John Rose, MD, MPH, applied for the GloCal Fellowship because he wanted to keep surgery on the global health agenda. He had been interested in surgery since he was a teenager and pursued that track in medical school, but noticed that surgery was largely neglected in global health data. The fellowship was a means for Rose to build his research capacity and “develop some models to contradict erroneous notions of surgery not being included in global health,” he said. As a GloCal fellow, he was able to contribute to groundbreaking research and participate in initiatives that he said advanced his career in remarkable ways.
The GloCal Fellowship gave Rose the opportunity to take time off from his surgical residency to ask new questions about the role of surgery and collaborate on global health research with surgical faculty at partner institutions. At UC San Diego, he worked with Dr. Stephen Bickler to develop estimates of surgical incidence—or, how often diseases and conditions require surgical intervention—using US data from a study on the Global Burden of Disease (GBD). Although surgery data was completely absent from the GBD 2010, the study was being used to generate priorities for health care spending in low- and middle-income countries (LMICs), with billions of dollars on the line.
Their modeling estimates showed that every category of disease from the GBD study requires surgery at some point, ranging from 1 to 80% of the time. Rose explained the implications of their findings on burden: “If we know what ailments have the greatest effect on human health, then we can prioritize allocation of resources to those 'high burden' problems and maximize the effect of limited resources.” They repeated the US modeling in other countries and helped show that “surgical interventions are key to strengthening health systems worldwide,” Rose said. Their work was included in several publications, including The Lancet Commission on Global Surgery report and the DCP3 Essential Surgery volume that led the World Bank to adopt new metrics and funding targets for surgical care.
As a GloCal fellow, Rose also worked in Mozambique with the Ministry of Health and academic surgeons at the Universidade Eduardo Mondlane to develop an electronic registry of surgical outcomes. Learning Portuguese with the help of a tutor, he conducted patient interviews and trained local practitioners to interview patients who came to the hospital for surgery and to monitor them for 30 days afterward. By recording what happened to the patients after surgery, the researchers could assess the risks for complications or death and find where to make quality improvements. They expanded their data collection to several hospitals throughout the country.
Being in Mozambique benefited Rose’s ongoing research on the burden of disease. “The beauty of being on the ground and doing work in Mozambique was being able to work on surgical burden estimates for all of Africa,” he said. He published three articles based on his fellowship research in Mozambique that could also be applied to other countries in sub-Saharan Africa, such as how often surgical conditions are treated at rural hospitals and how to build local capacity for surgical research and care.
Since completing his GloCal Fellowship in 2014, Rose has continued to publish research about the burden of surgical disease, health disparities, and targets for surgical care in both LMICs and the US. “The US needs as much improvement in surgical care as any other part of the world,” he noted. One area where the US lags is in acknowledging the existence of disparities in surgical care. At a National Institutes of Health summit in 2015, he presented findings on disparities in surgery that he and his coauthors from Harvard’s Center for Surgery and Public Health used to generate research priorities to inform future policy decisions. He said, “the United States has much to learn from global health's wealth of experience in documenting health inequality and creating solutions for the most vulnerable populations.”
Another recent study by Rose and his co-investigators looked at the experience of US trauma patients without health insurance. They found that, after receiving trauma care, more than 80% of uninsured patients suffer extreme financial hardship known as ‘catastrophic expenditure’. This commonplace global health metric had never been applied in the US. Rose called this figure “staggering” and especially troubling as the US Congress considers decreasing the insurance coverage provisions of the Affordable Care Act. At the same time, the World Health Organization and multitudes of other global health institutions and practitioners are advocating for Universal Health Coverage. Rose said, “There has never been a more important time for the US to learn from global health.”
Rose recently completed his final year as a resident physician in general surgery at the Brigham and Women's Hospital in Boston and is beginning a clinical fellowship in plastics and reconstructive surgery at Johns Hopkins University in July 2017. As he launches into the next phase of his surgical career, he reflects on his time as a GloCal fellow: “My experiences with GloCal were transformative for my career and led to amazing opportunities for me. I can truly say the GloCal fellowship was a springboard to many successes.”