following the second set of revisions, a modified Delphi method was utilized to achieve agreement on the proposed recommendations. A total of 15 participants from the AAGS Advocacy Committee and WHO-CC voted in two rounds of virtual meetings held in December 2022. Participants were not blinded. The statement and proposed solutions were presented systematically and a Google Form was used to aggregate responses. An ‘Agree, Disagree, Modify’ scale was used to tally votes for each individual recommendation set out in Figure 1, Table 1 and Table 2 of the statement. In Round 1, a panel of seven experts from the WHO-CC evaluated the initial recommendations. The recommendations were revised based on the feedback provided by these experts. To validate these modifications, we presented the revised recommendations to a different set of eight experts from the AAGS in Round 2, where the recommendations were reassessed. This approach ensured that the threshold for consensus was met or exceeded, thereby confirming the validity and robustness of the final recommendations. The consensus threshold for inclusion of recommendations was set at 80%. Descriptive statistics were used to summarize the consensus process and percent agreement was recorded for each point discussed. Responses were anonymous for other participants but not for the research team.

The writing group finally integrated these aforementioned collaborative efforts into a consensus statement, which was approved by the AAGS Executive Committee in October 2023.

Our review of 30 articles [3-6, 8-33] from the literature sheds light on the possible impediments to equitable LMIC representation at global surgery conferences. The LMIC frontline faces formidable barriers to participation, including heavy financial burdens, geo-political obstacles, and a lack of accessibility. These barriers not only impede diversity, equity, and inclusivity, but also pose a significant threat to their indispensable contributions [8–12].

Financial barriers

Several studies cite high financial burden as a primary barrier to LMIC participation at conferences. The costs start adding up from the time of conference registration: Arend et al found that only one out of 20 conferences included an equitable conference fee option [13]. Free registration is rare even in the new era of online conferences, with options for virtual attendance costing as high as USD 595 for non-members [14]. Even attending a seemingly “free” virtual conference comes with the hidden cost of internet broadband: a two-day, eight-hour online conference could cost in excess of 75% of the average monthly income for LMIC attendees [15].

In-person conference attendance can be extremely expensive for LMIC participants, especially when most major global health events are hosted in High Income Countries (HICs) [11]. With limited travel grants and scholarships on offer, attendance at high-impact events such as the WHO Framework Convention on Tobacco Control have decreased over time due to marked reductions in travel support offered [16]. In addition to prohibitively expensive flights and accommodation [17], visa applications pose an enormous financial and administrative undertaking [8,9]. For example, requirements to obtain a visa to attend the 2018 Women Leaders in Global Health Conference in the United Kingdom included an employment contract, bank statements from the previous six months, and income tax returns [3,18,19]. Even with adequate documentation, fully-funded scholars have been refused temporary visas. The high visa application fee is a sunk cost: it remains non-refundable in the case of refusals. The cost of appealing these refusals is also exceedingly high, and often associated with long processing times exceeding the date of the event itself, which would render the already expensive undertaking moot altogether [10,16,20].

Geo-political barriers

Geographical barriers to LMIC representation at conferences include the obvious constraints of prolonged travel distances, and are compounded by the addition of political barriers such as visa difficulties. A 2018 report found that 34% of African researchers and 40% of Asian researchers encountered visa-related obstacles, compared to only 9% of their European or North American counterparts. The same report highlights bureaucracy, complexity of applications, and discrimination as specific visa-related obstacles experienced by researchers from Africa and Asia, prohibiting them from registering for conferences entirely, to avoid the stress and hassle of visa applications [21].

The process of obtaining visas is time and resource-intensive – usually involving procurement of documents like invitation letters, proof of funds, return tickets, and hotel reservations. Some countries require proof of marital status and additional invasive, personal questions of no relevance to academic participation. Visa refusals (often despite meeting all the aforementioned requirements) are not unusual [9–12]. The frequent denial of visa applications for conference attendees from LMICs has been well-detailed in numerous news articles and blog posts in addition to academic literature, demonstrating the extensive depth and breadth of this problem [22–25]. In 2019, it was reported that the United Kingdom refuses visas to visitors from Africa at twice the rate of those from any other region [24]. The Canadian Association of African Studies also reports that African academics are increasingly facing more visa refusals for short-term visits to speak at conferences in Canada, with the most common reason for refusal being suspicions from immigration officers that they would not leave the country at the end of their stay [26]. It is important to note that even for travel within LMICs, visa procurement can be a challenge depending on one’s country of origin. Denied visas are one of many symptoms of a larger societal problem involving racism and discrimination. Corruption at local embassies, regional terrorist activities, economic blockades, and diplomatic sanctions are additional political barriers to conference attendance that disproportionately affect practitioners from marginalized countries [3,9–12].

Historically, conferences were almost all in-person. The COVID-19 pandemic started a paradigm shift towards online or virtual conferences. A possibly unintended byproduct of this was increased representation of participants from LMICs [8]. Although online conferences mitigated the physical distance barrier, they presented their own challenges such as variable time zones and unreliable internet connections in certain areas [27]. Wu et al found that the number of participants from underrepresented minorities increased in virtual conferences, nevertheless, the overall proportion remained low, accounting for only 9.89% of attendees. The authors suggest that factors beyond financial and logistical barriers hinder involvement [28].

Accessibility barriers

The time, location and call for abstracts are often advertised on independent platforms such as websites or social media accounts of organizations, inadvertently benefiting those with existing networks or prior knowledge [29]. Even with significant engagement from LMICs through abstract submissions, active participation in the form of speaking opportunities are limited as HICs submissions predominate amongst selected abstracts [3]. This may be reflective in the published literature as well, with a recent systematic review finding predominance of male and HIC-affiliated authors within global surgery research. The same review also highlighted that within the minority of LMIC authors, there was a consistent gender gap with fewer female authors at nearly all seniority grades of authorship [30]. This intersectionality of gender with country of origin further exacerbates the accessibility issue for a select few LMIC practitioners.

Moreover, speaking opportunities in the way of invited talks from experts are also prone to inequitable representation. At a recent ‘global’ surgery conference held in the United Kingdom, invited speakers represented nine countries worldwide, of which only one was a low-income country [31].

The post-colonial scientific discourse primarily uses English as a medium, making language a significant barrier to conference access as well [32]. While a commitment to multilingualism is the standard for many global forums including the United Nations Assemblies [33], increasing access to these facilities is key for encouraging diverse participation at conferences. The cost of simultaneous translation is also prohibitive in areas with limited resources, at times making this barrier insurmountable.

Consensus exercise

The consensus exercise involved a total of 30 proposed recommendations. These included a statement and a figure (Figure 1) to illustrate the basis for tiered recommendations (n=2), and two tables; one (Table 1) for the three tiers of recommendations for facilitators (n=16), and the other (Table 2) for identifying stakeholders and tangible action points (n=12). Initially, the proposed figure had 85.7% agreement, which increased to 100% after modifications in the second round. Fourteen recommendations in Table 1 and 11 in Table 2 exceeded the consensus threshold after the first round. Five and nine recommendations in Table 1 and Table 2 respectively achieved unanimous (100%) agreement in both rounds.

There were only two instances of disagreement with proposed recommendations in round one, and overall, most deviations from agreement were for modifications (n=15). Final consensus was above threshold for all (N=30) recommendations, with 26 having 100% agreement at the end of the second round. Detailed consensus statistics for each point are provided in Supplementary Table 1.

The consensus-based guidelines proposed henceforth are organized into three nested tiers – Basic, Standard, and Ideal – with each tier building on its preceding one. The tiers are designed based on the cost, effort, and time required to achieve the recommendations proposed within, offering a progressive approach to achieving equity (Figure 1). The timeline for implementation ranges from zero to ten years, with the ‘basic’ tier comprising simple interventions that can be implemented today, and the ‘ideal’ tier reflecting those that could take up to a decade to accomplish.

The ‘basic’ tier includes the simplest recommendations: these changes will be easy to incorporate, low-cost and low-effort, aimed at entry-level conferences. We defined ‘entry-level’ conferences as those arranged by student-led organizations or other smaller groups with limited funds, and have a small number of attendees. The ‘standard’ tier refers to the standard that all conferences should be aiming to achieve. These changes will be moderately difficult to incorporate at a moderate cost requiring moderate effort, and aimed at larger conferences held by more established organizations in the field of global surgery, with greater access to sponsorships and funds. The ‘ideal’ tier encompasses longer-term goals for conferences that we recognise will be difficult to incorporate, involving high-cost and high-effort changes that require greater collaboration across organizations and widespread campaigning (Table 1).

Actively engaging the stakeholders at an early stage in planning a conference can help achieve this shared goal of planning equitable conferences. Three broad categories of stakeholders encompass attendees, organizers and sponsors, and can vary according to the level of each conference. Identifying the exact responsibilities of individual representatives from local, national or international levels as well as governmental, non-governmental or private bodies, is essential. The following recommendations (Table 2) focus primarily on a few conventionally “privileged” HIC stakeholders, but also some LMIC bodies and relevant suggestions for change.

Recommendations

This statement seeks to suggest recommendations to mitigate the barriers to conference equity discussed above. Financial facilitators (such as conference fee waivers, travel grants, etc.), geo-political facilitators (such as hybrid conferences, political campaigns, etc.), and accessibility facilitators (such as mentorship, advertising guidelines, etc.) must be considered.

However, these solutions are not equal in their ease of implementation, nor in their financial or time requirements. Some will be easier to offer, some require greater monetary investments, some are longer-term proposals and some are deeper-rooted, necessitating complex socio-cultural changes. As such, this statement seeks to facilitate conference equity by proposing tiered guidelines for future conferences in the field of global surgery.

Actions Needed

In the pursuit of democratizing accessibility to high-value events specifically pertaining to LMIC health systems, and heading towards an ‘ideal’ global surgery conference, there is a need to identify and engage stakeholders of such conferences in an equitable way. Conference organizers must be held accountable by using ‘equity metrics’, audits, and Key Performance Indicators (KPIs), among other strategies. By measuring LMIC representation in the form of attendance, panel and presenter demographics, we can gain valuable feedback and affirm the success of inclusive practices.

Limitations

This study has some limitations. First, the literature review forming the base of our analysis of the barriers to conference equity discusses global health conferences in general, yet we propose recommendations for global surgery conferences. The mismatch primarily exists due to sparse literature specific to global surgery and conference equity. It is important to note that a large extent of the issues will be similar for global health and global surgery conferences given their commonalities in subject matter, overarching goals, audience, and stakeholders. However, it is possible that some barriers specific to global surgery conferences might have been overlooked as a result of this approach. Second, even though the AAGS is a global organization, the consensus exercise largely involved participants from the United States and India. This narrow focus may not fully capture the diverse perspectives, needs, and challenges faced by LMICs in regions such as Africa and Latin America. As a result, the recommendations may not fully reflect the global diversity of LMIC experiences. In order to mitigate this limitation, we conducted a comprehensive literature review to obtain perspectives from around the world. Additionally, the writing team consisted of a diverse representation of nationalities, and the manuscript was reviewed by the entirety of the AAGS executive committee, with global representation and long-term experiences with HIC-LMIC collaborations, which strengthened our consensus recommendations. Future consensus exercises should aim to include a wider range of stakeholders from various LMIC regions to ensure that the recommendations are more universally applicable. Third, the relationship between cost, effort, and ease of implementation underlying our tiered recommendations may not be as linear as suggested. Some, but not at all might be susceptible to additional contributing factors. Fourth, we must consider that frontline providers in LMICs are often sole practitioners whose absence, even for short periods to attend conferences, could adversely affect care delivery in their regions. This factor should be considered in future research to develop solutions that minimize such disruptions. Finally, the perspectives of conference organizers themselves were not comprehensively considered. Future work could explore the interaction of various implementation factors and feasibility of our proposed recommendations from the organizer perspective.

This statement intends to serve as a continuously evolving guideline for creating a more inclusive environment for the discussion of global surgical issues. Representation from those at the forefront of these issues is absolutely essential. Through a multi-pronged approach of tiered recommendations for conference organizers as well as necessary actions from a diverse set of stakeholders, inequities at “global” surgery conferences may be mitigated in the coming years. Time, effort, and widespread collaboration are required to achieve the goals set out in this statement to bring voices from LMICs from far afield to center-stage.

We would like to extend our sincere thanks to Dr. Christopher Dodgion for his insightful comments during the development of this statement. We are especially grateful to the WHO Collaborating Center for Research in Surgical Care Delivery in LMICs and the AAGS Executive Committee for their support.