Grey Water

Today I woke up without an alarm, an outlier to even my weekend routine since I left Ethiopia last in 2020. Also today, different from my last 3 years I awake immediately energized, excited, and enthusiastic to start the day. I peel off my cheap duvet and pop out of my bed constructed of two carefully bolted single mattresses and make my way to the shower.  Ethiopia prepared me for this, a quick 20 second burst of water, lathering of soap and then another quick 20 second burst to wash off. Except this water isn’t ice cold, what a treat.

              I can’t help but notice though that in my efforts to conserve water, it pools away from the drain. I use my feet and decades of soccer training to direct the gravity-induced, misbehaving water to its intended double-cylindered drain mechanism. While allowing debris to be filtered out in the first, the water eventually finds its way to the central cylinder. Here it is again induced by gravity and pulled into a system of pipes and collected as “grey water” to later be processed and used again to conserve water.

              I get dressed and walk up a flight of metallic steps in the “C Stairwell”, grab a cup of coffee and find a shady space to sit. As I stare out into the horizon of cascading high-rises, all with various off-white facades and structural integrities, the nearby orange lifeboat rises and falls gently as if the structure I sat on is taking slow and steady breaths. Above me, a small group of guys play short-sided soccer on a court entirely enclosed by netting. I haven’t yet raised the courage to ask to join, although I want to. The embrace of the warm, water-laden air combined with the smells and hazy horizon are all nostalgic to me, although I’ve never been here before.

              Everyone’s lives have changed a lot over these past 3 years, as has mine, but my sense of purpose, duty or whatever you want to call it has matured exponentially. My life-goal is to take the advantages I have to serve the underserved. I do (and will do) this through teaching, researching, mentoring and medical practice. If you haven’t already guessed, I’m currently doing so on a massive ship docked in the port of Dakar, Senegal with a decades old medical organization called Mercy Ships. At the tail end of my two weeks here, I will venture back to Ethiopia for the first time since I left in 2020 with the hopes of meeting up with my dearly missed friends from all over the country.


**Holland is not pictured here but she is responsible for most of the fun cartoons 🙂

To understand why I’m more energized today compared to most and why my commonly tangential thinking rests with grey water currently, I will need to explain whats happened over the last 3 years. The following is a self-serving, introspective and decidedly less entertaining explanation of where I sit today and how I got here. I will not be offended if you stop reading here, satisfied with the brief life update and I wholeheartedly appreciate your time and interest. Its been a while!


              As most of you know from one of my last posts in Ethiopia, my original plan to do locums in the states for a bit and then come back to Ethiopia failed, but one of the readers of the blog and a fellow pediatric ENT reached out and offered her position at Western University in Canada, temporarily, while she was on maternity leave. I jumped on the opportunity and by October of 2019, I was working in their children’s hospital getting reacquainted with high-income country surgery. It was like riding a bike and my Canadian hosts we so inviting, helpful and kind. I fit in well, integrated with the residents and even brought one of their residents with me back to Ethiopia in January of 2020. It was amazing to see. I had been gone for about 3 months and it was like nothing had changed. The quality of care was excellent, self-sustainable and a new batch of residents integrated in seamlessly. They didn’t need me at all. Both a sad, but incredibly satisfying reality. Days after I returned back to Canada, the COVID Pandemic took a hold of Canada and the hospital systems intentionally shut down. Now Canada no longer needed me.

At the same time, I joined a newly formed group called The Global OHNS Initiative (created by a mentor of mine, Dr. Blake Alkire). Conversations with the group were intensely stimulating and dived into the ways in which, us as a head and neck surgical community, could address the global burden of surgical head and neck disease. These meetings became my Saturday morning routine, connecting via zoom with people all around the world. Which was a needed distraction because no elective surgery was occurring at our hospital. Within this group, I’d partner with dozens of international ENTs, brainstorm, discuss, study and publish a half dozen articles in the next 2 years. If you’re interested, we discussed topics from an unseen burden of surgical disease, to the impacts of global gender disparities, to authorship inequalities in academic research, among others.

By the time COVID negated Canada’s need for my expertise, I had already accepted a position at Mayo Clinic Rochester to replace a fantastic pediatric airway surgeon that had moved on to a new job before the pandemic started. After finishing my time in Canada, I road-tripped through the closed US/Canadian border to start my new job, in the middle of an intense pandemic, in July of 2020. As I slowly ramped up at Mayo, I started my Master’s in Global Surgery with the University of British Columbia. Over the next 2.5 years, I will gleefully immerse myself within academic global surgery. My experience in Ethiopia provided a vital perspective, context and fuel for balancing the rigors of a full time job and complex subject material, homework and papers.

              This was a humbling experience. I knew I had made countless mistakes during my time in Ethiopia, but learning textbook global medicine showed me I made textbook mistakes. On the other hand, the level of sustainability we established through mentorship, organization and determination proved resilient despite my naive arrogance. I kept my finger on the pulse, so to speak, in Ethiopia. They would share cases, I’d invite them to meetings and educational events, do research together and we made plans for after the pandemic. At Mayo, I helped create a residency and medical school global surgery curriculum, a global surgery podcast, and continued to teach anyone who would listen about our work.

              But, as my last post on this blog explained, Ethiopia’s civil tensions boiled over into a full out civil war in November 2020. I followed this closely over its 2 years of devastation vastly ignored by the world’s media. I hoped for the best for my friends still in the middle of it, silenced by opposing forces, with little to no information getting in or out of the area. After countless acts of horror and two years of hostilities, the two groups agreed on a ceasefire in November of 2022, internet was re-established and I began to hear updates from all my residents and colleagues. All were safe somehow, some were now married, some with children. Many of the older residents were able to find jobs, some weren’t. But the medical care and the hospital suffered. Access to safe and affordable surgery was harder than ever, children passed away from issues easily managed pre-war and requests were made to help re-build a ransacked, crippled and disabled medical system.

              While attempting to internalize the reality that what we had spent over a year trying to create with our collective blood, swear and tears was actively being destroyed, I was also trying to categorize my life goals and future path within global surgery. In 2015, the Lancet Commission on Global Surgery concluded that 5 billion people do not have access to safe and affordable surgery and that 143 million additional surgeries would be needed annually to meet this need. I like to look at the world’s ability to meet this need organized into a pyramid using terminology adapted from a leader in our field, Dr. Mark Shrime. He is also an ENT by training but has dedicated his life to understanding safe and affordable global surgery. He also happens to be one of my co-surgeons on Mercy Ships these two weeks (along with a legend on Mercy Ships; Dr. Gary Parker). Very cool for me! Anyways, this is how I visualize it:

Policy makers can be at many different levels (international like the WHO, or a country’s ministry of health and so on). They are guided by research done in the field, like the Lancet Commissions and the work of the Global OHNS Initiative (that I joined back in 2019), that is eventually used to guide policy. Their impact can be massive and long-lasting, but it takes time and very few people actually do it.

The next step down is for institutions that can bring a high level of access and quality of care in one little neat package, often providing surgery at very little cost to the patient. Unfortunately, VERY few organizations like this exist in a sustainable way. Mercy Ships is an example and why I’ve decided to do a rotation with them. I encourage you to take a look at what they do, its pretty impressive. The major downside: they can’t be everywhere at once, and sustainable change for local medical systems is slow and sometimes not possible.

Next are a copious group, but an unorganized, non-regulated group of non-governmental organizations, fellowship programs and the like. New examples pop up every year run by dedicated, well-meaning people. In ENT alone, there are many, such as Smile Train, Operation Smile, Children’s Surgery International, Healing the Children, a head and neck fellowship run by a team at Vanderbilt, another by a team at Johns Hopkins just to name a few. They all do different things and mostly all aim to build sustainability through teaching. Many are flagship organizations for our final category, short term surgical trips.

Short term surgical trips (STSTs) usually last 1-4 weeks and involve a team of surgeons (and often include nurses, administrators, photographers and on and on) from high income countries who go to low/middle income countries and perform surgery, usually on a specific disease. This “vertical” approach to global surgery is not only the older, but by far the most common and well-known methodology. STSTs can get a bad rep sometimes. Although they are universally organized by well-intentioned people and organizations, their impact can have many unintended negative consequences on patients and local medical systems. But, in terms of the volume of donated surgical time and expertise, the vast majority of efforts given globally comes in the form of these trips.

Outliers to this pyramid are those individuals who uproot their lives and live in country, completely integrating and building from within. I was proud to be one of these outliers, but as an individual, its completely unsustainable. There are organizations that support this type of work in ENT, such as Samaritan’s Purse, but there are very few examples of such.

Within this pyramid, and including its outliers, there are thousands of amazing surgeons who want to volunteer their time, expertise and money to see improvement in global surgical care. We ENTs, as an entity, need to figure out how to organize this workforce into a meaningful approach toward sustainable improvements in safe and affordable global surgery.

This is what I want to spend my life pursuing. I don’t know how to yet, but I have ideas, friends, and a seat at the global table.

Perhaps I see this blog as transforming into a chronicle of this path and all the obstacles we will expose along the way. There will undoubtedly be many and I hope you will feel empowered to reach out and help me solve them.

One thought on “Grey Water

  1. Hey there Dr. Josh. I enjoyed reading your blog. I am glad you’re back to posting and sharing your insights and words of inspiration. Keep up the good work.
    Kind regards,
    Kathy McGovern


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s