Health systems strengthening through surgical and perioperative care pathways: a changing paradigm

Abstract

Global health has traditionally focused on the primary health development with disease-specific focus such as HIV, malaria and non-communicable diseases (NCDs). As such, surgery has traditionally been neglected in global health as investment in them is often expensive, relative to these other priorities. Therefore, efforts to improve surgical care have remained on the periphery of initiatives in health system strengthening. However, today, many would argue that global health should focus on universal health coverage with primary health and surgery and perioperative care integrated as a part of this. In this article, we discuss the past developments and future-looking solutions on how surgery can contribute to the delivery of effective and equitable healthcare across the world. These include bidirectional integration of surgical and chronic disease pathways and better understanding financing initiatives. Specifically, we focus on access to safe elective and emergency surgery for NCDs and an integrated approach towards the rising multimorbidity from chronic disease in the population. Underpinning these, data-driven solutions from high-quality research from clinical trials and cohort studies through established surgical research networks are needed. Although challenges will remain around financing, we propose that development of surgical services will strengthen and improve performance of whole health systems and contribute to improvement in population health across the world.

Full text

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KamarajahS, etal. BMJ Glob Health 2024;9:e015058. doi:10.1136/bmjgh-2024-015058
Health systems strengthening through
surgical and perioperative care
pathways: a changing paradigm
Sivesh Kamarajah ,1 Adesoji O Ademuyiwa,2 Rifat Atun,3 Alarcos Cieza,4
Fareeda Agyei,5 Dhruva Ghosh,6 Jaymie Claire Ang Henry ,7 Souliath Lawani,8
John Meara,9 Ben Morton ,10,11 Kee B Park,12 Dion G Morton,1 Teri Reynolds,13
Abdul Ghaffar14
Analysis
To cite: KamarajahS,
AdemuyiwaAO, AtunR,
etal. Health systems
strengthening through
surgical and perioperative
care pathways: a changing
paradigm. BMJ Glob Health
2024;9:e015058. doi:10.1136/
bmjgh-2024-015058
Handling editor Helen J Surana
Received 12 January 2024
Accepted 1 October 2024
For numbered afliations see
end of article.
Correspondence to
Abdul Ghaffar;
ghaffar. motla@ gmail. com
© Author(s) (or their
employer(s)) 2024. Re- use
permitted under CC BY.
Published by BMJ.
ABSTRACT
Global health has traditionally focused on the primary
health development with disease- specic focus such as
HIV, malaria and non- communicable diseases (NCDs). As
such, surgery has traditionally been neglected in global
health as investment in them is often expensive, relative
to these other priorities. Therefore, efforts to improve
surgical care have remained on the periphery of initiatives
in health system strengthening. However, today, many
would argue that global health should focus on universal
health coverage with primary health and surgery and
perioperative care integrated as a part of this. In this
article, we discuss the past developments and future-
looking solutions on how surgery can contribute to the
delivery of effective and equitable healthcare across the
world. These include bidirectional integration of surgical
and chronic disease pathways and better understanding
nancing initiatives. Specically, we focus on access to
safe elective and emergency surgery for NCDs and an
integrated approach towards the rising multimorbidity
from chronic disease in the population. Underpinning
these, data- driven solutions from high- quality research
from clinical trials and cohort studies through established
surgical research networks are needed. Although
challenges will remain around nancing, we propose
that development of surgical services will strengthen
and improve performance of whole health systems and
contribute to improvement in population health across the
world.
BACKGROUND
Access to timely, safe and affordable surgical
and perioperative care has started to move
to the centre stage of universal health
coverage (UHC) in the recent years.1 2 Histor-
ically, global health focused on vertical cost-
effective interventions that were convenient
to the government and funders, rather than
comprehensive care matched to the disease
burden of communities’.3 However, today,
many would now argue that strengthening
surgical pathways could benefits systems as a
whole for the community and hospitals. This
will address the outstanding challenges of the
2030 sustainable development goals (SDGs),
most notably 1, 3, 8, 9, 10, 16 and 17.4 In
this article, we contend that limited devel-
opment of surgical healthcare systems has
seriously held back the delivery of effective
and equitable healthcare across the world.5
We propose that investment in surgical path-
ways will improve performance of wider
health systems and population health globally
(figure 1). Notably, the importance of incor-
porating surgery into emergency and crit-
ical care systems is now being recognised in
recent recommendations and resolutions of
the World Health Assembly (WHA).6 Incor-
poration of surgery into wider health system
development, notably NCDs, should now be
a priority.
Delays in surgery may be due to access or
affordability for the patient (or the popu-
lation). All these delays are costly, resulting
in advanced disease or emergency presen-
tations, incurring substantially higher
morbidity, healthcare costs and a fivefold
SUMMARY BOX
⇒Perioperative care pathways are an important com-
ponent in strengthening health systems, including
for the Global South.
⇒Development of perioperative pathways, including
surgery, is especially needed to improve equity of
access to safe, effective care for non- communicable
disease.
⇒Several opportunities are available to integrate sur-
gery better into health systems through integrating
surgical and chronic disease pathways.
⇒The global surgical and perioperative care research
community can provide evidence to evaluate initia-
tives and implementation in health system strength-
ening in terms of patient outcomes.

2KamarajahS, etal. BMJ Glob Health 2024;9:e015058. doi:10.1136/bmjgh-2024-015058
BMJ Global Health
increase in surgical mortality.7 Early surgery, by contrast,
is safer surgery, but requires pathway integration into the
continuum of care and not least into primary care. An effi-
cient prehospital system could reduce delays in medical
as well as surgical treatment. Community- based rehabili-
tation services have started to show patient benefit8 and
could be further strengthened by community services
supporting postsurgical recovery. An operation is at the
core of surgical pathways, but it also represents a clearly
defined timepoint. This point of patient contact can be
used to promote community health services, address
multimorbidity, as well as return people back to full socio-
economic productivity. For example, care for persons
with diabetes will only be effective if surgery to treat
diabetic leg ulcers is integrated. Such surgical services
strengthen pathways from the community and back to
promote early diagnosis/prevention, as well as improved
rehabilitation after hospital care. Surgery is thereby a
mechanism for whole pathway strengthening at the level
of health systems.
The recent COVID- 19 pandemic has both highlighted
and accentuated the global need for preparedness and
resilience for safe emergency, critical and operative care.9
The fragility of the surgical care pathway made these
patients especially vulnerable both in the emergency and
elective setting. Huge delays occurred across healthcare,
with backlogs of elective surgery persisting into 2024.10 11
This created a wave of acute presentations overburdening
the emergency services. Breakdown of emergency surgery
has an adverse effect on all components of acute medical
services from maternity health to trauma to sepsis. Elec-
tive surgical services are required to sustain working- age
patients suffering from a wide range of NCDs, from
cancer to inguinal hernia, preventing advanced emer-
gency presentation and enabling a return to a full and
active life. The Lancet Commission on Global Surgery12
estimated the need for an additional 143 million surgical
procedures to save lives and prevent disability. Nearly half
of these procedures are owed to children below the age of
15, emphasising the role of surgery in sustainable health
for future populations. This article and those accompa-
nying it provide an overview of where we have reached
and what future action should be considered.
What has been achieved
In 1980, the previous Director General of the WHO,
Halfdan Mahler emphasised most of the world’s popula-
tion lacked access to skilled surgical care, highlighting a
grave social inequity in healthcare. Despite his plea, little
changed in global public policy. This was because invest-
ment in surgical care was expensive and neither identi-
fied as a priority or cost- effective to health systems. Impor-
tantly, surgery not being easily assigned to vertical disease-
based interventions.3 In 2008, there were growing calls
from the global surgical community highlighting surgical
care as a neglected component of global health.13 These
early calls marked the beginning of a renewed focus on
addressing the disparities in access to surgical services
and pathways on a global scale. In 2015, the World Bank’s
publication of the Disease Control Priorities, Third
Edition (DCP3) with a dedicated volume on surgery; and
The Lancet Commission on Global Surgery12 empha-
sised the urgency of addressing problems in surgical
pathways globally. This major commission identified
Figure 1 Integration of surgical pathway within wider healthcare systems.

KamarajahS, etal. BMJ Glob Health 2024;9:e015058. doi:10.1136/bmjgh-2024-015058 3
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that a staggering 5 billion people lacked access to safe,
affordable and timely surgical and anaesthesia care.14
The WHA resolution 68.15 marked the first time the
WHO acknowledged strengthening surgical care systems
is important to improve equitable healthcare delivery.
In the subsequent 8 years, the global surgery commu-
nity witnessed a transformative period. The World Bank
began publishing the key surgical indicators, providing
the first- ever surgical data in the World Development
Indicators. Global surgery gained a consistent presence
at the WHA meetings in Geneva, and the World Health
Summit incorporated global surgery into its annual
agenda. Collaboratives within surgery and periopera-
tive care, such as GlobalSurg,7 15 CovidSurg16 17 and the
NIHR Global Health Research Unit in Global Surgery,18
facilitated global collaboration among thousands of
clinicians for equitable research efforts. Countries and
regions responded by developing their National Surgical
Obstetric and Anesthesia Plans (NSOAPs),19 20 with the
South African Development Community region leading
a remarkable effort across 16 countries that prompted
other regions, including the Pacific Islands and Latin
America, to follow suit. Ecuador, under the leadership
of VP Borrero, recently launched its NSOAP, becoming
the first country in Latin America to embrace this
crucial step towards equitable surgical care.21 Global Alli-
ance for Surgical, Obstetric, Trauma, and Anaesthesia
Care (G4 Alliance), a network of more than 80 global
surgical organisations representing over 160 countries,
has observed that context- appropriate evidence base for
surgery to inform national policies and strengthen health
systems remains underdeveloped. The group summarised
the best level evidence on interventions geared towards
increasing the quality and safety of global surgical service
delivery. Data from systematic reviews,22–24 a framework
for appraising these articles25 and a Delphi across 27 low-
income and middle- income countries (LMICs) surgical
providers,26 formed the basis of 11 Best Practice Recom-
mendations25 with recommendations on the optimal
organisation of surgical services (figure 2). Further devel-
oping a high- quality up- to- date evidence base for surgical
service development in LMICs remains a priority today.
The emerging surgical research networks are well placed
to measure the patient- level benefits (or lack thereof)
from this health service strengthening.
What might be the solutions?
Integrating care through improved pathways
Multiple long- term health conditions or multimorbidity,
defined as the presence of two or more chronic condi-
tions,27 is an emerging challenge for international health
systems and provides an example of the increasing need
for integrated care systems.28 29 This is of particular
importance with the rising prevalence of ischaemic heart
disease, diabetes and hypertension, where primary care
in LMICs is often positioned towards child and maternal
health and poorly resourced to respond to the needs
of rapidly ageing populations.30 31 Therefore, there is a
high reliance on secondary hospital care for the preven-
tion of death and disability from both communicable
Figure 2 Key evidence for trauma and surgical services in low- and middle- income countries.

4KamarajahS, etal. BMJ Glob Health 2024;9:e015058. doi:10.1136/bmjgh-2024-015058
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and non- communicable diseases (NCDs).32 Herein, we
discuss the bidirectional opportunity for improving these
pathways.
First, the index surgical presentation, both in elective
and emergency settings, represents a unique opportu-
nity to improve diagnosis and management of chronic
diseases. This allows the surgical and perioperative
pathway to address the patient holistically, beyond the
surgical disease, thus improving access to UHC and
improvements in care.3 This process allows improved
short- term perioperative outcomes, but also improved
long- term outcomes for patients through an integrated
approach into primary care. It is a cross- cutting inter-
vention that has the capability to strengthen across the
breadth of health systems. It can thereby support whole
systems strengthening and be used as an objective
measure of the impact from such innovation. Examples
of this approach can be drawn from other areas such as
concurrent management of diabetes and hypertension in
patients with HIV.
A recent prospective cohort study identified that
the three most common chronic conditions in African
surgical patients were hypertension (16.3%, 1863/11
422), HIV infection (11.0%, 1253/11 422) and diabetes
mellitus (6.8%, 776/11 422).33 However, the clustering
and interaction of chronic disease are poorly described
in this context, a finding mirrored in the medical liter-
ature.34 The differentiation between primary conditions
such as hypertension, HIV and diabetes and secondary
complication conditions such as stroke, chronic kidney
disease and heart disease is important to draw as inter-
ventions designed to improve the control of primary
diseases could significantly reduce the medium- term and
long- term risk of secondary complications, disability and
death for surgical patients. In the elective surgical path-
ways, there is growing evidence that the elective waiting
list should be considered as the ‘preparation list’,35 to
acknowledge this expanding role. Although implemen-
tation of standard operating procedures to improve
chronic disease management for elective surgical care
patients is well described in high- income settings, this is
less well established in sub- Saharan Africa.36 For patients
who require emergency surgery, risk mitigation strat-
egies are required to recognise patients with chronic
disease to reduce the risk of perioperative complications.
Here, a key gap is the provision of critical care services
to monitor and manage patients in the immediate post-
operative period. Holistic approaches to combine emer-
gency, surgical and critical care capacity building37 in
low- resource settings are key to drive improved outcomes
for these vulnerable patients.
In this way, provision of surgical services will strengthen
wider health systems (strengthening pathways from
primary to secondary care as well as strengthening
the continuum of care from health promotion and
prevention to treatment and rehabilitation) as well as
enabling better management of multimorbidity in the
surgical patient. These wider health benefits must be
considered when the cost of surgical services come under
consideration.
Improving access to elective surgery
There is a need to strengthen surgery within current
NCD pathways. This means patients with ischaemic heart
disease or osteoarthritis requiring coronary artery bypass
graft or hip replacements should be able to have timely
access and safe surgery to them, respectively. In improving
access to surgical care for these conditions, several areas
need to be addressed in addition to financial investment
and political leadership. These include
1. A robust referral network system: this is important to en-
sure that there is a timely referral from the community
into first referral hospitals38 and also from the district
hospitals into the tertiary centres for more complex
care. Several nations have established a devolved sys-
tem of healthcare governance in which authority, re-
sponsibility and financial resources are redistributed
to different levels of government.39 This has the ad-
vantage of moving health services closer to the peo-
ple, enabling referral systems and potentially lowering
overall costs. It does however introduce challenges in
implementing large infrastructure investment. Thus,
strategic healthcare organisational strategies must
be employed for high- complexity and low- acuity in-
terventions to be referred to regional centres (re-
gionalised), with common emergency and essential
surgical interventions addressing low complexity and
high acuity interventions available at district hospitals
(decentralised) while employing a highly organised
and streamlined referral system (figure 3).26 A stream-
lined referral system is required from the community
to district hospital, as well as from district into region-
al centre. Strengthening these pathways of care can
promote earlier access to treatment and better pa-
tient outcomes, thereby benefitting the entire health
system.
2. Improving surgical capacity and preparedness: this requires
training of specialist nurses, anaesthetists, as well as
surgeons.40 41 District- level real- time granular data are
still required for these strengthening efforts to assess
relevance and impact. Global surgery and periopera-
tive care networks are ready and able to support such
assessments. For instance, the surgical preparedness
index42 could be useful for gauging system readiness
to provide effective and sustainable surgical care. This
index, recently developed with 1632 hospitals in 119
countries, demonstrated variation in preparedness
of hospital systems in external shocks such as the
COVID- 19 on elective surgical activity. Many lessons
were learnt through this pandemic, which requires
comprehensive planning and preparation for the fu-
ture. An example would be identifying segregated care
pathways or sites and workforce to continue or main-
tain elective surgical activity.43
3. Upscaling quality and safety: this is a particular con-
cern if a rapid expansion of services is instigated.

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Poor- quality surgery can cause more harm than good.
The G4 Alliance 11 Best Practice Recommendations
for Quality Safe, Surgery, and Anaesthesia Care25 fo-
cus on building systems of safety that have been shown
to be feasible and cost- effective in LMICs. A recent
systematic review highlighted that implementation of
evidence- based interventions in surgery and periop-
erative care within LMICs is limited.22 An example
is the implementation of the WHO surgical safety
checklist,44 45 where uptake is variable outside research
settings. Therefore, there is a great need to scale this
further to improve equity of care received by patients
globally.
These challenges correspond to the WHO health
systems strengthening building blocks seen through a
global perioperative care lens (figure 4). Policy develop-
ment in whole health systems needs to be informed by
high- quality evidence which can now be collected across
the surgical and perioperative care networks, assessing
current surgical capacities, standardisation of care,
effective governance and reported through prospective
contemporaneous patient outcomes data.
Figure 3 Health system building blocks, interventions and impact of perioperative pathways.
Figure 4 Key research areas and solutions for future research.

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Financing models
Operationalisation of surgical and perioperative care
pathways (figure 5) plans requires significant financial
investment.46 This remains a major challenge. Current
estimates for the cost of surgical system strengthening
are staggering, ranging from US$69.7 million in Rwanda
to US$16.8 billion in Nigeria.47 48 Financing these initia-
tives is complex and highly dependent on each country’s
political commitment to health, income level, existing
health financing system and relationships with external
partners such as development banks, philanthropy and
non- governmental organisations. Successful financing
requires context- specific solutions at regional, national
and local levels. These depend on the country’s ability to
identify shared interests and strategically design sustain-
able models for whole health system strengthening.
Although a dedicated funding package that addresses
the total costs of the National Surgical Plans (NSPs)
may be a preferred option, the fiscal constraints and
limited implementation capacity at the health minis-
tries make this unlikely. Zambia’s experience illustrates
how a piecemeal approach may be useful. For example,
Zambia commenced surgical subspecialty training
programmes immediately following the launch of their
NSP, with graduates now entering the surgical workforce.
Crucially, Zambia has established a national health insur-
ance scheme49 for the formal sector which included a
package of surgical care. This enables strengthening of
the whole healthcare system with surgery as a compo-
nent of this process. However, at this stage of develop-
ment, the overall capacity to deliver surgical care remains
constrained.50 51 A two- tiered system consisting of a non-
revenue generating public system for the poorest and a
revenue- generating system for those who can pay may
offer the combination of equitable access to essential
surgical care that is financially sustainable and poten-
tially accelerate the service development. For instance,
Rwanda has demonstrated the potential of such systems
by using donor health funding strategically to enhance
access.48
In 2001, Member States of the African Union
committed to spending 15% of their national budget
on health, known as the ‘Abuja Declaration’.52 However,
meeting this target has been elusive but development
of the national health systems to deliver equitable care
can encompass surgery. For some countries, a private–
public partnership model may serve to increase surgical
service delivery while attracting private investments into
the health sector. For example, a blended financing
model53 combines public and donor investments with
private capital to finance revenue- generating enterprises
that can deliver affordable surgical care to neglected
patients while generating sufficient revenues to be finan-
cially sustainable. This model can leverage concessional
catalytic capital (grants) to unlock private capital, often
several times the amount of grants.54
The discussion on financing must be contextualised
within the historical and ongoing economic relationships
that exist. It is crucial to acknowledge the extraction
of resources from LMICs during colonisation and the
ongoing unequal neocolonial economic relationships.55
The solution to global surgery should not rely solely on
private capital, as this can be dangerous and misleading.
Instead, fairer trade agreements and reparations should
be considered. The health of citizens in the Global South
should not be material for private investment and gener-
ating returns. A discourse focusing on private capital
further advances the interests of Global North companies
and industry at the expense of Global South citizens.55
Figure 5 Model of perioperative care pathway.

KamarajahS, etal. BMJ Glob Health 2024;9:e015058. doi:10.1136/bmjgh-2024-015058 7
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The substantial societal cost of inadequate surgical care
needs emphasis, especially in emergency care systems.
One study showed the cost of not providing treatment
for appendicitis alone is costing some countries more
than 1% of GDP.56 Providing the clinical capacity to
deliver care for emergency surgical diseases will substan-
tially strengthen the wider health system by improving
emergency response services. Considering surgery as
an integral part of the health system can enable further
investment and wider improvements to healthcare.46 By
2030, we hope to see LMICs funding their own NSOAPs
and demonstrating improved access. An example of an
LMIC funding greater access itself, even if it is the recip-
ient of donor health funding, is Rwanda, which has strate-
gically used donor funds to improve surgical access. This
demonstrates the potential for LMICs to take ownership
of their health financing and improve access sustainably.
Emerging solutions
We are halfway in time towards the 2030 SDGs. It is appro-
priate to now consider how to achieve these targets. One
critical action, initiated within the recent WHA resolu-
tion and outlined in this and the accompanying papers,
is to position surgery within the compass of health system
strengthening. This emphasises the key role of surgery
in the management of multimorbidity and NCDs and
demonstrates how surgery adds resilience to the health
system, defining it as a central part of sustainable health
systems. This realignment critically allows expenditure
on surgical services not to be seen in isolation, but as an
investment in the health systems as a whole.
Current service shortfalls must be addressed through
strengthening care pathways around district hospi-
tals, not just tertiary centres. Rapidly expanding these
district hospital services should be a priority. This clearly
requires much more than simply training more surgeons,
a target that is even being missed even in some high-
income countries. Development of allied health special-
ties will be required to deliver accelerated expansion of
services, encompassing the whole care pathway. Training
programmes, aligned with local district hospital needs, for
surgeons and allied health disciplines need to be devel-
oped and propagated within coordinated programmes of
south- to- south learning. Successes in one region should
be explored across a wider geography.
A comprehensive systems approach should address
end- to- end management from surveillance, prevention,
prehospital care, surgical care, to rehabilitation. The six
WHO health system building blocks can be used to help
achieve this comprehensive systems approach (figure 4).
However, this will require strong leadership from both
surgical teams and policy- makers. The existing research
evidence to support investment in perioperative care
is limited and requires urgent attention57 (figure 5).
However, evidence for investment in NCDs (such as
cancer) is growing and will require development of
peri/operative care services within their compass. High-
quality contemporaneous research evidence identifying
improved patient outcomes will support and drive this
policy change.
There is a risk associated with rapid expansion of
surgical services, namely an associated reduction in
quality and a rise in adverse patient outcomes. Once
again, it will be imperative that patient- level assess-
ment of outcomes is collected to ensure we maintain
and improve standards of care. This research activity
can also promote south- to- south learning and engage
the wider surgical community in this essential service-
strengthening programme. High- quality research
can be driven by the surgical and perioperative care
community and investigating the whole pathway of end-
to- end care will be essential to develop and maintain
these standards. Real- time patient- level data, collected
at the district level, ideally (and efficiently) provided
through global snap- shot audits, can be used to assess
uptake of innovation and impact on patient outcomes.
The surgical community across the world has shown
that it can be engaged in driving these critical health-
care developments.
Author afliations
1NIHR Global Health Research Unit on Global Surgery, University of Birmingham,
Birmingham, UK
2Surgery, University of Lagos, Akoka, Lagos, Nigeria
3Harvard University, Cambridge, Massachusetts, USA
4Department of Noncommunicable Diseases, World Health Organization, Geneve,
Switzerland
5Department of Surgery, Komfo Anokye Teaching Hospital, Accra, Ghana
6Department of Paediatric Surgery, Christian Medical College, Ludhiana, India
7Surgery, Baylor College of Medicine, Houston, Texas, USA
8University of Abomey- Calavi, Cotonou, Benin
9Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
10Liverpool School of Tropical Medicine, Liverpool, UK
11Malawi- Liverpool- Wellcome Trust Clinical Research Programme, Blantyre, Malawi
12Program in Global Surgery and Social Change, Department of Global Health and
Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
13Integrated Health Services, World Health Organization, Geneva, Switzerland
14Department of Community Health Sciences, The Aga Khan University, Karachi,
Pakistan
X Sivesh Kamarajah @Sivesh93, Adesoji O Ademuyiwa @soji_ademuyiwa, Fareeda
Agyei @Fareeda Agyei, Jaymie Claire Ang Henry @JaymieClaire, John Meara
@JohnMeara and Ben Morton @benjamesmorton
Contributors SK, DG and AG developed a draft of the protocol. All authors have
critically reviewed and edited the manuscript. All authors contributed to the design,
drafting and review of this paper. In addition to this, AG is the overall guarantor for
this article.
Funding This study is funded by the NIHR Global Health Research Unit on Global
Surgery (NIHR16.136.79).
Competing interests None declared.
Patient consent for publication Not applicable.
Ethics approval Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement There are no data in this work.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
others to copy, redistribute, remix, transform and build upon this work for any
purpose, provided the original work is properly cited, a link to the licence is given,
and indication of whether changes were made. See:https://creativecommons.org/
licenses/by/4.0/.

8KamarajahS, etal. BMJ Glob Health 2024;9:e015058. doi:10.1136/bmjgh-2024-015058
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ORCID iDs
SiveshKamarajah http://orcid.org/0000-0002-2748-0011
Jaymie Claire AngHenry http://orcid.org/0000-0003-3331-8704
BenMorton http://orcid.org/0000-0002-6164-2854
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