Global Musculoskeletal Health Equity Division (GMHED)

About GHMED

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. Learn more about GRACE

Due to the success of our anesthesia programs and the need for greater musculoskeletal surgical capacity in RLS, HSS endorsed the creation of GMHED in 2021. The HSS Global Musculoskeletal Health Equity Division is a division of HSS Global Partnerships founded 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.

The program aims to incorporate 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.

Orthopedic trauma patients wait for days, sometimes weeks in the hospital wards just to be seen by a qualified healthcare practitioner.

Our Mission

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, building local research infrastructure, and supporting efficient quality improvement innovations.

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:

• Assist partners on their terms, i.e. prioritize local agendas and timelines over our own, and, when possible, integrate our efforts into preexisting programs rather than impart new ones.
• Put collaboration ownership into our partners’ hands and allow local leaders to decide how resources can best be used to help their providers and patients.
• Build self-sustaining programs that can eventually be maintained locally without outside assistance.
• Periodically evaluate our programs’ success in order to use the results to inform improvements, publish useful findings and demonstrate progress to HSS and outside sponsors.
• Use sound scientific principles and methodology to assess needs and evaluate programs.
• Increase public recognition of the global musculoskeletal disease burden and inequities that exist in resource-poor settings in regards to access to treatment that is timely, affordable and high-quality.
• Share knowledge and resources freely for the betterment of the global health community.

Our Approach

Using Implementation Science to guide a systematic and outcomes-based approach to global health, we are utilizing the RE-AIM framework. Starting with a stakeholder meeting with all relevant members, each service line conducts a needs assessment to understand the needs of their specialty at a RLS site. The result of a needs assessment is a specifically tailored intervention that is meant to improve capacity. In our experience with both of our currently active sites, we have found that the need for subspecialty training in many areas is without a doubt, the overwhelming need.

After instituting the intervention with our team and local champions, we then evaluate the intervention using RE-AIM. Our goal is to teach until we find the local providers are self-sufficient and can then perpetuate the learning to their colleagues and trainees.

Below is a graphic representation of our GHMED model:

Each of our sites, and each service line at these sites, are in different stages of this model. Ultimately, our goal is to exit a site after 2-5 years, once we have confirmed self-sufficiency among the local providers. While we provide continuing education and feedback, it is mostly limited to virtual exchanges with the RLS.

Our Team

Leadership

Swetha Pakala, MD
Co-Chair GMHED

Swetha Pakala, MD

Co-Chair

Dr. Pakala is a board-certified anesthesiologist at HSS and a Clinical Assistant Professor of Anesthesiology at Weill Cornell Medicine. She is a well-recognized expert in the use of regional anesthesia in international health and resource limited settings. For her work as her department’s Global Health Initiative Co-Chair, Dr. Pakala was the first recipient of the Leon Root, MD Community Service Award in 2019. This award recognizes the outstanding leadership of those making significant contributions to the community through initiatives that improve the care of vulnerable and underserved populations. Since joining HSS in 2012, Dr. Pakala has been involved in several public health initiatives, short-term surgical missions, and sustainable teaching efforts in countries around the world including Vietnam, Uganda, India and Ghana. She completed her medical school and residency training at the University of California, San Francisco and received further specialization in Regional Anesthesiology and Acute Pain Medicine at HSS.

View Dr. Pakala's profile

Mark Brouillette, MD
Co-Chair GMHED

Mark Brouillette, MD

Co-Chair

Dr. Brouillette is an anesthesiologist within the Department of Anesthesiology, Critical Care & Pain Management. He completed medical school at University of Colorado and residency at University of Kansas prior to undertaking specialized training in Regional Anesthesiology & Acute Pain Medicine at HSS in 2017/2018. Dr. Brouillette began global health work in Ghana in 2008 and has been active teaching and researching there ever since. At HSS, he is the Co-Chair of the department’s Global Health Initiative. He is also a teacher for the World Federation of Societies of Anaesthesiologists Fellowship program in Ghana and serves as Vice Chair for the American Society of Regional Anesthesia’s Global Health Special Interest Group.

View Dr. Brouilette's profile

Jawad N. Saleh, B.S., Pharm.D., BCPS, BCCCP
Executive Director

Jawad N. Saleh, B.S., Pharm.D., BCPS, BCCCP

Executive Director and Pharmacy Champion

Dr. Jawad N. Saleh, B.S.Pharm., PharmD, BCPS, BCCCP is a registered pharmacist who is dual board-certified in Pharmacotherapy and Critical Care. He currently serves as the Manager of Clinical Services and Critical Care Specialist for the Pharmacy Department at the Hospital for Special Surgery. He is an Assistant Clinical Professor for the St. John’s University College of Pharmacy and Health Sciences and acts as a mentor for future pharmacists. Dr. Saleh received his Bachelor’s of Science in Pharmacy and his non-traditional post Doctor of Pharmacy degree from St. John’s University in Queens, New York. He is currently enrolled in the Harvard Medical School Master in Clinical Service Operations program with a strong focus to optimize efficiency and improve patient outcomes. Dr. Saleh created and implemented the first pharmacy clinical program at the Hospital for Special surgery. He authored and co-authored publications and presentations regarding perioperative impacts on patient care. He has presented numerous topics on both a national and regional level at organizations such as ASHP, FAH, UGM and Becker’s Healthcare. He also sits on several advisory boards to facilitate and improve innovative products coming to market. As the Pharmacy Champion on the Global Musculoskeletal Health Equity Division (GMHED) at HSS, Dr. Saleh utilizes evidence-based pharmacy best practices to improve musculoskeletal care in resource limited settings at home and abroad. Dr. Saleh is the secretary for the Pharmacy and Therapeutics Committee and co-chairs both the Antimicrobial Stewardship Committee and the Hematology Workgroup. He is the co-founder and co-chair of the hospitals Opioid Stewardship Committee and worked on countless quality initiatives within the organization. He currently holds a position on the Diversity, Equity and Inclusion leadership council and is a contributing member of numerous committees within the Hospital for Special Surgery.

Email:salehj@hss.edu

Linkedin

Physician Leads and Service Line Champions (HSS)

Andrew Grose, MD, MSc
Orthopedic Surgery

Andrew Grose, MD, MSc

Trauma Surgery Champion

Dr. Andrew Grose is an orthopedic surgeon specializing in the treatment of simple and complex fractures of the pelvis and extremities, as well as joint replacement of the hip and knee. He completed two fellowships at Hospital for Special Surgery, the first in adult reconstruction/joint replacement and the second in orthopedic trauma. For the past 12 years he has worked at level 1 trauma centers in close coordination with neurosurgeons, plastic surgeons, acute care trauma surgeons, chaplains and psychiatrists to restore patients following severe trauma. In addition to treating acute fractures, he also cares for patients referred to him for infection, nonunion, and malunion following trauma, and does both primary and revision hip and knee replacement surgery. Since 2011, Dr. Grose has studied and worked extensively in the field of patient safety. He was the recipient of an American Hospital Association-National Patient Safety Foundation Comprehensive Patient Safety Leadership Fellowship, and subsequently earned a Masters degree in Human Factors and System Safety. His area of interest is the direct observation of individuals and teams at work to promote both self-improvement and uncover system concerns that can be corrected to improve quality and safety.

View Dr. Grose's profile

Mark Brouillette, MD
Anesthesia

Swetha Pakala, MD
Anesthesia

Harmandeep Singh, MD
Chronic Pain Management

Harman Singh, MD

Chronic Pain Management

Dr. Harmandeep Singh is an interventional pain medicine physician who specializes in non-operative management of musculoskeletal, spine, and neurological pain syndromes. Dr. Singh understands the debilitating nature of acute and chronic pain that can affect a person's life physically, mentally, and emotionally. Therefore, he prioritizes a comprehensive patient assessment and individualized treatment plans to aid in improving functional status and quality of life.

View Dr. Singh's profile

Jawad N. Saleh, B.S., Pharm.D., BCPS, BCCCP
Pharmacy

Niharika Thakkar, PhD
Research

Niharika Thakkar, PhD

Research Champion

Niharika was born in India, and completed her schooling and junior college degree in Science from Bombay (now Mumbai). By 2009, Niharika graduated with a major in Psychology, and a minor in English literature, from Fergusson College, Pune. She earned her Master’s Degree in Clinical Psychology in 2011, ranking first at Fergusson College in the final semester. As part of her Masters, she completed a clinical internship and wrote her thesis in Graphology and Personality. At college, she excelled in academics and shined through when she was awarded the “most deserving candidate of the year” scholarship in her final year in 2011. Thereafter, until 2015, she worked in India as a clinical Psychologist at a hospital, headed the Psychology Department at a Rehabilitation Center, as a post-graduate teacher of Psychology, as well as ran her independent clinic in collaboration with Psychiatrists. In March 2015, she moved to USA, and also started her PhD journey in “Bullying and Victimization among Adolescents in India”, at the Department of Social and Behavioral Sciences at Leiden University, The Netherlands. Alongside her PhD, Niharika was involved in a National Science Foundation (NSA)-funded research project that focused on the conceptual understanding of key algebra concepts at the City University of New York. She later moved on to work as a Research Associate at the Center for Family Services, in greater New York. In July 2020, she founded PsychLine.in, an online mental health organization that aims to provide good-quality care and education to all in India. Niharika completed her doctorate in 2022, and has several international publications to her name. She was also recently invited by Elgar Publishing (UK) to contribute a book chapter to the Global Handbook of Bullying and Violence. Niharika is an internationally rated Chess player, loves to travel, and is a hopeless dog lover. She has a rabid social conscience, and wishes to pursue her purpose in creating global mental, emotional, and social health awareness.

Team Members

Erica Tafuro, MD

Erica Tafuro, MD, MBA

Dr. Erica Tafuro is a board certified anesthesiologist at Hospital for Special Surgery specializing in regional anesthesiology. Dr. Tafuro completed her anesthesiology residency at Montefiore Medical Center where she also served as chief resident in her final year. After residency, she completed a fellowship in regional anesthesia and acute pain medicine at HSS, accepting a position to return as an attending physician.

View Dr. Tafuro's profile

Lucia Lee, MD

Lucia Lee, MD

Dr. Lee is an assistant attending anesthesiologist at Hospital for Special Surgery.

GMHED Collaborations

GMHED is currently active at two sites in RLS: Ghana and India.

Each site is in different stages of progress within the GMHED framework.

Ghana 

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.

GMHED Progress: 

Regional Anesthesia

• Carried out GRACE training in ultrasound-guided regional anesthesia to Anesthesia department at KATH from 2017-2023 
• Developed a Regional Anesthesia and Chronic Pain Fellowship at KATH from 2021- current 
  • KATH Fellows: Obiageli Ofungwu, MD, Sophia Ankrah, MD, Gifty Sarpong, MD 

Chronic pain:

Dr. Harman Singh is currently leading the pain management global health initiative to establish and validate a framework for improving chronic pain care access through partnerships, education, training and capacity building in resource-limited settings. Currently, he is collaborating with Komfo Anokye Teaching Hospital (KATH) in Ghana to help establish a chronic pain division, train new pain management fellows, increase chronic pain management capacity, and improve access to care for patients.

Pharmacy:

Dr. Jawad Saleh is leading GMHED’s pharmacy branch. He has focused on areas such as global pharmacy assessments and standardization efforts to significantly improve healthcare outcomes in under-resourced regions, ensuring equitable access to quality pharmaceutical services and contributing to overall health system strengthening.

Surgery:  

Based on our unique needs assessment, including input from the government to the local interests of nurses and surgeons we idenitified the need for subspecialty fellowships in all fields of orthopaedics (they currently have only generalists) with the plan to make Komfo Anokye Teaching Hospital a center of orthopaedic excellence. This involves partnerships with Harvard and University of Calgary, for domains like musculoskeletal oncology and sports medicine, as well as internal partnership with Foundation for Orthopaedics and Complex Spine for planned spine and arthroplasty fellowships.  

This year we started with our trauma program, using an OTA-based curriculum developed in concert with the Ghanaian College of Physicians and Surgeons.  Dr. Andrew Grose is supervising this, with visiting experts from Netherlands (Diederik Verbeek & Peter Kloen), Canada (Geoffrey Wilkin & Allan Liew), and the US (David Wellman, Gele Moloney, Jaimo Ahn, Milan Sen, Kanu Okike, Jason Mckean and Charles Cornell).

With respect to the orthopaedic aspect of our work in Ghana, this project includes training of nursing, surgical techs, central sterile professionals, and will also include upgrades to anesthesia machines, OR tables, and hopefully new central sterilization systems. We have also worked to find cost-effective but good quality instrument/implant supply to make this sustainable within the Ghana economy.

India

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.

GMHED Progress:

Regional Anesthesia Training program:

Initiated the GRACE Training Protocol to teach ultrasound-guide regional anesthesia to a group of 14 members of the OGH Anesthesia Department.   

• Taught the program from 2019 to 2023 
• Currently evaluating the uptake and dissemination of GRACE skills at OGH

Point of Care Ultrasound (POCUS) Training program:  

Point-of-care ultrasound (POCUS) has become quite popular in the U.S. because of its wide range of uses and benefits. However, in the field of anesthesiology, there is a lack of standard practice and training, especially in low-resource settings. Additionally, the utility of POCUS is tremendous in RLS, as the modality enables immediate diagnosis and intervention without the need for prohibitively expensive imaging. We conducted an assessment at Osmania General Hospital (OGH) to understand the specific training needs for POCUS. This helped us create a tailored training program that fits the needs of these settings and ensures it is sustainable.The GMHED team organized a week-long, hands-on training course for POCUS in February of 2023, which included fellows, experienced anesthesiologists, and POCUS experts. We collected and analyzed data before and after the training to measure its effectiveness. We returned to OGH for a follow-up refresher course in December 2023. Our experience in India helped us develop a blueprint for POCUS training that can be used in other low-resource settings.

Trauma Surgery:  

We are currently in the needs assessment phase for trauma at OGH. Dr. Jason Mckean teaches orthopedic trauma at OGH while assessing their needs.

Teaching and Research

Regional Anesthesiology Fellowship

In 2013, Dr. Swetha Pakala launched a global health track of the HSS Regional Anesthesiology & Acute Pain Medicine Fellowship. One to two fellows per year have 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 a concise education or research-focused project 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, and enhanced fluency in multidisciplinary and cross-cultural communication and collaboration. Based on the project of each fellow’s choosing, he or she will have the opportunity to teach the expertise they have learned at HSS in a low-resource setting. To date, completed teaching programs have included ultrasound-guided regional anesthesia and point of care ultrasound (POCUS). 

Current and Past Fellows:

2013/2014: Carolyn Dejean and Jesse Ng
2014/2015: Anjali Rosario
2015/2016: Lee Rasamny
2016/2017: Lauren Nakazawa
2017/2018: Mark Brouillette and Patrick Loughlin
2018/2019: Benjamin Johnson and Joseph Keaveney
2020/2021: Kareem Zuaiter and Mark Harris
2021/2022: Desean Thom
2022/2023: Erica Tafuro and Lucia Lee
2023/2024: Monica Anise and Jason Haidar
 

Research

The Global Musculoskeletal Health and Equity Division at the Hospital for Special Surgery is dedicated to advancing global health equity through cutting-edge research and innovative approaches. Our research approach is grounded in Implementation Science and the RE-AIM model, ensuring that our findings are not only scientifically robust but also practically applicable and impactful on a global scale.

Implementation Science is a key focus of our research strategy. This discipline emphasizes the systematic uptake of research findings and other evidence-based practices into routine practice, thereby improving the quality and effectiveness of health services and care. By leveraging Implementation Science, we aim to bridge the gap between research and practice, ensuring that our discoveries lead to real-world health improvements.

The RE-AIM model further guides our research efforts. RE-AIM stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance, and it provides a comprehensive framework for evaluating the impact of health interventions. This model helps us to:

• Reach: Assess the extent to which our interventions reach the target population.
• Effectiveness: Evaluate the impact of our interventions on important outcomes, including health status and quality of life.
• Adoption: Determine the uptake of our interventions by target settings and institutions.
• Implementation: Examine the fidelity and consistency of our interventions as they are delivered in real-world settings.
• Maintenance: Assess the sustainability of our interventions over time.

By integrating Implementation Science and the RE-AIM model, our division ensures that our research is not only innovative and evidence-based but also practical and sustainable. This approach allows us to make significant strides in improving musculoskeletal health and equity worldwide, ultimately enhancing the quality of life for individuals and communities across the globe.

Publications

• Brouillette MA, Kaiser SP, Konadu P, Kumah-Ametepey RA, Aidoo AJ, Coughlin RC. Orthopedic surgery in the developing world: workforce and operative volumes in Ghana compared to those in the United States. World J Surg. 2014;38(4):849-857. doi:10.1007/s00268-013-2314-0 
• Brouillette MA, Aidoo AJ, Hondras MA, et al. Anesthesia Capacity in Ghana: A Teaching Hospital's Resources, and the National Workforce and Education. Anesth Analg. 2017;125(6):2063-2071. doi:10.1213/ANE.0000000000002487 
• Brouillette MA, Aidoo AJ, Hondras MA, et al. Regional anesthesia training model for resource-limited settings: a prospective single-center observational study with pre-post evaluations. Reg Anesth Pain Med. 2020;45(7):528-535. doi:10.1136/rapm-2020-101550
• Dohlman LE, Thakkar N, Jivanelli B, Pakala S, Brouillette MA; Global Regional Anesthesia and Pain Management Research Group. Regional anesthesia global health collaborations- a scoping review of current intervention methods. Curr Opin Anaesthesiol. 2022 Oct 1;35(5):647-653. doi: 10.1097/ACO.0000000000001178.
• Pakala S, Brouillette M, Thom D, Hargett MJ, Reddy N, Gbaje E, Thakkar N. Anaesthesia global health programmes in North America: organisational structures and impact of the COVID-19 pandemic. Br J Anaesth. 2023 Apr;130(4):e445-e447. doi: 10.1016/j.bja.2023.01.010.

Interns and Research Assistants

GMHED is committed to mentoring interns or research assistants who are interested in global health within the musculoskeletal space. 

Current interns:

• Viren Seghal, Medical Student, MS2: CUNY 
• Kingsley OseiKariKari, Medical Student, MS3: Cornell
• Alaka Gorur, Medical Student, MS4: Columbia
• Niyam Reddy, Pre-medical Student, Pepperdine University

External Relationships

Corporate and Non-profit Relationships

Johnson and Johnson
Synthes
Americares
Project cure
FOCOS Orthopedic Hospital

Academic and Society Relationships

UCSF: University of California, San Francisco: Center for Health Equity in Surgery and Anesthesia
Harvard Musculoskeletal Oncology
Texas Children's Hospital
University of Calgary Sports Medicine
WFSA: World Federation Society of Anesthesiologists
ASRA: American Society of Regional Anesthesia
USABCD: UltrasoundAirwayBreathingCirculationDolor

Funding and Support

GMHED is currently funded through the generous support of HSS, and operates with the assistance of implant/equipment donations from Synthes and Johnson & Johnson.  We are actively working to fundraise for the program, in order to expand the scope of our work.

If you are interested in donating to this important cause, please visit www.hss.edu/give and enter GMHED as the designee for the donation.

Thank you!!