Publications

Background Injuries are one of the leading causes of death worldwide; however, 90% of these deaths occur in low-and middle-income countries where trauma systems face significant barriers. Project Trauma Haiti (PROTRA Haiti) aims to enhance trauma care through a multistage initiative. The objective of this study was to assess perceptions of healthcare provider readiness to implement Primary Trauma Courses, Trauma Registries, and Morbidity & Mortality meetings at Hôpital de l’Université d’État d’Haïti (HUEH). Methods To evaluate readiness to implement quality improvement projects at the individual, team, and facility levels at HUEH, surgical team members were asked to complete the Safe Surgery Organizational Readiness Tool (SSORT). The SSORT is a validated tool that provides insight into organizational cultural domains that support planned quality improvement initiatives. Survey responses were analyzed, and mean scores and interquartile ranges were calculated for each domain. Responses were categorized as high readiness if the average was  on a 5-point scale and low readiness if they were below 3. Results  Twelve surgical team members at HUEH including surgical providers, anesthesia providers and surgical ward nurses completed the SSORT. Using a 5-point Likert scale, high readiness was observed in the domains of appropriateness (4.23/5), team valence (4.22/5), team efficacy (4.00/5), team learning orientation (3.98/5), learning environment (3.33/5), and vision of sustainability (3.17/5). The domain of resistance to change, which had an inverse score, had a mean score of 1.52, indicating low levels of individual resistance to change. However, facility capacity (2.03/5) and communication about change (2.91/5) exhibited lower readiness, highlighting potential implementation challenges. Conclusion Our results reveal that surgical team members strongly believed that interventions at HUEH were appropriate at individual and team levels. Before implementation, a new focus will be placed on discussions with facility leadership to address concerns facility support and resource needs. This study underscores the ability of the SSORT to evaluate multilevel readiness before implementing health system-strengthening interventions.

Background: Trauma is a leading cause of morbidity and mortality worldwide, with low- and middle-income countries bearing a disproportionate burden of orthopedic trauma. In Sub-Saharan Africa, limited resources and systemic challenges often delay surgical care. This review maps existing evidence on treatment timelines and factors contributing to these delays. Purpose: To synthesize literature on orthopedic trauma care timelines in Sub-Saharan Africa, identify barriers to timely surgery, and highlight research gaps to inform strategies for improving patient outcomes. Methods: This scoping review was conducted in accordance with the PRISMA-ScR guidelines and the Arksey and O’Malley framework. A comprehensive literature search was performed across PubMed, Cochrane Library, Web of Science, African Index Medicus, and Global Health databases for English-language studies published between January 2010 and January 2025. Studies were included if they involved patients undergoing orthopedic trauma surgeries in Sub-Saharan Africa and reported time to-surgery data. Two independent reviewers screened studies and conducted data extraction.  Descriptive and thematic analyses were used to summarize findings and identify barriers to timely surgical care. Results: 44 studies met inclusion criteria, representing 8,116 patients with 8,132 injuries across 17 Sub-Saharan African countries. Most participants were male (66.1%) with a mean age of 34.9 ± 13.2 years. Road traffic accidents were the most common mechanism of injury, followed by falls, assaults, and gunshot wounds. Femoral and tibial fractures predominated, with surgical management most commonly involving open reduction and internal fixation, intramedullary nailing, plating, and external fixation. Time to treatment varied: many studies reported that patients were admitted within 24 hours of their injury, but surgery was frequently delayed for days to weeks. Several causes of surgical delays were identified: 23 studies reported financial cost barriers, 21 studies reported lack of surgical equipment, and 19 studies reported limited operating room availability, with additional studies reporting inadequate personnel, imaging deficiencies, poor pre-hospital care, and transportation challenges. Conclusion:  Orthopedic trauma in Sub-Saharan Africa is characterized by a disproportionate burden of road traffic injuries, high prevalence of long-bone and spinal fractures, and systemic delays in accessing surgical care. The overwhelming variability in time to admission and definitive intervention reflects systemic gaps in trauma infrastructure, compounded by financial barriers, limited surgical capacity, and shortages of surgical equipment. Collectively, these findings highlight both the urgent clinical needs of trauma patients and the systemic health challenges that perpetuate poor outcomes in Sub-Saharan Africa. Addressing these barriers through targeted investments in surgical workforce development, infrastructure expansion, and affordable access to essential implants and imaging is critical to advancing trauma care and reducing the morbidity and mortality associated with musculoskeletal injuries in this region.

Background: Neurotrauma (ie, TBI and SCI) is a leading cause of death and disability globally, disproportionately concentrated in low and middle-income countries (LMICs). Reliable epidemiological, time-to-care, outcome, and economic data are scarce, which hampers policy, workforce, and funding decisions. Methods: We conducted a narrative synthesis of both peer-reviewed and grey literature through September 2025, by searching PubMed, Google Scholar, as well as relevant organizational reports (WHO, WFNS, regional registry consortia). Eligible sources reported at least one of the following in the context of LMIC: burden of neurotrauma, registries and surveillance, outcome measurement, barriers to implementation, or economic information. Results were synthesized thematically and used to derive a pragmatic minimum dataset, implementation mitigations, and a prioritized research agenda. Results: Multicentre reports and feasibility studies confirm that while registry activity is emerging in many LMICs, content and completeness are highly heterogeneous. Common areas of strength are the collection of core clinical variables (age, mechanism, GCS, in-hospital interventions), but major inconsistencies persist: inconsistent prehospital and referral timestamps; poorly captured, validated post-discharge functional outcomes; limited economic/cost data; and frequent funding/governance vulnerabilities that threaten sustainability. Pragmatic mitigations consist of (1) use of a brief, harmonized minimum dataset that prioritizes timestamps and includes a 30-/90-day functional outcome, (2) bedside-feasible hybrid paper→digital data capture with dedicated clerks, (3) routine remote (phone/SMS) follow-up for outcome ascertainment, and (4) explicit sustainability pathway that links seed funds to institutional or MOH support. Piloting of a harmonised dataset with embedded mixed-methods implementation evaluations and a small economic module will provide a rich source of evidence for informing policy and practice. Conclusion: Standardized, sustainable neurotrauma registries that collect a compact core dataset with routine outcome and basic economic modules represent the single most important research priority in global neurosurgery. Integrated pilot implementation among selected LMIC centers with implementation science evaluation and sustainability planning will generate the burden, outcome, and cost data required to inform workforce, financing, and system interventions to decrease neurotrauma mortality and disability.

For decades, think outside the box has been a foundational philosophy for problem-solving and innovations in global health. The phrase suggests that groundbreaking solutions require breaking away from conventional wisdom and seeking inspiration from novel ideas. Under certain considerations, such an approach can work well. For instance, within the biomedical paradigm, it is common to test a new intervention in a small study sample before deploying it into a larger population with the consideration that what works in the study should work for the larger group of people. For biopharmaceutical drugs, such an approach might work, in that drugs tested in the Global North will be effective for people in the Global South. Historically, such an approach has helped make significant progress for several therapeutics (e.g., synthetic insulin) and vaccines (e.g., polio vaccines) whose discovery or invention were quite outside the box [1,2]; though there have been instances of impediments to translation and ethical transgressions in certain cases. On some occasions, innovators in global health have been mindful to tailor the interventions in ways that they would be more acceptable and appropriate for the local settings where the use of such innovations is targeted to ensure long-term sustainability.

While appealing in theory, ‘thinking outside the box’ can often fall short in practice since innovators try to look so beyond the box, that they get removed from local context. We argue that the key to effective and sustainable solutions in global health lies not in thinking outside the box, rather thinking inside it, leveraging contextually appropriate, culturally embedded, and locally available resources to address health challenges.

2025 marks the inaugural decade of the Global Surgery Movement. Progress toward making surgical care accessible, safe, and affordable has been shaped by key milestones. The movement’s roots trace back to 1980, when WHO Director-General Dr. Halfdan Mahler underscored the global lack of surgical access as a matter of social justice [1]. Although launched with considerable commitment from governments, organizations, and frontline surgical care providers alike, challenges ranging from the pandemic to geopolitical conflicts have interfered with its momentum since the Lancet Commission on Global Surgery in 2015 [2]. Following the 2015 World Health Assembly resolution WHA68.15 that recognized surgery and anesthesia as essential components of Universal Health Coverage, countries initiated National Surgical, Obstetric, and Anesthesia Plans to operationalize surgical systems strengthening in this domain [3–6].

On 24 July 2025, the Program in Global Surgery and Social Change (PGSSC) convened an hybrid roundtable discussion via Zoom, to discuss the politics shaping surgical systems strengthening in low- and middle-income countries (LMICs). Professor Salome Maswime (S.M.), Dr. Walt Johnson (W.J.), and Professor Nobhojit Roy (N.R.) shared their perspectives on a discussion co-moderated by PGSSC’s Director of Policy and Advocacy, Dr. Kee B. Park (K.P.), and research fellow Dr. Nardos Getachew Bulfeta. This article presents the key reflections of the roundtable panel discussion, highlighting the perspectives and policy reflections shared by the participating policy experts.

In his opening remarks, Dr. Park emphasized that health is inherently political and that academia should move beyond solely publishing research to directly engaging in critical discussions on the policy front. The conversation focused on understanding the effects of the current global health landscape, differing perspectives on the cohesion of the Global Surgery movement, and reshaping future efforts for sustained success in surgical care provision for all.