Challenges of maintaining overseas orthopaedic partnerships during the pandemic

Daniel Yeomans, James Berwin, Rosemary Wall (on behalf of the WOC-Guyana Orthopaedic Partnership) and Chris Lavy

Daniel Yeomans is an ST4 trainee in the Severn Deanery. He has a keen interest in Global Health and is the current World Orthopaedic Concern (WOC-UK) representative on the BOTA committee.

James Berwin is a Specialist Trainee (ST8) in Trauma and Orthopaedic Surgery in the Severn Deanery and co-founder of the Bahir Dar Orthopaedic Network and Exchange with Severn (BONES) Partnership.

Rosemary Wall is a Specialist Trainee (ST6) on the Warwickshire training programme.

Chris Lavy is a Consultant Orthopaedic and Spine Surgeon in Oxford and elected council member of the Royal College of Surgeons. His passion is improving surgical services and surgical training globally. He has built orthopaedic hospitals in Malawi, Zambia and Zimbabwe, and was a founder of COSECSA the regional surgical training college for East Central and Southern Africa.

As international travel came to a standstill in March 2020 overseas partnerships needed to find new ways in which to adapt and maintain relationships with colleagues in Low and Middle Income Countries (LMIC). COVID-19 brought the world online, and with it a unique opportunity to provide regular remote support to such projects. World Orthopaedic Concern UK (WOC-UK) was able to provide a platform for information sharing and resource pooling to support the continuing international education and training.

Casting our mind to the June 2019 JTO issue featuring a WOC subspeciality on ‘How the global surgery agenda is changing’ – no one anticipated quite how much it would have to change over the following two years. The dedication and enthusiasm of UK orthopaedic surgeons has enabled many partnerships to continue to thrive and provide excellent learning resources for overseas colleagues.

In this article, we hear from three such examples. Two trainees, Rosemary Wall and James Berwin, on their experiences of supporting orthopaedic departments in Guyana and Ethiopia. Thirdly from Professor Chris Lavy, whose plans to build a new paediatric hospital in Zimbabwe were in the final stages when the pandemic began.

The Guyanese Orthopaedic Residents Training Programme started in 2017. It encompasses a Master’s degree alongside achievement of clinical competencies. The Guyanese orthopaedic faculty is small, currently four consultants at Georgetown Public Hospital, the tertiary referral centre. This was the impetus behind the creation of the Guyana-World Orthopaedic Concern-UK teaching partnership. This encompasses West Midlands orthopaedic trainees, under the supervision of trauma consultant Deepa Bose, facilitating bi-monthly, consultant delivered Zoom teaching sessions to support the Guyanese residents’ curriculum. This has been running since July 2018.

The primary impact of the COVID-19 pandemic on surgical teaching was to restrict face-to-face interactions. Our partnership was already based upon remote interaction so this did not directly impact our sessions. In fact, we found benefits from the new restrictions. One advantage of the enforced change in teaching practice was a widespread up-skilling of surgeons in the use of online learning platforms. Suddenly, we were forced to use Zoom or Teams daily, resulting in a cohort of experts with new confidence in presenting online. Our partnership grasped this opportunity. The newly screen-confident consultants were willingly recruited throughout the UK and remotely delivered teaching sessions to the Guyanese residents in their sub-specialty areas of expertise.

The pandemic resulted in the team on both sides of the Atlantic enhancing their experience and knowledge of the logistics of online learning. We had a much better understanding of how to achieve a balance between switching personal cameras on for better interaction versus off to improve reception in areas with limited bandwidth, the importance of well-structured pre-reading and the use of breakout rooms to simulate small group discussions. The Guyana residents reported more confidence and ease interacting remotely from the safety and comfort of their own home.

Of course, some topics are challenging to cover remotely and there is no substitute for hands on patient examination. However, thanks to Mr Faisal Ali, a Consultant Knee Surgeon based in Chesterfield and the master of orthopaedic clinical examination, the Guyana residents have enjoyed 12 months of FRCS-level clinical examination virtual teaching and have even sat a virtual full-length mock clinical exam. Once again it is questionable whether we would have had the confidence to engage in this without the impact of the pandemic.

Although initially designed to support local teaching, the increased confidence in remote interaction the partnership gained during the pandemic has led to us working together in new areas. We are developing a collaborative research project on open fractures and it is largely down to the strengthening of our relationship during the pandemic that this is progressing so well. In addition, the Birmingham Orthopaedic Network trainee collaborative has assigned a new board member this year to future proof and drive forward the Guyana-UK partnership.

The easing of restrictions and the ability to travel will no doubt change our partnership once more. Areas of the curriculum will be developed locally with the long-term goal of self-sufficient local faculty to take over the running of the teaching programme. Nevertheless, as one resident put it, “even during the pandemic, when the world was brought to a standstill… our education was still going full speed ahead.”

The BONES project was founded in 2019 and is a regional orthopaedic partnership between Bahir Dar, Northern Ethiopia, and Severn Deanery. The project focusses on reciprocal teaching and learning but is guided by the educational needs of the Bahir Dar trainees.

Following start-up funding from the Tropical Health and Education Trust (THET) along with support from AO Alliance and WOC-UK, we were able to fund a series of trips to perform a capacity assessment, provide a Primary Trauma Care (PTC) course, paediatric orthopaedic and trauma teaching. With support from BOTA, we hosted two trainees from Bahir Dar who visited a series of hospitals in Severn Deanery, were able to attend an AO basics course and were guest speakers at the WOC-UK trainee session at the BOTA Annual Congress.

Whilst a global pandemic and civil war in neighbouring Tigray prevented travel to our friends in Bahir Dar, innovation was born out of a necessity to keep the partnership going. Trainees from Bahir Dar were invited to join online regional registrar teaching and were also given access to the Bristol Orthopaedic Registrar’s Group (BORG) app – a compendium of recorded regional teaching lectures, FRCS revision notes, operative techniques and more. We utilised virtual reality training by collaborating with Virti, an interactive VR healthcare platform. We are also incredibly grateful to Dan Perry and the Bone and Joint Journal (BJJ) Research Committee for granting full remote access to their online research methodologies course.

Dr Biniyam Biresaw is a consultant trauma and orthopaedic surgeon in Bahir Dar, and he was a trainee when we first met in 2019. This is what he has to say about the BONES partnership, “I am a surgeon working in a limited resource setting and I have had the chance to collaborate with partners from across the globe. The partnership we have with Severn has been a game changer. They have provided us with hands on as well as remote teaching, academic support and inventory… they give us the opportunity to tell them what we need and they will do everything they can to provide it. For us, they are more like family.”

A huge thank you to everyone involved for their ongoing support. We are hopeful that BONES will continue to grow from strength to strength. We are tentatively planning in-person visits towards the end of this year or beginning of next year.

Orthopaedic Surgeons Collen Msasanure and Chris Lavy, from Bulawayo and Oxford have been friends for many years through COSECSA the College of Surgeons of East, Central and Southern Africa. They both had a dream of setting up a hospital in Zimbabwe where children could be a priority andwhere high-quality orthopaedic plastic and reconstructive surgery could be offered. Back in 2013 they teamed up with UK businessmen Neil Brown and Richard Little. The first step in this project was to contact all the orthopaedic surgeons in Zimbabwe to discuss the vision. This happened in Harare and was hosted by joint replacement surgeon and jazz pianist Alban Bowers at his colourful Jazz club.

The next step was to form a local NGO, Zimbabwe Orthopaedic Trust (ZOT). ZOT worked with the Ministry of Health (MOH) to find a suitable site and an old isolation hospital in Bulawayo was chosen. The buildings had sadly been destroyed by fire but with the help of local architect Bruno and local builder Leo they were beautifully renovated, and a surgeon designed, operating block with three large theatres was built from scratch. The MOH and the management of the United Bulawayo Hospitals team worked with ZOT to set up an innovative public private partnership to manage the hospital, where the MOH retained overall ownership of the land and ZOT undertook to run the site and provide the services.

The conditions that disabled children in sub–Saharan Africa are sadly often linked to poverty and malnutrition and the hospital was therefore providing services for one of the lowest economic groups in society. The initial aim was to fund paediatric surgery by also having a private ward where market prices would be charged to adults for joint replacement and semi elective trauma surgery. Chris Lavy had experience of this model having used it in hospitals he had previously set up in Malawi and Zambia. It is a good model in terms of sustainability for a LMIC, but like any business requires careful management to avoid the risk of becoming just another private hospital and serving the affluent. We were very fortunate at the finishing stages of the hospital for ZOT to team up with Cure International, a US based Christian children’s surgical mission who offered their expert and experienced services to help fund and run the hospital.

Cure Zimbabwe Children’s hospital was opened in the middle of COVID lockdown in May 2021 by the president of Zimbabwe Edson Mnangagwa and took prime spot on Zimbabwean TV that evening. The key surgeons are Collen Msasanure and Tongai Chitsatamunga, who having completed his training in Zimbabwe, spent two years in UK under the RCSEngland sponsored fellowship scheme in Oxford and Derby. They are joined by WOC-UK member Rick Gardner from Bristol who already has seven years consultant and teaching experience in the Cure Hospital in Ethiopia.

Collen, Tongai and Rick have already started a local training scheme for fellows from Harare and Bulawayo and hope to become a regional centre for children’s orthopaedics.

I have no doubt there are many other overseas partnerships in the UK which have adapted to new challenges just as the examples in this article. As demonstrated, the involvement of trainees in overseas partnerships is invaluable and engagement can develop many additional skills. This year has seen the first set of WOCUK/BOTA bursaries awarded to trainees of all levels to help with the travel costs of overseas visits (or ongoing costs of virtual projects). We hope this will continue to be awarded annually to support trainees with a passion for such work.

I would be delighted to hear from anyone who is interested in this kind of work or would like more information on the work of WOC-UK and can be contacted at: danyeomans@gmail.com.