The American College of Surgeons (ACS) Operation Giving Back (OGB) initiative was created with the mission “to leverage the passion, skills, and humanitarian ethos of the surgical community to effectively meet the needs of the medically underserved.”* Fellows of the ACS are committed to this vision and are providing care to underserved patients around the globe.
In an effort to acknowledge the service that these surgeon-volunteers provide, OGB is profiling some of these volunteers and partners to showcase their work and to describe how they met specific challenges providing care to the medically underserved around the world. This month’s profile is an interview with Nia Noelle Millan Zalamea, MD, FACS, a general surgeon in Memphis, TN. Dr. Zalamea is involved in two international volunteerism programs—the Memphis Mission of Mercy and the University of Tennessee Health Sciences Center Global Surgery Institute (UTHSCGSI).
Describe the aims of the Memphis Mission of Mercy.
Memphis Mission of Mercy is a family-run, not-for-profit organization founded by my mother, Norma Zalamea, RN, and my father, Renato Zalamea, CRNA. This organization has delivered short-term medical and surgical care to various communities in the Philippines annually, and sometimes biannually, since 1999. Our model has been short-term medical and surgical care, in the form of open clinic and elective major operations. Our scope of care primarily includes otolaryngology and general surgery procedures, with an average of 40 major surgical cases per mission. Our team continues to evolve from relationships with health care professionals, family, and friends who either live, work, or have trained in Memphis. This network has generated a log of more than 150 volunteers.
Why did your parents start Memphis Mission of Mercy?
My parents are both from the Philippines and started Memphis Mission of Mercy because they saw an opportunity to serve our native country. In 1998, my father participated in a mission trip to Guyana organized by the American Association of Nurse Anesthetists (AANA). While there, he taught professionals about regional anesthesia, covering everything from blocks to spinals and epidurals. On the way back to the U.S., he was thinking about what he might be able to accomplish in the Philippines, an area of even greater need. John Hodges, MD, FACS, an ear, nose, and throat (ENT) plastic surgeon, overheard my father discussing the idea with a colleague in the recovery room at Methodist Hospital in Memphis and offered to be our first volunteer physician. The rest is history.
How do patients find out about the Memphis Mission of Mercy?
We share and promote the Mission of Mercy work in targeted communities in various ways: through social media, via local community health care providers and social workers, friends and family of volunteers who spread the word in their communities, previous patients who have friends or family with health care needs, and area leaders and politicians with whom we have worked in the past and who follow our movement in the country. The local military, police, and clergy also help to promote the upcoming missions to people in remote and mountainous areas using open speakers on trucks, at health fairs, announcements at church services, and so on.
What criteria must patients meet to receive care through the Memphis Mission of Mercy?
Memphis Mission of Mercy partners with local social workers, community health workers, and hospital administrators to focus on patients with limited resources. We have no hard and fast financial line. The local community leaders and workers help us target people with economic and medical need. This level of screening and targeting is for our surgical patients. All patients are welcome, however, as we have an open and free clinic staffed by primary care professionals. We almost always identify candidates for surgery here as well.
The other international volunteer program you work with is the UTHSCGSI. What was the impetus for starting this program?
The UTHSCGSI is a developing division within the department of surgery with the purpose of better organizing, supporting, and developing opportunities for work and training in low- and middle-income countries (LMICs). The initiative sprang from a discussion between myself and Martin Fleming, MD, FACS, chief, division of surgical oncology, UT. During a physician leadership class, in the fall of 2015, I told Dr. Fleming that my family was looking to perform more long-term work in the Philippines, possibly by forming a mission hospital. For the past year, we have engaged with new and old partners alike, including academic partners, to establish a mission hospital for the purpose of developing a surgical system of care for low-income patients around the world. It was out of this conversation that we began to learn about the level of interest among faculty, residents, and students to provide care in LMICs.
To learn more about this interest in working in LMICs, we deployed a survey during a four-month period of time. Our survey was limited to UT Memphis medical students, surgical residents, and surgical faculty. Surgical departments that were a part of the survey included the following: ENT, general surgery, pediatric surgery, pediatric thoracic, and urology. These departments represent faculty members who expressed an interest in participating in developing the vision of this institute. A total of 64 medical students, 40 faculty members, and 23 surgical residents responded to the survey for a total of 127 respondents.
From this study, we learned that faculty respondents engage in a combined total of 58.5 weeks of surgical work in LMICs annually. Not only is the interest in international rotations and experience high among surgical residents and medical students, but more than half of the trainees and student respondents said they have already engaged in medical and/or surgical volunteer work in a LMIC. Armed with the knowledge of this on-the-ground activity, coupled with a strong interest in these opportunities as revealed in this survey, we decided that now would be the time to grow and sustain the work that we do in LMICs.
In addition, there is a distinct parallel between our work with the medically indigent patients in Memphis and the work that we perform in the communities we serve overseas. We know that a better understanding of the social history of our surgical patients in Memphis makes us not just better surgeons, but better physicians in general. This knowledge is applicable in the international setting as well. We also understand that lessons learned from our work in LMICs strengthen and inform our work here at home. We aim to dig deeper into this reciprocal relationship.
The UTHSCGSI will support and help coordinate work that is already being carried out by the UTHSCGSI faculty in South America, Africa, and parts of Southeast Asia.
What is the relationship between the UTHSCGSI and Memphis Mission of Mercy?
The two organizations are collaborating to establish a permanent mission site in Victorias, Negros Occidental, the Philippines. Victorias has a population of slightly more than 90,000 people, but that population is distributed among several islands where the poor have limited access to primary care, much less to surgical care. To find our mission home, we gathered public health data and accessed information from several towns and communities with which we had an existing relationship. We settled on the town of Victorias based on need.
What are the health care needs of the people served by this collaboration?
The community of Victorias is one of the largest in the region. The population is largely composed of plantation workers, laborers, and impoverished people. Approximately 40 percent of the population has nutritional deficiencies, and 20 percent of the population lives below the poverty line.
The community we are looking to serve has access to primary care for indigent patients, fueled with financial support from a local foundation that is supported through contributions from local philanthropists and businesspeople. The primary care center offers urgent care, emergency room, and infirmary services, as well as some cancer screenings, including fecal occult blood tests (FOBT) and pap smears with visual inspection and acetic acid. In 2016, 73 cancer patients were diagnosed in Victorias, and as of March 2017, a total of 47 had already died. Access to surgical care is a challenge, and poor patients on the island and in the region have limited access to surgical services.
Cancer remains a largely untreated disease in the region of Victorias. As was stated earlier, there is minimal screening, partially due to cost and access. There is no colon cancer screening, aside from FOBT, and mammography is costly. Unfortunately, the incidence of breast and colon cancer is on the rise in the Philippines, partially attributed to the emulation of the Western diet.
No formal or published data are available on untreated surgical issues in the community because medically indigent people often do not seek medical care for surgical problems until they need emergency care. Elective surgery is really reserved for those patients with financial means. The limited patient data that Victorias has shared with our team include the following:
- The top five chronic diseases in Victorias are pulmonary tuberculosis; chronic obstructive pulmonary disease; diabetes/hypertension/cerebrovascular disease; cancer (all types); and chronic kidney disease.
- The top five acute diseases in Victorias are acute respiratory infection (bronchitis, pneumonia); acute gastroenteritis and intestinal parasites; acute myocardial infarction; acute urinary tract infection skin lesions; and infections, often related to trauma and resultant wounds.
Our collaborative efforts have served this community eight times on short-term missions, and each time we have been invited to include surrounding island communities of need.
What is the ratio of physicians to patients in the region that you will be serving through this collaborative effort?
From the city of Victorias, a total of 20 surgeons are within one-hour driving distance of a population totaling more than 600,000. This total does not include the communities that access care in Victorias by boat. These surgeons are of various disciplines (orthopaedics, general surgery, and so on), but patients with limited resources are unable to access such care on an elective or planned basis. As a result, many people obtain care only in the most catastrophic of circumstances—not unlike what happens with uninsured patients here in the U.S.
How did you become interested in the health care challenges facing patients in Victorias?
We were introduced to the community of Victorias by an orthopaedic surgeon from the neighboring town of Bacolod City. He was in Memphis doing some training at Campbell Clinic Orthopaedics, and when we were looking for a site, he introduced us to Victorias. What then followed was a series of eight Memphis Mission of Mercy short-term visits since 1999. We have come to deepen our knowledge and understanding of the community, and the community has done the same with our mission group.
How do you get funding?
Memphis Mission of Mercy’s funding begins with our original contributors: my family, our family friends, and then every volunteer who has come with us, as well as friends in the community who have supported our work. Each mission volunteer is responsible for his or her own plane ticket, but the host community provides board and lodging on our short-term missions. Our surgical instruments have been donated by area hospitals in Memphis, but we also have a relationship with Scanlan International, which has generously supplied us with high-quality ear, nose, and throat, plastic, and general surgery instruments.
With respect to the disposable or nonreusable supplies we use, we acquire much of that equipment through donations from hospitals in the Memphis area, including Methodist Le Bonheur; Regional One Health; Baptist Memorial; St. Francis; Johnston Memorial Hospital, Abingdon, VA; and Santa Barbara Cottage, CA. We also purchase supplies through Medical Assistance Program International, Americares, and Ethicon. We joke that we are equal opportunity beggars with regard to resources, supplies, and donations. All of these sources contribute by saving us out-of-pocket expense. Our annual short-term medical and surgical mission work has an average cost of approximately $15,000, which serves an average of 1,800 patients in clinic and 65 in surgery, for a per patient cost of $7.82. If we perform a surgery-only mission, our annual cost is down to $7,000–$8,000.
What educational resources do your efforts use?
I am working with the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Global Outreach Committee. We are building the hospital to accommodate telemedicine capability for the purpose of conducting grand rounds and morbidity and mortality conferences.
Where do you see the future of the health care situation in the areas you serve?
We aim to supplement the existing infrastructure in the community, and invite others to join us. The academic partnerships need to cross country lines. We look forward to partnering with academic institutions in the Philippines so that the learning is cross-cultural. We anticipate that by bringing relationships, resources, and infrastructure to partner with the community, we may be able to invite people in the community to serve, as well. Ultimately, we believe that by working in this sort of international surgery center, we can convene like-minded and mission-driven people so that in time, the community and local health care professionals will be able to sustain it independently.
What advice would you give other health care providers who want to work with underserved patients or who are interested in starting similar programs?
I don’t think of any of us as experts in this work, as we have learned much and continue to learn every day, but I think the strength and depth of work is dependent on relationships and need. A great way to begin this kind of project is by listening to the people around you; be with the people you serve and get to know them. Try to understand and ask about their challenges, barriers, and needs. If this is domestic work, find partners who have similar interests, or other organizations that may serve your targeted community in a different way.
Find the gaps in the system, and consider whether you can mold or modify what you do to fill the void. If our mission is to serve, then we can allow the need and the people to shape how and where we serve. All that mission leaders bring is the “why.” I have found that every time we try to recruit surgeons and other physicians to serve with us, they never give “no” as their answer. The barriers that keep people from serving are the same challenges that affect any of our decisions: financial, family, work commitments, and so on. It is a matter of finding a mutually compatible time.
You mentioned a parallel between your international outreach work and serving low-income patients in Memphis. Could you expand on that concept a bit?
Domestically, I have worked in a private for-profit setting, then a private not-for-profit setting, and now I am in an academic-affiliated, hospital-employed practice. In working for a not-for-profit and now working for a hospital, I have been blessed with the opportunity to target my work to the under- and uninsured. While at the not-for-profit Church Health Center, we partnered with a hospital that gave us the financial backing to write off the expenses we incurred providing care for the center’s surgical patients. When I transitioned to my present hospital-employed practice, I negotiated with the hospital chief executive officer to not only bring my entire uninsured practice from the Church Health Center with me, but also to remain the main surgical referral target for the Church Health Center and other faith-based not-for-profits that provide care to the poor in Memphis. It is wonderful to find like-minded institutions and leaders with a mission to care for the poor. The patient population continues to be around 85 to 90 percent uninsured, with the remaining being mostly Medicare or Medicaid patients.
My advice to anyone interested in serving domestically is to first find and surround yourself with professionals who think and work similarly, or who at least understand and support your mission. Second, don’t be afraid to negotiate volunteerism into your contract. We negotiate call schedules, vacation, Continuing Medical Education, and so on, so I think we can and should negotiate outreach and service with just as much gusto and enthusiasm. It is one of many ways we can bring our community and its needs to the table. When I negotiated the contract for my present position, my key stipulations were the ability to continue mission work abroad, and the ability to have an open door to my more than 800 patients from the Church Health Center, as well as new consults from the center and other providers with unlimited uninsured and Medicare/Medicaid patients. When I expressed surprise at the immediate affirmative response from our chief executive officer, he said that he spends more time negotiating “call schedules and Teslas,” so my requests came as a breath of fresh air. We should be careful in assuming that only physicians and nurses go into health care to help people.
What advice would you give other health care professionals who want to provide volunteer and humanitarian services more generally?
I co-facilitate a course called Serving the Underserved at UT for medical, pharmacy, dental, and other health care students. We teach that the foremost aspect of service and volunteerism is first to strive for excellence in all that you do. One of the most disparately distributed and unjust aspects of care for the poor is quality. Being involved in quality improvement does not necessitate that we be in high-resource settings. It requires that we care enough to see patients through to the end result and back around again. It asks us to be humble and to always learn from our work and patients’ experiences.
The other lesson I have learned is that we need to continually ask ourselves why we do what we do. Do I serve because I feel called to do so? Is this a way to live out my faith? Do I serve because I love humanity? Do I feel obliged? Once we have our why, we can set honest expectations. For me, working with poor and marginalized patients certainly is rooted in a sense of justice, but, more so, I have realized that my work is a way to truly live my faith. Working with the poor is a way for me to love. With that in mind, especially in rough spots, I turn to the scriptures, and sometimes to this statement by Mother Teresa for clarity: “We are not called to be successful. We are called to be faithful.” This is my individual view of why I do what I do.
What can the ACS and OGB do to help?
The ACS and OGB are already helping by creating and inviting people to contribute to the database of volunteers and opportunities. I would love for us to have an ACS Surgeon Specific Registry for our international work. When we have the time, we enter our data into the database, but I am not sure volunteers do this consistently. It would be illuminating to compare my thyroid or hernia outcomes with those of surgeons doing similar work in similar contexts in other parts of the world. The data boxes would need to include some factors like water sources, operating room set up, availability of energy sources, and so on.
Also, with regard to the educational work, it would be helpful to share curricula across continents. SAGES is doing some work with an international laparoscopy curriculum, but I believe the College can contribute a quality improvement curriculum and other educational resources.
Lastly, The Lancet Commission on Global Surgery work gave us a beautiful map of surgeons and areas of shortage and challenge as part of the Global Surgery 2030 campaign. It would be great to be able to map the work that surgeons do through ACS OGB and compare it with those that the commission has identified. I can only guess that millions of private dollars are spent annually on work like ours. We need to work smarter.
I think it would be helpful for someone who is thinking about pursuing this work to look at the map, see what areas are not being served, and maybe go there and start learning. Similarly, it would be great to identify areas in which overlap occurs. We run into other volunteer health care provider groups at the Manila airport on occasion, and it makes me wonder about redundancy. If we are in this work then we have a responsibility to distribute resources in a way that not only demonstrates good stewardship, but more importantly, in a way that is most helpful to the community.
*American College of Surgeons. Operating Giving Back. About Operating Giving Back: Our Mission. Available at: facs.org/ogb. Accessed July 20, 2017.