The HSS Global Musculoskeletal Health Equity Division (GMHED) is a humanitarian group dedicated to empowering our partners in resource-limited settings to build and lead essential training programs and care centers in the musculoskeletal health field.
More than five billion people worldwide, most of whom reside in resource-poor areas, lack access to limb and life saving surgery and anesthesia. Reduced musculoskeletal health care capacity, especially provider shortages, means injuries, deformities and degenerative conditions often go untreated. When treatment is available, it is commonly provided at understaffed hospitals, which is correlated with high complication rates and suboptimal pain management.
In the 21st century, there are increasing calls to action by international health authorities to address these inequities. While providers historically travelled to resource-limited settings to care for patients directly, we now know that supporting locally led education and research is more cost-effective and sustainable.
Learn more about our program, staff and initiatives in the tabs below.
The HSS Global Musculoskeletal Health Equity Division (GMHED) is a division of HSS Global Partnerships founded in 2021 by Swetha Pakala and Mark Brouillette to provide humanitarian services in places where the need for musculoskeletal care is great and access to safe high-quality care is lacking.
In 2012, Swetha Pakala, MD founded the Global Health Initiative (GHI) within the Department of Anesthesiology, Critical Care & Pain Management. The focus of this program was to address the need for improved anesthetic capacity in low-resource settings by supporting regional anesthesia training. GHI’s first program was conducted at the Hospital for Traumatology and Orthopedics in Ho Chi Minh City, Vietnam. The program later expanded its work to sites in Uganda, Ghana and India.
In 2017, GHI launched GRACE (Global Regional Anesthesia Curricular Engagement), which was a novel training model for resource-limited settings. GRACE enabled us to create teaching curricula using a systematic framework based on a partner site’s specific needs. It also offered a platform with which to measure intervention outcomes.
Thanks to the support of HSS Global Partnerships, in 2021 global health efforts were expanded to consider all of the relevant service lines under the HSS musculoskeletal health care umbrella. A multidisciplinary program like this has the potential to increase the positive impact on providers and patients in resource-limited settings. To date, we are enthusiastic to have HSS Orthopedic Surgery (Trauma, Spine and Sports), Anesthesiology and Pharmacy Departments on board for the GMHED launch in Ghana this year.
The GMHED mission is to improve musculoskeletal education, research and practice at our partner institutions in resource-limited settings at home and abroad by supporting clinical training programs and building local research infrastructure
Our vision and guiding principles are to develop and deploy evidence-based, adaptable methods to assess the musculoskeletal health care needs of hospitals in low-resource settings and evaluate the impact of global health initiatives aimed to address gaps in training, research and care while observing the following principles:
Swetha Pakala, MD
Mark Brouillette, MD
Sariah Khormaee, MD, PhD
Spine Surgery Champion
Andrew Grose, MD, MSc
Trauma Surgery Champion
Benjamin Nwachukwu, MD, MBA
Sports Surgery Champion
Niharika Thakkar, PhD
Jawad N. Saleh, B.S., Pharm.D., BCPS, BCCCP
The Republic of Ghana has a population of 31 million and is situated along the Gulf of Guinea in West Africa. Ghana is a multinational state that gained independence from the British in 1957. The government is a unitary constitutional democracy, and English has been adopted as the common language. With respect to musculoskeletal disease, the burden of trauma, chronic degenerative states and congenital deformities is high, but much of the infrastructure and workforce needed to care for these conditions is lacking. GMHED currently collaborates with the two largest teaching hospitals in Ghana. Our programs there focus on increasing the orthopedic surgery and anesthesiology workforce by training local doctors and conducting research.
Komfo Anokye Teaching Hospital (KATH): Kumasi, Ghana
HSS and KATH began working together in 2017, though Dr. Brouillette has led several US academic centers’ global health programs with the KATH Directorate of Trauma and Orthopaedics and Directorate of Anaesthesia & Intensive Care. KATH is a 1,200-bed academic center built in 1952 and located in the city of Kumasi. KATH is the primary referral center for the northern two-thirds of Ghana and the teaching institution for the Kwame Nkrumah University of Science and Technology Medical School. More than 10,000 surgeries are performed at KATH annually; 16% for musculoskeletal conditions, many of which are road traffic injuries. KATH offers postgraduate medical training in most disciplines, including Trauma & Orthopaedics and Anaesthesia & Intensive Care. Subspecialty fellowship training in Regional Aneaesthesia and Interventional Pain Management is now available.
Korle Bu Teaching Hospital (KBTH): Accra, Ghana
HSS began collaborating with KBTH in 2020. KBTH is a 2,000-bed academic center built in 1923 and located in the capital city of Accra. KBTH is the oldest and largest referral center for the country and also sees patients referred from its West African neighbors. KBTH houses the University of Ghana Medical School and offers postgraduate training in 14 medical disciplines, including Trauma & Orthopaedics and Anaesthesia & Intensive Care.
Korle Bu Teaching Hospital anesthesiologists Dr. Alex Akowuah
and Dr. Kofi Mensah and HSS anesthesiologist Dr. Mark Brouillette
launch the KBTH-HSS collaboration in January 2020.
India, officially called the Republic of India, is the seventh largest country by area, the second most populous country and the largest democracy in the world. It is a pluralistic, multilingual, and multi-ethnic society. India has become a fast-growing major economy and a global hub for information technology services. Despite the economic advances, India is also overwhelmed by unyielding poverty, both urban and rural. Additionally, religious and caste-related prejudice permeates many sectors of society. In poverty-plagued communities, healthcare resources and workforce are dire, which leads to a high burden of disease. Musculoskeletal disease, particularly trauma, comprises a large proportion of unmet need.
Osmania General Hospital (OGH): Hyderabad, India
HSS and OGH began working together in 2019 when the HSS anesthesia Global Health Initiative (GHI) introduced the GRACE training model to the OGH department of anesthesiology. OGH is the second largest government hospital in South India and provides free medical care to the indigent population of Hyderabad and the surrounding areas. OGH houses 1,000 beds within three specialty buildings, has 62 operating rooms of various specialties and performs roughly 62,000 surgeries per year. OGH offers the premier anesthesiology residency training program in South India, with approximately 90 new residents annually. Although physician anesthesiologists have been performing regional anesthesia techniques for several years, there is a large variability in skill and success rates among practitioners. The OGH faculty therefore sought to collaborate with GHI to improve their knowledge and skill level.
The GMHED initiatives are the blueprints that guide how we approach global health work. They are the recipes we use to support our partners’ educational and research programs. The idea is that we, or any global health group, can follow an initiative’s prescribed steps, in any resource-limited setting, and end up with a sustainable intervention that is tailored to the unique needs of the local hospital or health care network and that can be examined periodically for changes associated with the intervention’s implementation, thereby informing program improvements and gauging success.
GRACE is a framework to design and measure the impact of a regional anesthesia training program. It was first piloted at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana in 2017. The first step is to conduct a needs assessment. Since no validated assessment could be found in this field, we devised and ran an original one. The results of the needs assessment are then summarized for the host and visiting teams who created a novel curriculum with the help of an expert panel’s consensus recommendations.
At predetermined intervals, the four-part Kirkpatrick method is used to evaluate changes in 1) trainee satisfaction (survey), 2) knowledge (written examination), 3) clinical skill (observed structured clinical examination) and 4) changes in regional anesthesia utilization and patient outcomes (audit). View the detailed GRACE methods used at KATH published in 2020.
While GRACE focused on the subspecialty of regional anesthesiology, the development of AMHEN started in 2021 and focuses on musculoskeletal health as a multidisciplinary domain of health care. Similar to GRACE, AMHEN is currently being developed to guide the design, implementation and evaluation of a musculoskeletal intervention targeted to help providers and patients in low-resource settings. Unique to AMHEN, the process began with a Stakeholder Meeting held on July 17th, 2021 at the Golden Tulip Hotel in Kumasi Ghana. KATH hospital leaders and department heads were present, with HSS partners (including our CEO Lou Shapiro and Surgeon-in-Chief Bryan Kelly) participating virtually to discuss the current state of musculoskeletal health care in Ghana and propose ways to address existing challenges to practice.
The HSS Regional Anesthesiology & Acute Pain Medicine Fellowship offers 1-2 Fellows per year the opportunity to take part in the Global Health Track. Dr. Brouillette and Dr. Pakala serve as the Fellow’s mentors and help them gain an in depth understanding of existing global musculoskeletal health care disparities as well as the traditional versus modern strategies used to address health care inequities. Fellows will also have the chance to design and execute an academic project at one of our GMHED sites or at a low-resource institution of their choosing at home or abroad, travel safety guidelines permitting. This is typically concise education or research-focus protocol that can be completed and disseminated in the fellowship year. Up to four weeks of travel is sponsored depending on the project specifications.
Fellows will graduate from our track with an enhanced appreciation for the unmet orthopedic needs worldwide, evidence-based tools to join or build new global health initiatives in their future careers, enhance fluency in multidisciplinary and cross-cultural communication and collaboration and the knowledge and skill set to perform a variety of regional techniques such as transarterial and paresthesia-seeking approaches to the brachial plexus block, ultrasound-guided suprainguinal fascia iliaca and pericapsular nerve group blocks for hip analgesia, nerve stimulator-guided femoral and proximal thigh (anterior and posterior) sciatic nerve blocks for lower extremity operations and the landmark-based ankle block for foot surgery.
KATH anesthesiologist Dr. Anastasia Ohene and
2017/2018 RAAPM Fellow Dr. Patrick Laughlin
take part in a clinical skills examination
GRACE Tools: View GRACE article
To get in touch with the GMHED team, please contact our Program Coordinator, Lindsey Janoskie, by phone at (646)714-6577 or via email at email@example.com.