James Johnston, M.D., is a professor in the UAB Department of Neurosurgery and director of the Pediatric Neurosurgery Fellowship. He practices at the Children's of Alabama (COA) and is the medical director of its Global Surgery Program. Martina Gonzalez Gomez, M.D., M.Sc., recently joined the Department of Neurosurgery as a program manager for its recently established Global Neurosurgery Program.
This program aims to achieve health equity for all people in need of surgical care, with an emphasis on underserved populations. Both Johnston and Gonzalez are working together with the Mary Heersink Institute for Global Health and other partners across the university to make UAB a hub for global surgery education, service, and research.
Before attending medical school at Washington University in St. Louis, Johnston spent two years in Dakar, Senegal, working for the Fox Chase Cancer Center as a database coordinator on a hepatitis B and liver cancer epidemiology study with the Senegalese Military Health Service. The experience solidified his interest in medicine and global health.
“When I went to Washington University for medical school, I thought I would end up eventually practicing in the traditional realms of global health, like virology, infectious disease, and epidemiology,” said Johnston. “During my medical school rotations, I had a great experience on service and was fortunate to encounter strong mentors in neurosurgery. Though I ended up in neurosurgery, I have always maintained that interest in global health.”
Gonzalez finished medical school in Bogota, Colombia, and began working in different hospitals throughout the country. Her experiences during this time led her to recently earn a master’s degree in Global Health and Global Surgery from King's College in London.
“Neurosurgery has been a passion of mine since the beginning of my medical career,” said Gonzalez. “Still, I always had this multidisciplinary view and a desire to focus on more than just the clinical and surgical areas. I realized that while local health is vital, knowing how things work in different countries can allow us to help each other and improve healthcare.”
We sat down with Dr. Johnston and Dr. Gonzalez to gain insight into their lives and work in global health.
Q: What led you to your focus area?
Johnston:
I went into medical school thinking I would do tropical medicine or HIV because of previous work I did surrounding hepatitis while working in Senegal. But when I got into medical school, it turned out surgery was a better fit for my personality and what I like to do. During my training at Washington University, I met some incredible mentors in neurosurgery who showed me that this is what I wanted to do. With my experience in Senegal and living abroad, my interest in global health grew, and I wanted to turn it into a formalized part of my career.
Gonzalez:
I finished medical school in 2014, and since then, I have been working in different settings in Colombia, specifically in neurosurgery, in public, private, rural, urban, and low-resource settings. Throughout my medical career, I was always focused not only on the clinical part but also on access and infrastructure. Many things I saw within my practice brought about an interest in different social determinants of health.
Q: What are the big issues in your focus area?
James Johnston, M.D.Johnston:
For many years, surgery was considered to be outside the normal boundaries of global health. Global health was traditionally focused on infectious diseases and programs for the control of infectious diseases. Of course, these have been very powerful achievements of global health, and the success of these and other initiatives have opened the door for efforts in global surgery.
Traditionally, educational infrastructure and funding systems have always revolved around communicable diseases. Now, all of a sudden, it's a different set of issues in terms of how to strengthen a surgical system.
We have to consider how to initiate effective knowledge transfer while maintaining the ethics of intervention, the distribution of medications, availability of resources, etc. For instance, although we can do surgery, should we do surgery when there is no appropriate follow-up and long-term care? Also, how does that affect local caregivers? There's this whole academic field of global surgical capacity building, which is so new, and it's very exciting to be part of the very beginnings of all that.
It is such an exciting time to do all this, and we’re thankful to be part of the larger UAB ecosystem, which allows us to better integrate global surgery, not just global neurosurgery, with the larger global health enterprise at UAB, Sparkman, MHIGH, etc. We want to be able to benefit from the incredble global health expertise at UAB so we can better contribute to our partnerships and larger global surgery effort. We can be so much more effective if we coordinate work as a larger institution as opposed to individual surgeons or divisions.
Q: How did you connect with UAB?
Johnston:
After completing my neurosurgery residency at Washington University and then pediatric neurosurgery fellowship at Saint Louis Children’s Hospital in 2010, I was fortunate to be hired on as junior faculty at UAB by Dr. Jim Markert, chair of Neurosurgery, and Dr. Jerry Oakes, chief of Pediatric Neurosurgery. Both have been incredibly supportive of my efforts to build a global neurosurgery program at UAB and COA, and UAB has been a fantastic place to grow my skill set as a neurosurgeon and global surgery advocate.
Along the way, I have been fortunate to spend time working with partners in Vietnam, Ghana, Egypt, Uganda and Haiti. I have also been able to work as a Global Surgery intern at the World Health Organization and study Global Health Policy at the London School of Hygiene and Tropical Medicine. In addition, UAB was a founding partner of InterSurgeon.org, an online social network that helps facilitate collaboration between individuals and organizations working in global surgery, obstetrics, trauma, and anesthesia.
Gonzalez:
In the past year, I've looked at different strengths and challenges of global neurosurgical care. I was looking for an option allowing different neurosurgical education and care opportunities worldwide. All the work that COA has done is amazing. They have sustainable, bi-directional partnerships created through the years that are multidisciplinary; they are based on technological collaborations and offer an important education for both sides.
Q: How did you connect with your global partners?
Johnston:
Establishing global surgical partnerships traditionally has been somewhat random – chance encounters at a meeting, mutual acquaintances, or a scholarship program are common connectors. That's how we started our program in Vietnam and Ho Chi Minh City. The COA Global Surgery program was established in 2014 as a way to consolidate surgery training efforts between COA and a few large partner children’s hospitals in order to build more substantial, sustainable, and equitable collaborations. After hosting global fellows from Ho Chi Minh City, we were able to connect with partners in Hanoi because of their relationships with each other, leading to a new collaboration. The interests in program development were different in Hanoi than in Ho Chi Minh City, with different levels of financial support from the government, resulting in different program development initiatives.
We have always tried to play a role on that local level as advocates for our Vietnamese partners, while at the same time not compromising their authority and letting them determine the priorities of the relationship. Sometimes well-meaning teams from HICs come in and dictate priorities, talk directly to the government, and leave the local team out of their program. We've always believed the best approach with our partners is being there to bolster their position as opposed to replacing it.
Every partnership is unique, with different interests, levels of expertise, and available resources. In global surgery, assessment of local healthcare infrastructure, surgical capacity, and training needs can be complicated and takes time, mutual trust, and real friendship.
Martina Gonzalez Gomez, M.D., M.Sc.Gonzalez:
One of the most important things is the definition of goals for each visit or training. Creating an impact in a multidisciplinary way has been very important so that the work can impact not only neurosurgery but, for example, nursing. Taking a team-based approach increases this possibility of self-sufficiency in the end.
Coming from Colombia, I have been exposed to different kinds of partnerships that I've seen between, for example, rural and urban settings. Also, as a middle-income country, sharing conferences and meetings with other high-income countries increased knowledge on both sides. The different settings and scenarios are enriching for every type of education. The burden changes, and the different types of patients seen in different hospitals changes. So, those interactions of education are also significant for partnerships.
Q: What is innovative about your work?
Johnston:
Throughout my time in neurosurgical training and practice, I've been very interested and keen to develop a global health effort to build tools for knowledge transfer and surgical capacity building with partners in developing health systems. With my fantastic partners here at UAB and COA, we have helped establish long-standing neurosurgical collaborations with large children's hospitals in Vietnam and Egypt, as well as a craniofacial program collaboration in Ghana. This has all been under the umbrella and with the generous support of the COA Global Surgery program.
The next stage of this effort, which is why Martina is here, is to formalize these collaborations under the umbrella of UAB Global Neurosurgery into a program based on best practices that will provide supplementary training to our residents in global neurosurgery, with didactic lectures as well as the opportunity to learn alongside faculty working with our global partners.
Q: What has been the impact of your work?
Johnston:
We have been successful with our partners in building multidisciplinary, advanced clinical programs in neuro-oncology, epilepsy, craniosynostosis, neurotrauma, hydrocephalus, and spina bifida. The work has resulted in multiple papers and invited presentations, the majority conceived and written by our partners as primary and/or senior authors, as well as UAB internal grant and philanthropic funding.
Q: What are your goals for the future of your initiatives?
Johnston:
The larger goal is to create a yearlong UAB Global Neurosurgery Fellowship, which will be available for UAB residents and non-UAB residents and faculty to spend time here at UAB with an effective curriculum in global surgery as well as working with our partner sites.
Bidirectional collaboration has always been fundamental to our program. Over the past 10 years, we've hosted many global fellows here at COA for observational fellowships - neurosurgeons, but also neurologists, pathologists, oncologists, anesthesiologists, and EEG technicians.
An important aspect of our efforts has been to develop tools for virtual collaboration. Since 2015 we have worked with partners in Vietnam to establish a novel system using HelpLightning augmented reality software with smartphones and iPad for virtual mentoring in neuroendoscopy. This experience turned out to be very important during COVID, and we are now using a similar system with Vuzix smartglasses for craniofacial surgery training.
Dr. Johnston and Dr. Gonzalez have several educational, research, and service projects with opportunities available. Many of these opportunities are available to medical and public health students and faculty. If you are interested in connecting with them, please email mgonzalezgomez@uabmc.edu. If you would like to connect with the Global Surgery team or would like your work highlighted by the Mary Heersink Institute for Global Health, reach out to ghi@uab.edu.