Direct comments

45 Responses to "Direct comments"

balumuka d. darius says:

14 December, 2013 at 3:04 am

The way to progress in global health is to ensure education in the low and middle income countries.
why education? education is sustainable because when all the funds delivered to the African governments are misappropriated at least the knowledge and skills will remain. It is important to note though that achieving surgical education in the developed world following training in low and middle income countries is very hard. so most of the global health commissioners should focus on that.
working in partnership with the available medical practitioners/ NGO who are keen on improving the current situation in the low and middle income countries would provide a way out of government controlled institutions that are known to be corrupt and have already misappropriated funds meant for other global health initiatives like global fund.
reciprocity should also be born at the back of every strategy while entering the low and middle income countries . we are used to people coming in the name of helping but only get research data and publications without any change in the community. so when there is an environment of LMIC learning from the western world and the reverse through exchange of staff, then lasting relations based on mutual respect and common goals guide the way.
thanks a lot
balumuka darius

Reply
1. admin says:
  
  7 January, 2014 at 10:47 pm
  
  Thank you for posting your ideas and comments. We will make certain that the commissioners see them. We definitely agree that education is hugely important. Education and Training will be the focus of one of four working groups. The other working groups are Healthcare Delivery and Management, Information Management, and Economic and Financing. Please keep sending ideas and suggestions! We want input from all involved in surgical care delivery.
  
  Reply
  1. Dr. Sanjeevanee Kelkar.M.S. says:
    
    31 January, 2014 at 4:26 am
    
    How are we going to implement all this globally? What is the plan about it?
    
    Reply
Dr. J. Gnanaraj says:

16 January, 2014 at 8:27 am

DIAGNOSTIC AND SURGICAL CAMPS MODEL: THE COST EFFECTIVE WAY OF TAKING CARE OF THE SURGICAL NEEDS OF THE POOR AND THE MARGINALIZED

BACKGROUND
World Health Organization says that 11% of the Global disease burden can be treated with surgical procedures. While there are, 2 billion people who have no access to basic surgical care of the 234 million surgeries carried out World’s poorest third get only 3.5%.

The major problems in rural areas relate the availability, accessibility and affordability of surgical care. It is expensive to set up surgical facilities in remote areas and if available getting surgeons and others to staff them are even more difficult. If facilities and staff are available, the workload and paying capacity might not be sufficient to sustain the facility in rural areas.
THE DIAGNOSTIC CAMP/SURGICAL CAMP MODEL
The diagnostic camps take all the diagnostic facilities that are usually available at the hospitals to remote rural areas. The entire laboratory with all the possible investigations, the Pharmacy, the Gastroscopies, the cystoscopies, the ultrasound examinations, etc is available at the remote area. X rays are logistically difficult. The local Churches, social service organizations or the villages themselves organize these Diagnostic camps. They use the consultation fee to cover their expenses and patients are happy to pay for the investigations, medicines and procedures.
The surgical camps are at the nearby hospitals or health care facilities. Advanced surgical procedures, endoscopic surgical procedures and laparoscopic surgical procedures are possible with the set of mobile equipment earmarked for these camps. Qualified and trained personnel are available at these hospitals for the surgical camp. Half the fee that the patients pay is for organizing the surgical camps and the other half is for the local hospital.
DISCUSSION
We have carried out these diagnostic camps and surgical camps for over 3 decades in remote areas in Gujarat and Northeast India. The first publication regarding these camps received the Barker Memorial prize given by Tropic Doctor [1]. It was possible to take advanced surgical procedures to remote rural areas.
The study published in Indian Journal of Surgery [2] showed that, the model is a financially viable one. Donations were necessary only for the capital items. Many patients in rural areas benefited from minimally invasive surgical procedures.
In another study published in the Australia, New Zealand Journal of Surgery [3] calculations showed that more than half the patients who would have required surgical intervention for prostate disease did get the necessary treatment with this model.
The advantages of this model are many. They are as follows
1) It is a cost effective model that has been around for over 3 decades. Funds are necessary only for the capital needs
2) About three fourths of the patients requiring surgical intervention were diagnosed for the first time during these camps in remote rural areas. The ultrasound examinations and scopies contributed a lot to the diagnosis of surgical conditions.
3) The surgical camps offered a great way for training the local surgeons and trainee surgeons, as the numbers of surgical patients were much higher during the surgical camps.
4) Thousands of patients were able to have modern minimally invasive surgeries at a very nominal cost
5) Various innovations were possible during these surgical camps. Many articles were published in national and international journals from the findings and innovations during these surgical camps
6) Unlike the medical conditions diagnosed during the diagnostic camps surgical treatment often provides permanent cure
7) The model has been successfully replicated by others

REFERENCES
1. How to bring Surgery to remote tribal areas
Gnanaraj J, Gnanaraj L, Shah VK
Trop Doct 1997 Jul: 27 (3) : 163 – 5
2. High quality surgical care at low cost: The Diagnostic camp model of Burrows Memorial Christian Hospital
J. Gnanaraj, Lau Xe Xiang Jason, Hanah Khiangte
Indian Journal of Surgery Vol. 69, No.6, December 2007 p 243-247
3. Transurethral electrovaporisation of prostate. A boon to the rural surgeon.
Gnanaraj J, Lionel Gnanaraj
Aust N Z J Surg 2007 Aug; 77 (8) 708

Reply
says:

13 February, 2014 at 4:00 am

There has been numerous excellent articles in respected journals and the WHO publications showing that trauma and the surgical burden of disease far outways the need of HIV, Malaria and TB combined. However 80% of all international funding goes into those 3 conditions with less than 5% going to surgical need. There needs to be a radical refocus of international funding to match the actual burden of disease as evidenced by demographic data.
The 3 limiting factors to improved surgical care in Africa is:
1) funding deficit
2) manpower deficit ( which reflects inadequate education and poor staff retention)
3) appropriate resource deficit ( not enough money/support is given to companies who do research and product development for appropriate tools for surgery and anaesthesia in LMIC’s).

I believe that not enough is done to motivate the governments responsible to invest infrastructure in health services. It is appauling that hospitals in capital cities in many LMIC’s still have power and water shortages but one will never see this in the presidential palace. i.e. It is possible to resolve these issues but the problem is lack of political will. I believe the world bank and international donor governments should apply significant pressure on these governments to focus adequate resources toward basic infrastructure for their hospitals.

I find the attitude of many LMICs toward immigration of professional skills rather concerning. It is unreasonably difficult to get foreign nurses and doctors work permits and medical registration in many countries. This means these desperately short-staffed countries chase away the very help they need. Many countries pay ex-pat doctors less than their local doctors for the same job – this is clearly descrimination and again chases valuable skills away.

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Dr. Hilary Edgcombe says:

25 February, 2014 at 11:55 am

I would like to make a comment relating to the contribution of medical practitioners from high income countries to surgical care in low and middle income countries. Large numbers of volunteers from the developed world give time and finance in order to practise on a short or long-term basis in countries other than those where they trained.

This sort of contribution can be enormously valuable or potentially damaging depending in large part on the knowledge, skills, and attitudes of the volunteers in question.

In anaesthesia there are a small number of training courses / conferences worldwide* (one of which I co-direct) which aim to address the gap between the training a volunteer has from their own country and the skills needed to work effectively in a new (and likely less well-resourced) setting.

The scope of this training includes technical skills, familiarisation with relevant drugs and pathologies seen infrequently in the volunteer’s home country and discussion of non-clinical topics including sustainability, good and bad models of volunteering, psychological issues such as culture shock. Increasingly there is partnership with anaesthetists from LMICs in delivering this training to the benefit of both parties.

Recognising the enthusiasm and mobility of medical volunteers to contribute in countries other than their own, I believe this type of training is vital to increase the safety and effectiveness of expatriate workers within the global surgery context.

* courses of which I am aware include:

“Anaesthesia in Developing Countries” organised by the University of Oxford, held in Kampala, Uganda
“Developing World Anaesthesia” organised from Bristol, UK
“Real World Anaesthesia” based in Australia / New Zealand
“Anaesthesia for Global Outreach” based in North America (Halifax / Seattle)

Reply
GlobalSurg Steering Group says:

26 February, 2014 at 1:15 pm

Comment to the Lancet Commission on Global Surgery By the GlobalSurg steering group

Dear Commissioners, GlobalSurg is a collaborative research project that proposes a novel approach to collecting data on surgical outcomes globally (http://globalsurg.org/). Through a multicenter, international, prospective cohort study, collaborative methodology can be used to create a ‘snap-shot’ clinical data collection that demands minimal involvement from each study collaborator, but that, when compiled, provides a really impressive dataset. This methodology has previously been used in the UK to produce research papers published in major surgical journals [1]., We subsequently published a full description of these novel collaborations through a comment article in the Lancet [2]. During September and October 2014, we will be rolling out GlobalSurg study on an international scale. Any hospital in the world performing emergency general surgery is eligible to enter. Each center needs to contribute only two weeks’ worth of consecutive patients. The primary outcome measure of this first global attempt will be the 24-hour peri-operative mortality rate, as this is easy to measure and relevant. The secondary endpoint will be 30-day inpatient mortality. With over 200 collaborators registered from over 44 countries to date, we are hopeful that this data will be able to inform the data collection process following the launch of the commission’s report in early 2015. Authorship will be devolved, where no one person or group will take credit. Rather, several committees will be created, representing everyone’s contribution. A final writing committee will be internationally representative or developed and developing nations. This novel methodological approach will also help develop grass-root surgeon-led networks. This will facilitate faster delivery of multicenter studies at global level, in addition to building international audit and research capacity in surgery. We will further engage medical students and trainees in surgical research in a compelling manner, increasing capacity for the future. We would be delighted if the commissioners would work with us to promote GlobalSurg to their current contacts and collaborators. The full protocol and registration form is available at: http://www.globalsurg.org. We feel that working with the commission will be mutually beneficial.

GlobalSurg Committee and Collaborators http://www.globalsurg.org Contact: Aneel Bhangu, MBBS, PhD

References
1. Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy. Brit J Surg 2013; 100(9): 1240-52.
2. Bhangu A, Kolias AG, Pinkney T, Hall NJ, Fitzgerald JE. Surgical research collaboratives in the UK. Lancet 2013; 382(9898): 1091-2.

Reply
J L CRAVEN MD FRCS says:

26 February, 2014 at 1:20 pm

I have been involved in African surgery for more than 40 years and totally agree that the primary objective must be to have WHO recognise surgery as a primary health need. If that is achieved in 2015 then most effort must be focussed on the Governments of developing countries acknowledging their responsibilities in this. They will initially need external support from donors to achieve this but the support must be contingent on their adoption of completely transparent and accountable methods of disbursing funding for health. There will be no progress without transparency and accountability. Adequate surgical provision will be a complex and expensive health task, it will demand novel approaches to the training of medical, nursing, paramedic and management personnel; it will demand an improvement in infrastructure, such as roads and the electricity; a public health initiative is essential with the enforcement of vehicular speed limits an early objective. The target is simply stated – to ensure that emergency surgical treatment shall be available within 2 hours for everyone. The economic benefits of this are known to you and me but these will need to be emphasised in all discussions with Governments. I have a memory of one patient that makes this point most vividly – a peasant in a remote part of Northern Uganda sustained a compound fracture of his tibia and fibula falling from a tree. He was admitted to hospital 5 days later, the delay being caused by the family seeking funds for taxi transport, the wound was infected and our wound toilet was unable to prevent the osteomyelitis which developed. After several procedures over four months we had no option but to do a through knee amputation. He was discharged on crutches there being no prosthesis available and of course was thereafter quite unable to play his part in providing for his young family. Case presentations like this should make the case for primary surgical services when arguing the case with Governments

Reply
says:

5 March, 2014 at 2:30 pm

Dear Commissioners,

Central to your vision of ‘universal access to safe, high quality surgery and anesthesia’ has to include efficient access to knowledge and education in low- and middle-income countries (LMICs). There is an abundance of free high quality online medical material which if combined with efficient methods of dissemination through social media could gain similar popularity to that seen in other free educational programmes particularly in LMICs [1]. The Schoolofsurgery.org has been analysing its social media data to start developing a model to support this.

The Schoolofsurgery.org is a not-for-profit surgical news channel which uses social media to disseminate free educational content across the planet. This is maintained by surgical trainees from the United Kingdom who provide short synopses of evidence based medicine in their specialist areas. This is uploaded into social networks and content is overseen by an Editor-in-Chief and Editorial board (www.schoolofsurgery.org). In addition, we freely share our content with other groups and organisations including the Association of Surgeons of Great Britain and Ireland, Association of Surgeons in Training, Vascular Society of Great Britain and Ireland, and OnSurg. Thus, collectively the Schoolofsurgery.org content is viewed by an estimated 300,000 surgeons around the world.

As of January 2014, the Facebook pages of the Schoolofsurgery.org alone had over 50,000 followers. Using over 5 million interactions with Facebook over a two year period, we have been able to gather information on our audience and their interactions with the social media site. Our subscribers are typically surgeons aged less than 35 years (87% vs. 13% >35 years), males (62% vs. 38% females) and based in LMICs (81% vs. 19% high-income countries). When an educational post is shared on our Facebook site, 97% of the post views occur within 36 hours and half of all views come from a mobile phone or device. In addition, our data suggests that followers of our site will readily share our content producing significant rises in the numbers of people who see our content and page. We are currently replicating such studies with data from Twitter. Separate studies suggest that individuals put more weight on the opinions of the people they trust [2]. Taken together, this supports a hypothesis that social media platforms could provide efficient, cost effective methods to disseminate key educational messages to surgeons particularly within LMICs.

As a group, we are happy to share our expertise, networks and this and new data as we recognise the enormity of the task that faces Global Surgery. Maybe naively, we believe that there should be no reason that the care a patient receives should differ because of their location. This has been our core philosophy and rationale of disseminating free educational content.

On Behalf of the Schoolofsurgery.org

References
1. The Editors. Big Data Makes Big Inroads into Schools. Scientific American, 2013; 309, 48-52.
2. Edwards G, Amos M. Using Social Networks to Improve Operations. (Online) Available from: http://blogs.hbr.org/cs/2011/12/using_social_networks_to_impro.html Accessed 14th January 2014

Reply
Becky Sandford says:

10 March, 2014 at 2:32 pm

I have a research interest into the prevalence of vascular disease in Africa, having worked in Malawi and treated patients with peripheral vascular disease and stroke which I had not expected to encounter in this setting.

I would welcome comments and communication from anyone with a similar interest – a research protocol with ethical approval is ready to go!

Brief background:
It is known that there is a burden of non-communicable disease (NCD) in Africa including cardiovascular disease such as hypertension and ischaemic heart disease. This has not yet been extensively studied and health care has been largely targeted towards infective diseases such as malaria, tuberculosis (TB) and Human Immunodeficiency Virus (HIV).

With increasing urbanisation and development in Africa, the spectrum of health problems is evolving and a more ‘western’ pattern of disease is emerging. This may be related to an emerging affluent ‘middle class’ with a higher prevalence of vascular risk factors such as hypertension, obesity, type 2 diabetes and smoking. In addition to this, there is a well recognised vasculopathy associated with HIV, the prevalence of which remains very high in this region.

The purpose of this research is to document the prevalence of vascular disease in Malawi and Kenya, including different regions within these countries (both rural and urban), in order to guide future health promotion campaigns and healthcare provision.

Rationale of the Project

This study aims to document the current prevalence of vascular disease amongst different populations with Kenya and Malawi. These countries have been selected as they represent contrasting populations within the same region in terms of poverty and economic stability and growth.

Malawi is one of the world’s ten poorest countries; much of the population is rural, supporting a living through subsistence farming. In contrast, Kenya is an emerging business hub for East Africa and has a well established tourist industry which contributes to a more stable economy independent of international aid.

In each arm of the study, three populations will be included: those in rural hospitals, in city teaching hospitals and in city private hospitals. This will enable a less wealthy rural population, an urban population and a wealthy urban population to be studied in each country. By including subjects in a variety of clinical settings and countries, it is anticipated that trends in vascular disease may be identified. Therefore, if a trend towards increasing prevalence in vascular disease associated with affluence and urbanisation is present (as may be expected), this study is designed to demonstrate it.

Few studies to date have looked specifically at vascular disease in Africa and therefore this study would generate new knowledge. In the short term, this will confer some benefit to the individuals studied as lifestyle advice and health education will be offered to those who are found to have vascular disease. In the longer term, the study will provide data regarding vascular disease in this setting and this will be important in shaping future health services research, healthcare provision and staff education, and health promotion campaigns.

Literature review

Non-communicable diseases (NCD) have begun to emerge as a significant health problem in low and middle income countries like those in this study. The World Health Organisation (WHO) has set out a strategy document in order to tackle this problem (1), the scale of which is as yet unknown. Cardiovascular death is the leading cause of mortality in low income countries and therefore investing in this area of healthcare has implications not only for the individuals, but also for the communities and wider economy to which they belong.

Studies have documented an increasing burden of cardiovascular disease throughout developing regions of the world (2,3). Although there are thought to be new risk factors emerging (eg HIV vasculopathy), the major contributors to this pattern are likely to be hypertension, diabetes and smoking, in addition to dietary and lifestyle changes which accompany increasing urbanization.

Population based studies describe an untreated hypertensive population, with a prevalence amongst rural African populations of up to 20%, rising to nearly 40% in the urban groups (4,5). Control of hypertension in one study ranged from 400 million individuals affected by 2030, 80% of whom live in the developing world. (6,7) Complications resulting from diabetes are common in this setting and limb loss secondary to diabetic foot complications are frequent (8). Again, in countries which lack expert rehabilitation and social care facilities, this has very significant economical as well as healthcare implications.

Other presentations of vascular disease such as stroke are frequent in developing countries. Unpublished data from a Wellcome Trust supported study into stroke patients in Malawi suggest an 8% incidence of carotid artery stenosis in association with stroke and a 13% prevalence of peripheral vascular disease amongst the same group of patients (Dr L Benjamin, Malawi-Liverpool Wellcome Trust). This is slightly lower than in the UK figures where 20% of patients presenting with transient ischaemic attack or stroke are found to have significant carotid artery stenosis.

Despite this emerging body of evidence of a significant burden of cardiovascular disease in developing countries, there have been very few studies to date which focus on peripheral vascular disease. As this is both a reliable marker for cardiovascular disease, and a significant risk factor for limb loss, this area remains an important focus for research.

A recent systematic review (9) highlights the global burden of peripheral arterial disease, and although lower rates were found amongst low and middle income countries (LMIC) compared with high income countries (HIC), almost 70% of those living with peripheral arterial disease were found to be in LMIC. This review included only 2 papers which specifically studied peripheral vascular disease in African countries. The first was a cross-sectional study of the general population in 2 urban central African populations (Bangui and Brazzaville). Amongst nearly 1000 participants, the prevalence of peripheral arterial disease was found to be 15% in Bangui and 32.4% in Brazzaville (10). The second study used ankle brachial pressure index (ABPI) as a marker for risk of future cardiovascular events. As might be expected, the prevalence of a reduced ABPI increased with age and was found to be almost 40% in those aged 70 years or older (11).

Vascular disease is already prevalent amongst low and middle income countries. With an increasing trend towards westernised diet and sedentary lifestyle, in addition to the significant prevalence of undiagnosed and untreated hypertension and diabetes, the prevalence of vascular disease is likely to rise. This is particularly significant amongst populations where there is little or no government funded welfare state social support and where individuals remain economical contributors until very late in life. This is an area which is poorly described warrants further research.

Reply
Michael Dobson says:

11 March, 2014 at 9:04 am

Safe surgery and Anaesthesia – a worldwide need and an infrastructure problem

WHO estimates that 8.1 million operations per year are carried out in the poorest countries in the world, in 120,000 operating rooms where reliable supplies of oxygen and electricity may not be available. It also quotes overall death rates of 5-10% for major surgery in developing countries, and imputes a significant part of this toll to anaesthesia.

A survey conducted among anaesthetists in every African country that has a national society of anaesthesia (there are 21) found only five teaching hospitals in the entire continent that claimed to have good quality supplies of both electricity and oxygen. (World Federation of Societies of Anaesthesiologists 2011, unpublished data)

In the last 40 years, western anaesthetic and critical care monitoring apparatus has changed from a purely mechanical/pneumatic technology, to today’s sophisticated “workstations”, whose gases are most likely to be derived from a pipeline source, and which incorporate lung ventilators and a range of sophisticated monitors. Current monitoring requirements include not just the patient’s parameters, but self-monitoring by the anaesthetic apparatus of its own integrity and functioning.

Because these machines have been developed in a rich and sophisticated environment, their infrastructure requirements are based on unspoken assumptions. They include the availability of good quality, reliable electrical power, compressed medical gases in effectively limitless supply, and specialist technicians to keep the machines working.

Efforts to specify suitable equipment for LMIC’s require knowledge of the size and scope of infrastructure problems. Enquiries to WHO, the World Bank and Unicef have revealed that there appear to be no central sources of information concerning the quality either of oxygen or electricity supplies on a global basis.

The infrastructure needed to support “western” machines will not rapidly appear. This is clearly seen in countries like post-apartheid South Africa, where failure to increase capacity and poor maintenance of infrastructure, at a time when extensive electrification was taking place in populations previously without electricity, has resulted in frequent power outages even in major cities. Faults develop because machines cannot withstand the regular power outages, brown-outs (“220volt” mains coming in at 180 volts, unstable mains frequencies) that are a regular feature of life in LMIC’s

Efforts to specify suitable equipment for LMIC’s require knowledge of the size and scope of infrastructure problems. Anaesthesia machines, monitors and ventilators are needed that can cope with the existing conditions in poorly resourced areas. The challenge is to define exactly what the performance requirements of those machines must be.

The current ISO standard assumes the universal existence of the infrastructure which is lacking in many countries with large populations; at present equipment certified as ISO and CE compliant is mostly only suitable for use in high-income countries.

Unfortunately, most large western manufacturers simply want to sell to the LMIC’s what they have manufactured for the west. We need are more information about available infrastructure, and more equipment robust enough to deal with today’s real infrastructure problems.

Michael Dobson
Oxford, March 2014

Reply
Evelyn T. Nguyen says:

14 April, 2014 at 3:15 pm

Pediatric Surgery in Sub-Saharan Africa: An Unmet Need

Although surgery has been increasingly recognized as an important component of global health, pediatric surgery has not been given much individual attention [1]. It is important to recognize that children have surgical needs distinct from that of adults, and many developing countries are in dire need of this care [2]. Sub-Saharan Africa is one region comprised of such countries. Although the proportion of pediatric surgical burden has not been assessed [1], there are some estimates for certain conditions requiring surgical care. For example, injuries are the most frequent cause of surgical conditions in Africa [2], with sub-Saharan Africa possessing the highest rates for injury-related childhood disability-adjusted life years (DALYs) [3]. Also, congenital diseases that are surgical conditions affect 543 of 10,000 children between 0 and 14 years of age, with the aggregate risk of surgical treatment necessity at 85% [4]. In sub-Saharan Africa, major congenital abnormalities have an exceptionally high mortality rate [4].

One of the main issues of this burden is clearly the lack of manpower. South Africa has a severe shortage of pediatric surgeons, with merely one pediatric surgeon per two million people [5]. Amongst the countries surveyed, a recent study found that of these few surgeons, an overwhelming majority (90%) of them practice in large tertiary hospitals clustered in major cities [6]. This exacerbates the shortage problem because over two-thirds of the African population reside in rural areas [6].

Some of these unmet needs can be aided by surgical volunteerism [7]. The Global Pediatric Surgery Network is one way of coordinating these efforts [1]. However, it is important to realize that sporadic aid from foreign pediatric surgeons is insufficient for lasting results [4]. Sustainable solutions that can be adapted to the local conditions are critical for long-term effects [4]. Improvements include a greater health care budget from African governments, enhancements in medical facilities, incentives to help retain African medical school graduates, greater involvement of pediatric surgeons in Africa in mentoring trainees, and collaboration amongst African pediatric training institutions for maximal use of resources [6].

In addition to resources, a change in mindset regarding pediatric surgical care is a necessity. In developing countries, surgical care is often seen as a luxury rather than as a vital part of child health care [2]. It is imperative that communities realize that proper surgical care can benefit their child’s health when the applicable situation arises [2]. There also needs to be a change in the political environment. In their research, Bickler and Rode stated that there is no government agency health action plan that focuses on pediatric surgical care needs [2].

It is clear that many things must be done to ameliorate the insufficiency in pediatric surgical care in sub-Saharan Africa. In addition, greater attention must be given to the imperative issue of pediatric surgical care needs. Otherwise, progress in addressing these needs will remain stunted, and millions of children will continue to either suffer with their surgical conditions or perhaps succumb to their ailments.

Evelyn T. Nguyen

Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA

References
[1] Ozgediz, D., and Poenaru, D., 2012, “The Burden of Pediatric Surgical Conditions in Low and Middle Income Countries: A Call to Action,” Journal of Pediatric Surgery, 47(12) pp. 2305-2311.
[2] Bickler, S. W., and Rode, H., 2002, “Surgical Services for Children in Developing Countries,” Bulletin of the World Health Organization, 80(10) pp. 829-835.
[3] Deen, J. L., Vos, T., Huttly, S. R., 1999, “Injuries and Noncommunicable Diseases: Emerging Health Problems of Children in Developing Countries,” Bulletin of the World Health Organization, 77(6) pp. 518-524.
[4] Calisti, A., Belay, K., Mazzoni, G., 2011, “Promoting Major Pediatric Surgical Care in a Low-Income Country: A 4-Year Experience in Eritrea,” World Journal of Surgery, 35(4) pp. 760-766.
[5] Elhalaby, E. A., Uba, F. A., Borgstein, E. S., 2012, “Training and practice of pediatric surgery in Africa: past, present, and future,” Seminars in pediatric surgery, Anonymous Elsevier, 21, pp. 103-110.
[6] Chirdan, L. B., Ameh, E. A., Abantanga, F. A., 2010, “Challenges of Training and Delivery of Pediatric Surgical Services in Africa,” Journal of Pediatric Surgery, 45(3) pp. 610-618.
[7] Butler, M. W., 2010, “Fragmented International Volunteerism: Need for a Global Pediatric Surgery Network,” Journal of Pediatric Surgery, 45(2) pp. 303-309.

Reply
John Jiao says:

14 April, 2014 at 5:02 pm

The need for adequate trauma surgical care in low- and middle-income countries

Traumatic injury is an overlooked epidemic in developing countries, leading to approximately 5.8 million deaths worldwide annually[1]. This is roughly equal to the number of deaths from HIV/AIDS, tuberculosis, and malaria combined, and of these deaths 90% of them occur in low- and middle-income countries (LMICs)[2]. It is also the leading cause of death of individuals between the ages of 5-45 in these countries, and for each person who dies from trauma it is estimated that 3-8 more are permanently disabled[3].

Despite these alarming figures, there is a decided lack of political and academic attention paid to either the prevention or the treatment of injury in LMICs, while a significant amount of resources are directed toward the control of communicable disease. As a result, though considerable strides have been made in many countries around the world in the treatment of disease, health care systems in LMICs are generally ill-equipped to handle the burden of trauma care.

The country of Honduras is a prime example of the trauma care disparities facing many LMICs. Despite being a nation of approximately 8 million people, there is not a single dedicated trauma center within its borders[4]. Only eight hospitals are reported to offer “general care including trauma”, five of which are in the capital of Tegucigalpa and the rest in various cities. Thus, more than 80% of the entire country’s population must travel anywhere from a few hours to over a day to reach a center that offers trauma care. This correlates with a disproportionate 48% of all male deaths in Honduras being injury-related[5]. Additionally, over 80% of all males aged 12 to 49 who died did so from injuries, a mortality rate 4.5 times that of the United States.

There is little doubt that injury is a neglected health care burden in LMICs. Not only is there a serious lack timely access to treatment for traumatic injuries, which by their nature often require expedience, but numerous assessments have reported trauma training in LMICs to be severely lacking[6-10]. Greater attention from the global public health community is greatly needed, particularly on training physicians in LMIC on standardized trauma protocols as well as on the establishment of more readily-accessible trauma care in these countries. It has been estimated that the lives of 2 million patients could be saved each year from improved trauma care globally[11], a number that is likely dwarfed by the number of permanent injuries that could be prevented as well. A great deal of research, planning, and implementation lies ahead in order to ensure such change is effective, sustainable, and long-lasting.

John X Jiao

Department of Biochemistry and Molecular Biology
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD 21205, USA

Conflicts of interest: The author has nothing to disclose.

References

[1] Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, Eds. Global burden of disease and risk factors. New York, NY. The World Bank and Oxford University Press, 2006.

[2] Gosselin RA, Spiegel DA, Coughlin R, Zirkle LG (2009). Injuries: the neglected burden in developing countries. Bulletin of the World Health Organization 87: 246.

[3] Beveridge M, Howard A (2004). The burden of orthopaedic disease in developing countries. J Bone Joint Surg Am 86-A(8): 1819-22.

[4] U.S. Embassy recommends the use of private hospitals in Honduras. Retrieved from

[5] Richman M, Shayne P, Heron S, Lowery D, Todd KH (2000). Injury control in Honduras: a survey of injury mortality. Ann Emerg Med 36(4): 333-9.

[6] Aboutanos MB, Mora F, Rodas E et al (2010). Ratification of IATSIC/WHO’s guidelines for essential trauma care assessment in the South American region. World J Surg 34(11): 2735-44.

[7] Arreola-Rise C, Mock C, Vega Rivera F et al (2006). Evaluating trauma care capabilities in Mexico with the World Health Organization’s Guidelines for Essential Trauma Care publication. Rev Panam Salud Publica 9: 94-103.

[8] Hanche-Olsen TP, Alemu L, Viste A et al (2012). Trauma care in Africa: a status report from Botswana, guided by the World Health Organization’s “Guidelines for Essential Trauma Care”. World J Surg 36: 2371-83.

[9] Son NT, Thu NH, Tu NT et al (2007). Evaluation of trauma care capabilities in four countries using the WHO-IATSIC Guidelines for Essential Trauma Care. World J Surg 30: 946-56.

[10] Mock C, Nguyen S, Quansah R et al (2006). Evaluation of trauma care capabilities in four countries using the WHO-IATSIC Guidelines for Essential Trauma Care. World J Surg 30: 946-56.

[11] Mock C, Joshipura M, Arreola-Rise C et al (2012). An estimate of the number of lives that could be saved through improvements in trauma care globally. World J Surg 36: 959-63.

Reply
says:

14 April, 2014 at 5:13 pm

Initial report from the Bernard Johnson Advisor for the International Programmes (BJA-IP) for the Royal College of Anaesthetists (RCoA)
Safe anaesthesia is a key component of safe surgery worldwide.
The RCoA, via the IP, supports anaesthetists from all over the world, especially those from poorly resourced and developing countries (DCs).
The role of the IP is multifaceted, but its main strands are
1) Support for International Medical Graduates (IMGs) who wish to spend time in the UK improving their skills and knowledge. For those who wish to spend time training in the UK, the IP acts as sponsors for the Medical Training Initiative scheme (MTI) which allows IMGs to train in the UK for up to 2 years. They are also able to take the Primary and Final FRCA examinations.
2) The RCoA also supports doctors in DCs achieving the qualification of MMed (Uganda and Zambia as examples), through both training programmes and financial assistance. It also assists with the training of non-medical anaesthesia providers.
3) Sharing standards of training and education: in 2013 a course was held at the RCoA for Iraqi doctors who wished to update their skills and knowledge as trainers. This unique ‘Training the Trainers’ course can be developed on a bespoke basis; doctors from DCs can also attend the many options held by the Anaesthesia as Educators group.
4) The RCoA supports and encourages UK anaesthetists, especially trainees, to spend time working and training in DCs. There is a specific Unit of Training in the 2010 curriculum which allows trainees to get their time counted towards their Certificate of Completion of Training (CCT).
This ensures robust supervision and maximum gain for both trainee and patients. There are RCoA Fellowships being developed which drive this forward.
5) The RCoA has established an Anaesthesia Clinical Standards Accreditation (ACSA) programme. It is a voluntary scheme for NHS and independent sector organisations that offers quality improvement through peer review. The RCoA could develop a similar programme for DCs.
6) The RCoA , through the AAGBI International Grants Committee, supports a wide variety of in DCs financially which espouse the College’s pillars of training, education and raising standards.
Additional information, including a detailed table of how to access some of the above information, can be obtained by contacting the IP.

Jo James
Bernard Johnson Adviser-International Programmes
Royal College of Anaesthetists | Churchill House| 35 Red Lion Square | London WC1R 4SG

Reply
Bistra Zheleva says:

14 April, 2014 at 6:55 pm

Dear Commissioners,
As we all know, surgery can mean many different things to different people. We know that access to surgical services is essential for women who need emergency obstetric services, people who need emergency abdominal surgery, or anyone who needs surgery for trauma, for example. Yet there are other areas that should not be overlooked. While we realize that health care spending priorities are different in many countries, we should not forget the need for some specialty surgical services such as congenital heart surgery. The facts do stand that the majority of patients around the world do not have access to quality and safe pediatric cardiac care. Access to quality pediatric cardiac care is essential to be able to save lives of patients who would otherwise die. Some health budgets will be able to tackle this, others may not, but given that there is no known prevention for congenital heart abnormalities, countries should be thinking of ways to take care of this patient population. Only 7% of the population has access to life-saving congenital heart surgery in the developing world (1), where congenital anomalies are the eighth leading cause of death in children (2). Approximately 90% of births worldwide occur in developing countries that have limited resources and high expected morbidity and mortality due to congenital heart disease (3,4). The establishment of surgical programs allows an increasing number of children access to life-saving surgery.

There are many organizations that have been working hard to address this disparity. Children’s HeartLink is one of them, the The International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries (IQIC), the The Global Forum for Humanitarian Medicine in Cardiology and Cardiac Surgery and The International Children’s Heart Foundation are others. We would welcome the opportunity to participate in the discussions and to provide feedback.

Kind regards,
Bistra Zheleva
VP International Programs
Children’s HeartLink
IQIC founding member

1. Pezzella AT. International cardiac surgery: A global perspective. Semin Thorac Cardiovasc Surg. 2002;14(4):298-320.
2. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al. Disease Control Priorities in Developing Countries. 2nd ed. Washington DC: The International Bank for Reconstruction and Development/The World Bank Group; 2006.
3. Saxena A. Strategies for the improvement of cardiac care services in developing countries: What does the future hold? Future Cardiol. 2012;8(1):29-38.
4. Tchervenkov CI, Jacobs JP, Bernier PL, Stellin G, Kurosawa H, Mavroudis C, et al. The improvement of care for paediatric and congenital cardiac disease across the World: A challenge for the World Society for Pediatric and Congenital Heart Surgery. Cardiol Young. 2008;18 Suppl 2:63-69.

Reply
Anesthesia Global Outreach Group says:

15 April, 2014 at 11:42 am

Dear commissioners,

We would like to echo the thoughts of Dr Hilary Edgcombe, above, and are writing on behalf of the Anesthesia Global Outreach course mentioned in her comment.

In particular, we agree that despite a large number of volunteers investing their time in work in low- and middle-income countries (LMIC) this kind of endeavor can be done well, or done badly, sometimes resulting in significant harm despite best intentions. Appropriate preparation and training is key, especially for the increasing number of trainees who want to get involved in this kind of work and this is the main goal of our Anesthesia Global Outreach course.

However, individual abilities and competencies are only one part of the puzzle when it comes to effective “global outreach” work. We would also like to highlight the importance of working with organizations, both academic and non-governmental, that support a longitudinal program, based on some kind of needs assessment and in partnership with physicians and organizations in the LMIC. Global outreach that primarily focuses on providing service has the potential to make a huge impact in the lives of a relatively limited number of patients, and is particularly important in natural or man-made emergencies, but we recognize that this may represent a short-term solution. Programs that focus on building capacity, through training healthcare workers and improving systems of perioperative care are much more likely to be part of a sustainable solution to the problem of the global inequity between the burden of surgical disease and access to safe surgical care. It is vital that such programs consider all the other programs doing similar work in the same area, as there is often much overlap and poor coordination. There is still little published data on the outcomes of outreach programs/partnerships between high-income and LMICs, monitoring and evaluation of these programs needs to be prioritized and lessons learned disseminated so that similar programs can learn from successes and failures.

Anesthesia Global Outreach Group

Reply
Karen Beattie, Associate Vice President, EngenderHealth says:

15 April, 2014 at 12:48 pm

Universal health coverage requires an essential package of quality surgical services, affordable and accessible to the whole population, including the geographically disadvantaged. We request the Commission to consider an essential surgery package to safeguard women’s health and well-being as a priority.

Maternal mortality and morbidity place a huge burden on low- and middle-income countries, including impacts on newborn and child health. Maternal and perinatal conditions requiring surgery account for at least 10% of DALYs in low-income countries.1 The surgical burden of breast and cervical cancer cost an additional estimated 17 million DALYs in less developed regions.2 The Millennium Development Goal for maternal health focused on reducing maternal deaths.3 As maternal mortality declines, there are compelling indications that a substantial proportion of deaths averted may result in severe, acute morbidities and long-term health consequences.4,5 Safe, quality surgical care is required for essential maternal and reproductive health care, including:
• Emergency obstetric care, including Cesarean-section
• Repair of obstetric fistula and pelvic organ prolapse
• Post-abortion and comprehensive abortion care (in compliance with local regulations where legally restricted)
• Breast and cervical cancer treatment
• Permanent methods of contraception

These needs are often intertwined. A lack of the full range of contraceptive options for women and couples who have completed their family size contributes to unwanted pregnancies. It contributes to the risks of childbearing in settings without access to C-section services. Lack of timely C-sections increases intrapartum stillbirths and the risk of outcomes such as obstetric fistula. For example, in Niger, the total fertility rate remains at 7.6 lifetime births per woman.6 The Demographic and Health Survey (DHS) also found a C-section rate of just 1.6% among births in the past three years. While the exact prevalence of fistula is unknown, hospitals in Niger report a backlog of at least 26%.7 Studies have also estimated significant surgical repair backlog in Nigeria and other settings.8,9

A recent study in Ethiopia10 found that C-section was the most commonly performed operation (29% of major procedures) and the most commonly performed emergency operation. Yet the population-level C- section rate was just 0.6%, far below levels expected given the incidence of obstructed labor and other conditions requiring surgical intervention.

Such findings indicate the crucial role of an essential surgery package in averting mortality and morbidity. Satellite centers could provide this essential surgery package to complement referral hospitals, focusing on the above-mentioned areas of surgical care. These services require the availability of trained surgical teams, support staff, operating theater management, inpatient care, supplies and equipment, and infection prevention procedures that, while available in some places, are not necessarily accessible to rural and remote populations. Satellite centers could provide routine surgical services and serve as screening and referral points to support more complex surgeries like fistula repair and cancer-related surgeries. Telemedicine to support emergency procedures could also enhance the capacity of satellite centers.

References:

1. Disease Control Priorities Project. Promoting Essential Surgery in Low-Income Countries: A Hidden, Cost-Effective Treasure. Available at: . Accessed: April 10, 2014.
2. Ginsburg OM, Breast and cervical cancer control in low and middle-income countries: Human rights meet sound health policy, Journal of Cancer Policy, Volume 1, Issues 3–4, September–December 2013, Pages e35-e41.
3. United Nations (UN). The Millennium Development Goals Report 2012. New York, NY: UN, 2012.
4. Wilson RE, Salihu HM. The paradox of obstetric “near misses”: converting maternal mortality into morbidity. Int J Fertil Womens Med 2007 Mar-Jun; 52:121–7.
5. Cochet L, Pattinson RC, Macdonald AP. Severe acute maternal morbidity and maternal death audit—a rapid diagnostic tool for evaluating maternal care. S Afr Med J 2003 Sep; 93:700–2.
6. ICF International. The DHS Program StatCompiler. Available at: http://www.statcompiler.com/. Accessed: April 6, 2014.
7. Fistula Care Project, EngenderHealth. Project reports (unpublished).
8. Ramsey K, Iliyasu Z, Idoko L. Fistula Fortnight: innovative partnership brings mass treatment and public awareness towards ending obstetric fistula. Int J Gynaecol Obstet 2007 Nov; 99 Suppl 1:S130–6.
9. Tunçalp Ö, Isah A, Landry E, Stanton CK. Community-based screening for obstetric fistula in Nigeria: a novel approach. BMC Pregnancy Childbirth 2014 Jan 24;14:44.
10. Reshamwalla S, Gobeze AA, Ghosh S, Grimes C, Lavy C. Snapshot of surgical activity in rural Ethiopia: is enough being done? World J Surg 2012 May; 36:1049–55.

Reply
Himaja Gaddipati says:

15 April, 2014 at 1:46 pm

Obstetric fistula is a complication of childbirth that is almost exclusively a problem in

the undeveloped parts of the world. The Global Burden of Disease Study estimates an incidence

of 8.68 and a prevalence of 51.35 per 10,000 women in low resource regions. Resulting from

obstructed labor, this complication has serious ramifications to both the baby and mother. The

baby often dies, while a hole in the mother’s vagina or rectum provides an avenue for leakage

of urine and feces. Given that the prevalence is highest among the disadvantaged in areas like

Sub-Saharan Africa, South Asia, and the Middle East, there are also the compounded effects

of stigma and social degeneration due to lack of awareness. These women are often socially

isolated, leading them to suffer from solitude and feelings of shame and discrimination. This

ultimately leads to other chronic medical problems, such as depression [3].

Although prevention is most certainly a key strategy for ending fistula, awareness

and recognition of surgery needs to be disseminated. This poses a challenge as the disparity

in surgical services is lacking with respect to multiple aspects, including proper equipment,

training, infrastructure, and financing, among others. However, if appropriate protocols were

established, fistula complication and outcomes could be comparable to the industrialized world.

Aspects such as skilled attendance at all births, and providing comprehensive emergency

obstetric care for women who develop complications would make great strides towards the

eradication of fistula [1].

Rushwan et al. supports such an approach. By creating the Global Competency-Based

Fistula Surgery Training Manual, they aimed to accomplish four objectives: 1. Promote doctors

to acquire the knowledge and skills to prevent, treat, and provide psychological care for women

who incur fistula 2. Using a standardized curricula, recruit trainees to become competent in

this area 3. Increase the number of equipped training and service centers for fistula care, and 4.

Establish a data collection system to enforce monitoring of progress [2].

Although this approach will clearly require commitment and deliberate allocation of

resources, the efforts are much needed. As of 2012, significant progress has been with the

support of 168 co-sponsors from all different regions. 27,000 women have received fistula

treatment with direct support from United Nations Populations Fund (UNFPA) and the

Campaign to End Fistula partners. However, there is still much work to be done. Without

compromising this momentum, hopefully the enforcement and availability of competent surgical

care can eradicate obstetric fistula [4].

References
[1] Linden, A, Sekidde, FS, Galukande, M, Knowlton, LM, Chackungal, S, McQueen, K.

Challenges of Surgery in Developing Countries: A Survey of Surgical and Anesthesia Capacity

in Uganda’s Public Hospitals. World J Surg (2012) 36:1056–1065.

[2] Rushwan, H, Khadaj, S, Knight, L, Scott, R. Need for a global obstetric fistula training

strategy. International Journal of Gynecology and Obstetrics 119 (2012) S76–S79.

[3] http://www.fistulafoundation.org

[4] http://www.unfpa.org

Reply
Himaja Gaddipati says:

15 April, 2014 at 2:37 pm

Obstetric fistula is a complication of childbirth that is almost exclusively a problem in the undeveloped parts of the world. The Global Burden of Disease Study estimates an incidence of 8.68 and a prevalence of 51.35 per 10,000 women in low resource regions. Causing obstruction of labor, this complication has serious ramifications to both the baby and mother. The baby often dies, while the hole on the mother’s vagina or rectum provides an avenue for leakage of urine and feces. Given that the prevalence is highest among the disadvantaged in areas like Sub-Saharan Africa, South Asia, and the Arab region, there are also the compounded effects of stigma and social degeneration due to lack of awareness. These women are often socially isolated, leading them to suffer from solitude and feelings of shame and discrimination. This ultimately leads to other chronic medical problems, such as depression [3].

Although prevention is most certainly a key strategy for ending fistula, awareness and recognition of surgery needs to be disseminated. This poses a challenge as the disparity in surgical services is lacking with respect to multiple aspects, including proper equipment, training, infrastructure, and financing, among others. However, if appropriate protocols were established, fistula complication and outcomes could be comparable to the industrialized world. Aspects such as skilled attendance at all births, and providing comprehensive emergency obstetric care for women who develop complications would make great strides towards the eradication of fistula [1].

Rushwan et al. supports such an approach. By creating the Global Competency-Based Fistula Surgery Training Manual, they aimed to accomplish four objectives: 1. Promote doctors to acquire the knowledge and skills to prevent, treat, and provide psychological care for women who incur fistula 2. Using a standardized curricula, recruit trainees to become competent in this area 3. Increase the number of equipped training and service centers for fistula care, and 4. Establish a data collection system to enforce monitoring of progress [2].

Although this approach will clearly require commitment and deliberate allocation of resources, the efforts are much needed. As of 2012, significant progress has been with the support of 168 co-sponsors from all different regions. 27,000 women have received fistula treatment with direct support from United Nations Populations Fund (UNFPA) and the Campaign to End Fistula partners. However, there is still much work to be done. Without compromising this momentum, hopefully the enforcement and availability of competent surgical care can eradicate obstetric fistula [4].

References

[1] Linden, A, Sekidde, FS, Galukande, M, Knowlton, LM, Chackungal, S, McQueen, K. Challenges of Surgery in Developing Countries: A Survey of Surgical and Anesthesia Capacity in Uganda’s Public Hospitals. World J Surg (2012) 36:1056–1065.
[2] Rushwan, H, Khadaj, S, Knight, L, Scott, R. Need for a global obstetric fistula training strategy. International Journal of Gynecology and Obstetrics 119 (2012) S76–S79.
[3] http://www.fistulafoundation.org
[4] http://www.unfpa.org

Reply
Kelly McQueen says:

15 April, 2014 at 4:29 pm

Guiding Patient Safety and Anesthesia in LMICs

The Global Anesthesia community is committed to patient safety in every setting. This extends to the poorest countries and most austere settings. Until now however, major guidance for improving patient safety when resources and providers are scarce, have come from the World Health Organization (WHO) and the World Federation of Societies of Anaesthesia (WFSA) in the form of minimum guidelines. We urge The Lancet Commission on Global Surgery to critically review these guidelines.

In 85 low and middle-income countries (LMICs) worldwide, hospitals cannot reach the existing WHO/WFSA guidelines. They are acknowledged as a benchmark against local standards and improvements, and this is decidedly important. However the majority of the world’s patients are not provided for by the minimum guidelines of these leading global organizations.

Millions of patients around the world receive surgery and anesthesia in austere conditions. For these patients nothing else is available. Anesthesia- related death rates reported from these settings are staggering. These outcomes can be improved on and must be. Collecting and reporting perioperative mortality rates (POMR) is a first step. Practical and low cost approaches to patient safety must be emphasized as global unmet surgical need is addressed.

In 2013 oxygen was added to the WHO Model of Essential Medicine List. While the addition was long over-due, the inclusion of oxygen has not insured that patients will receive it when needed. In LMICs the list of “essential” medicines is also a unrealistic guideline. A majority of the LMIC operative settings have no reliable source of oxygen, and most have no ability to provide mechanical ventilation if required. Similarly, anesthesia and pain medicines are critically limited, and life-saving medicines such as epinephrine are absent. This is the real minimum faced by those caring for women with post-partum hemorrhage, injured children, and patients with cancer.

Of even greater concern is the reality that there are too few trained anesthesia providers in LMICs. Those providing anesthesia today in LMICs not only face the conditions described above, but also have few skills life saving skills. The best possible is provided based on local expectations, but rarely is the safest care possible provided. With training and real guidance, these providers can improve patient safety and outcomes, even with the same limited resources.

There are many low-tech, inexpensive options for improving patient safety. Patient oxygenation is improved with timely maneuvers on room air, an important range of data is obtained from a very inexpensive precordial stethoscope in the absence of other monitors, and vital signs are obvious to trained fingers and vigilant eyes. These techniques are preventive and life saving, and must be part of the global guidelines recommended and taught in LMICs.

Safe anesthesia is a required component of surgical care and outcomes. More true today in LMICs than ever, safe surgery (may) save lives, but only when more than a checklist is implemented. No one will argue the important role of a pulse oximeter, but until there is a pulse oximeter with continuous monitoring by a vigilant trained provider and the essential medications in every operating theater, we must guide those providing care.

We urge the commission to recognize the importance of a realistic, bare minimum approach to anesthesia and patient safety in LMICs.

Respectfully,
Kelly McQueen, Tom Coonan, Haydn Perndt, Alison Froese, Andrew Ottaway, Simon Hendel, Robert Neighbor
USA, Canada, Australia, UK

Reply
Joe Lippi says:

15 April, 2014 at 8:30 pm

In much of the world, there is a perception that plastic surgery is a specialty service. Often associated solely with cosmetic procedures, there is a lack of awareness of the applications of plastic surgery to health issues encountered in developing countries. As a result, it tends to be among the last departments to be prioritized and developed at a hospital. But while cosmetic surgery is a major application for plastic surgery in developed countries, the reality is that plastic and reconstructive surgery is enormously important for the treatment of conditions seen commonly in the developing world and is both life-changing and life-saving. Severe burns are a good example.

Burns are among the leading causes of DALYs lost in the developing world. While many people die from the burn injuries they suffer, those who survive are usually left with disabilities that can profoundly impede their ability to live productive lives. These disabilities develop because without access to properly trained health workers and adequate health facilities at the local level, burn wounds are left to heal by themselves, creating scar tissue (contractures) that can destroy function and movement, and cause terrible disfigurement.

There is a vast shortage of doctors, surgeons and facilities for burns in developing countries; when care is available, few poor people can afford it. Over the last 45 years, we at ReSurge International have seen far too many children with a burned foot fused to the shin, for instance, because they did not have access to proper care at the time of injury, and because there was no reconstructive surgeon either available or willing to repair the debilitating burn scar contracture.

To address the needs of not just burn victims, but others in need of reconstructive surgery – including victims of trauma and those with congenital anomalies – an expanded workforce of surgeons with knowledge of plastic and reconstructive surgery is needed. This will require a real exchange between surgeons in both the Global North and South. In our experience, surgeons in developing countries are often more skilled in treating things like severe burn scar contractures, as they treat these conditions on a more regular basis than their counterparts in the developed world. More training programs are needed both within and across countries in the developing world in order to broaden the skill set of existing surgeons to include reconstructive surgical techniques and to increase the number of specialized plastic and reconstructive surgeons operating in these regions of the world.

Reply
Julia Webber says:

15 April, 2014 at 10:18 pm

Dear Commissioners,

The way to disrupt the lack of political priority and support of scalable solutions for strengthening surgical care in low resource settings is to secure surgery as a public health priority. Dr. Mahler, then Director-General of the WHO, stated in 1980 that essential surgery needed to be provided to the masses (1980). It has been over thirty years and this need has not been met and I believe this is due to surgery’s prevailing status as the “neglected stepchild of global public health” (Farmer, 2008).

In both my public health undergraduate and graduate degrees, I could not escape smallpox, tobacco or HIV; however, it was not until my final semester that I began considering surgery had a role in public health after I sought out a class on the topic. Millions in low income countries do not have the luxury to wait for public health workers to stumble upon their neglected stepchild. Fortunately, over the past few decades many have struggled to secure surgery a place on the public health foundation.
One of these organizations was the WHO, who identified common fallacies causing surgery misrepresentation in global public health (WHO, 2014). Below I will discuss five of these fallacies.

1. Surgery is not cost effective.
In reality, in a hospital in Sierra Leone, savings of all surgical care provided was $32.78 per DALY averted as compared to oral rehydration treatment for diarrhea savings of $35.00 per DALY averted (Gosselin, 2006).

2. Surgery addresses only a small portion of the global burden of disease.
In reality, at least eleven percent of the global burden of disease can be treated with surgery (WHO, 2014).

3. Surgery is too complicated to set-up and to provide. It needs high-tech equipment.
In reality, technologies such as the Universal Anesthesia Machine provides cost-effective and safe anesthesia to be delivered in areas with unreliable electricity and oxygen supplies. This machine uses a car filter for easier, local replacement and similar technologies are continually being invented. (Gradian Health Systems, 2012).

4. Surgery can only be provided by surgeons.
In reality, after attaining intensive training, assistant medical officers in Mozambique were compared with specialists in obstetrics and gynecology and there were no differences in the cesarean section outcomes (Pereira, 1996). As task-shifting continues to increase, quality surgical care will become more available on a wide-scale basis.

5. Surgery can only be introduced after there is strength in a health system
In reality, Dr. Edgar Rodas created Cinterandes which brings surgical care to Ecuadorians in an operating room in a van to overcome the health system that is disrupted by distances (deVries, 2012).

It was over five years in the public health arena before the connection between surgery and public health was brought into my viewpoint. My scalable solution is to tap into the resources of public health. Eliminating the archaic and inaccurate prejudice against surgery as a public health endeavor facilitates appropriate application of that most valuable public health resource – young, idealistic, enthusiastic, intelligent, creative people.

References:

deVries, C. R., & Price, R. R. (2012). The Innovator’s Scalpel: Remodeling Surgery. Global surgery and public health: a new paradigm. Sudbury, MA: Jones & Bartlett Learning.

Farmer, P.E., Kim, J.Y. (2008, March 3). Surgery and global health: A view from beyond the OR. World J Surg (2008) 32:533–536. DOI 10.1007/s00268-008-9525-9.

Gosselin, R.A., Thind, A., Bellardinelli, A. (2006, April). Cost/DALY averted in a small hospital in Sierra Leone: What is the relative contribution of different services? World Journal of Surgery. Volume 30, Issue 4, pp 505-511.

Gradian Health Systems. (2012). The universal anesthesia machine. Retrieved from: .

Mahler, H. (1980, June 29). Surgery and health for all. Retreived from: http://www.who.int/surgery/strategies/Mahler1980speech.pdf?ua=1.

Pereira, C., Bugalho, A., Bergstrom, S. Vaz, F. Cotiro, M. (1996, June). A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique. Br J Obstet Gynaecol. 103(6):508-12.

WHO. (2014). Surgery: the neglected component of primary care. Retrieve from: http://www.who.int/surgery/esc_component/en/.

Reply
Sebastian B. Shu Yip and Laura M. Luque Bustamante says:

15 April, 2014 at 11:02 pm

In our personal experience, being a medical student and a young physician from a LMIC has not made our way easy towards Global Surgery. We have bumped into several limitations along the road in different aspects, but basically we would like to emphasize on two:

a) Limited access to information: There is still limited free access to information related to surgical development. We barely have occasional resources such as scientific articles, books, etc. We find few or non-reliable data regarding surgical issues, especially those with higher priority in low resource settings. We lack vital tools and information in order to develop projects that may be able to give us valuable information on surgical outcomes.

b) Absence of guidance: In spite of the great recommendations given by Finlayson1, still many surgeons and other professionals in surgery do not know how to aboard Global Surgery. For almost 2 years one of us have been trying to find someone who can guide into the path surgical research with no success. Our impression is that most surgical professionals underestimate the importance of surgery in public health issues. We truly consider this is a main challenge for the following years.

Due this situation, we propose to the commission to take in consideration the following point for discussion:

• Facilitate access to information throughout including ¨Global Surgery¨ in MeSH as a key word in Pubmed2. This will make easier to find accurate information. Also considering the example of the Ptolemy Project3 of how high income countries can facilitate access to information in resource limited settings and looking for building a critical mass in surgical research.

• It might be helpful to diffuse a fact sheet or a review publication of the concept of Global Surgery in a free access source. The WHO could to be a good and possible candidate.

• Encourage surgeons and other surgical providers to expand their knowledge in clinical epidemiology. This will lead to a better understanding regarding the countries distribution and to highlight the importance of having the correct metrics and indicators available when needed.

• Promote the enforcement between medical and public health schools in LMIC in order to work for Global Surgery. GlobalSurg4 is an example of how mutual cooperation can strengthen local research groups.
We hope this comment is a useful inside perspective of how to promote the aims in Global Surgery among the medical community.

Sebastian B. Shu Yip1 and Laura M. Luque Bustamante2
1. Universidad Peruana Cayetano Heredia. Lima, Peru.
2. Harvard Medical School. Boston, USA.

References
1. Finlayson SRG. How should academic surgeons respond to enthusiasts of global surgery? Surgery. 2013 Jun;153(6):871–2.
2. Shu SB. Una perspectiva de la cirugía desde la Salud Pública: Cirugía global. Revista Médica Herediana. 2013 Oct 2;24(3):258.
3. Derbew M, Beveridge M, Howard A, Byrne N. Building Surgical Research Capacity in Africa: The Ptolemy Project. PLoS Med. 2006 Jul 11;3(7):e305.
4. Bhangu A, Kolias AG, Pinkney T, Hall NJ, Fitzgerald JE. Surgical research collaboratives in the UK. The Lancet. 2013 Sep;382(9898):1091–2.

Reply
Ayobami Ward says:

15 April, 2014 at 11:07 pm

The Need for Self-Sustaining Surgical Care in Low and Middle Income Countries

It has been approximately 6 decades since the first set of indigenous African surgeons were trained in the United Kingdom and United States [1] , and the landscape of surgical intervention in low and middle income countries has evolved substantially. Despite this evolution, 45% of Disability-Adjusted Life Years (DALYs) in low and middle-income countries are a result of non-communicable diseases (NCDs). Surgical conditions comprise about one-quarter of these at 11% [2] . One of the most critically absent aspects to this statistic is the presence of well-trained and qualified surgeons. Not only do LMICs experience a scarcity of dedicated practitioners, but also a large number of surgical missionaries are being brought in to complete the necessary operations. Unfortunately, there is no current data that calculates the efficacy of these services on the global burden of disease, leaving us to question the long-term efficacy of these programs. When you couple these factors with the infrastructural deficiencies present in LMICs, it becomes apparent that more needs to be done to narrow the gap in access to surgical care between LMICs and high income countries.

According to the WHO, more than 90% of deaths from injuries occur in LMICs [3], yet there are currently no global funding organizations with dedicated support to surgical care. With adequate funding, we may be able to reverse the progression of injury-related deaths, but I believe we must think further ahead. There is a need for the establishment of self-sustaining surgical care in LMICs. By providing training for local health professionals, sources of clean water, sterilization units, and anesthetics, surgery may be safely performed in resource-limited environments, by local practitioners. In fact, Médecins Sans Frontières recently reported that as long as trained staff members could perform with these basic surgical supplies, the rate of operative mortality could be kept low [4]. Furthermore, this new system needs to be able to bolster the surgical infrastructure over time to meet the high rate of injury related deaths. Studies indicate that the cost of many basic surgical procedures such as emergency cesarean section, elective hernia repair, and cataract surgery compare favorably to many treatments at the forefront of public health initiatives in LMICs, such as anti-retroviral therapy for HIV, vitamin A supplementation and breastfeeding promotion [5].

By supporting LMIC surgical care, investing in adequate surgical education and tools for local practitioners by mission surgeons, we can create a self-sustaining surgical care system in LMICs. By reducing the 90% statistic, which primarily burdens breadwinners in LMIC families, we can increase family stability and improve health outcomes in resource-limited regions of the world, while simultaneously reducing the burden of NCDs on these same areas. Further research is needed to adequately implement these suggestions into public health initiatives abroad, and I fully advocate for its future consideration by health organizations around the world.

Ayobami Ward
Johns Hopkins Bloomberg School of Public Health
Department of Biochemistry and Molecular Biology

References:

1. Bode, C. O., C. C. Nwawolo, and O. F. Giwa-Osagie. “Surgical education at the West African College of Surgeons.” World journal of surgery 32.10 (2008): 2162.
2. Farmer, Paul E., and Jim Y. Kim. “Surgery and global health: a view from beyond the OR.” World journal of surgery 32.4 (2008): 533-536.
3. Peden M, McGee K, Krug E. Injury: A leading cause of the global burden of disease. Geneva: World Health Organization; 2002.
4. Chu KM, Ford N, M. T. Operative Mortality in Resource‐Limited Settings: the Experience of Médecins Sans Frontières in 13 Countries. Archives of Surgery. 2010;145(2):154‐60
5. Grimes, Caris E., et al. “Cost-effectiveness of Surgery in Low-and Middle-income Countries: A Systematic Review.” World journal of surgery 38.1 (2014): 252-263.

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Joe Lippi says:

15 April, 2014 at 11:46 pm

In much of the world, there is a perception that plastic surgery is a specialty service. Often associated solely with cosmetic procedures, there is a lack of awareness of the applications of plastic surgery to health issues encountered in developing countries. As a result, it tends to be among the last departments to be prioritized and developed at a hospital. But while cosmetic surgery is a major application for plastic surgery in developed countries, the reality is that plastic and reconstructive surgery is enormously important for the treatment of conditions seen commonly in the developing world and is both life-changing and life-saving. Severe burns are a good example.

Burns are among the leading causes of DALYs lost in the developing world. Many burn victims die, and those who survive are often left with disabilities that can profoundly impede their ability to live productive lives. These disabilities develop because without access to properly trained health workers and adequate health facilities at the local level, burn wounds are left to heal by themselves, creating scar tissue (contractures) that can destroy function and movement, and cause terrible disfigurement.

There is a vast shortage of doctors, surgeons and facilities for burns in developing countries; when care is available, few poor people can afford it. Over the last 45 years, we at ReSurge International have seen far too many children with a burned foot fused to the shin, for instance, because they did not have access to proper care at the time of injury, and because there was no reconstructive surgeon either available or willing to repair the debilitating burn scar contracture.

To address the needs of not just burn victims, but others in need of reconstructive surgery – including victims of trauma and those with congenital anomalies – an expanded workforce of surgeons with knowledge of plastic and reconstructive surgery is needed. This will require a real exchange between surgeons in both the Global North and South. In our experience, surgeons in developing countries are often more skilled in treating things like severe burn scar contractures, as they treat these conditions on a more regular basis than their counterparts in the developed world. More training programs are needed both within and across countries in the developing world in order to broaden the skillset of existing surgeons to include reconstructive surgical techniques and to increase the number of specialized plastic and reconstructive surgeons operating in these regions of the world.

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Maryana Boulos, Ophthalmic Assistant and MPH Candidate says:

15 April, 2014 at 11:58 pm

Seeing a Way Out of Depression: The Need to Implement Global Cataract Surgery

The five basic human senses are the means by which we perceive everything in life. Blindness is not an isolated condition because sight heightens one’s ability to establish the purpose of living. Working with patients that struggle with low-vision lifestyles, I have been astonished by the mental health troubles they confide in their ophthalmologist. The anxiety they express, the tears they shed, some having contemplated suicide since their vision loss, is enough for me to acknowledge that vision is more than a luxury. Mental illness is complicated and difficult to treat. Blindness, on the other hand, is not always so; with increased promotion of innovative public health projects, surgery could not only be the solution to blindness due to cataracts but also an improvement to the quality of life for millions of people globally.

Cataract surgery cannot cure all forms of mental illness, but reversing blindness due to cataracts and, in turn, dependency and depression issues is a valid starting point in reducing the suffering of many people worldwide. However, public health professionals commonly misconceive surgery as an overly-expensive intervention that addresses only a limited portion of the global burden of disease. Although the 20 million people bilaterally blind due to cataracts may not be a large enough population for public health interests, the estimated 350 million people affected by depression worldwide is substantially greater. With the genesis of innovative surgical projects occurring internationally, the support and influence from the World Health Organization (WHO) on global surgery is the key to make an impact on this issue. One surgery at a time, cost effective surgical projects could begin to alleviate these health conditions affecting the disability-adjusted life years for so many.

The lack of global support of surgery as a public health endeavor limits the expansion of organizations that are making an impact on providing cataract surgery in low resource areas. The Himalayan Cataract Project has designed teaching programs with simplified surgical techniques and established locally-run lens factories to allow cataract surgery to be performed in Nepal for as little as twenty dollars. This project is gradually expanding with academic and private partnerships to help several other communities in low- and middle-income countries. The cost effectiveness and sustainability of their project to other parts of developing world gives hope that more growth is possible in the field of global surgery.

Providing surgery as a public health intervention for the people who struggle with mental illness due visual impairment will impact several WHO initiatives. I have seen the detriment to one’s mental state when they struggle with vision loss, and I have witnessed the euphoria that follows the recovery of vision. The WHO currently has several initiatives to support conventional means of treating mental illness. However, additional support and awareness of the WHO Initiative for Emergency and Essential Surgical Care would be another pivotal movement to improve mental health globally, while returning the gift of sight to millions.

Reply
1. Julia Webber says:
  
  16 April, 2014 at 1:06 pm
  
  Maryana,
  
  I completely agree and share in your idea that public health is an untouched resource for global surgery. What an interesting connection between blindness and mental health! It completely makes sense, but I just had not thought about it. I don’t know the source but I remembering hearing that at the end of life, people mostly wished they could still see, hear and be mobile.
  
  Good work.
  
  Reply
Gautam Shrivastava says:

16 April, 2014 at 12:15 am

The Growing Need for Laparoscopic Surgery Training

Laparoscopic surgery represents a growing field of study and practice across much of the developing world, and offers the key benefits of reducing blood loss and exposure to external contaminants, which are serious issues in low resource environments. The difficulties with expanding surgeries to include this option for much of the developing world is plagued by problems associated with poor availability to resources, underscoring Farmer and Kim’s assertion that surgery is the “neglected stepchild of global health”1.
In a study examining laparoscopic surgery over a year at a Nigerian teaching hospital, the chief problems included defective equipment, power outages, and dead light source bulbs driving the conversion of about a quarter of the laparoscopic surgeries to open surgeries2. These issues are mostly related to inadequate funding and infrastructure, which represent another side of the sphere of medical development, while an improvement in laparoscopic methods may reduce risks to patients.
There are also success stories coming out of the African continent, particularly from South African. In assessing the outcomes of laparoscopic inguinal hernia repairs at a private hospital, there was only a 7.9% complication rate in a sample of over 500 patients, as well as a low incidence of persistent post-operative pain3. This goes to show the progress that can come with the growth of training and equipment availability at hospitals.
With the benefits provided by this minimally invasive style of surgery for a growing number of surgical procedures, it is the efforts of teams like UCSF’s Dr. Jessica Beard’s who, in conjunction with Muhimbilii University in Dar es Salaam Tanzania, developed a low-cost laparoscopic trainer to teach and improve laparoscopic skills by surgeons practicing in low resource settings. The group worked with surgical residents, of which a minority had previous experience, resulting in an average MISTELS practice time of 8.67 hours4. This type of work opens the door to more widely accessible alternatives to open surgeries, which could dramatically change the complication profile for resource poor setting hospitals.

Works Cited

1) Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008; 32: 533–36.

2) Ismalia BO, Shuaibu SI, Ale AA. Laparoscopic surgery in a Nigerian teaching hospital for 1 year: challenges and effect on outcomes. Niger J Med 2013; 22(2): 134-37

3) McGuire CI, Baigrie RJ, Theunissen D, Fernandes NL, Chapman LR. Outcome of laparoscopic inguinal hernia repair in a South African private practice setting. South African Journal of Surgery 2012; 50:4 115-18

4) Beard J.H., Akoko L, Mwanga A, Mkony C, O’Sullivan P. Manual Laparoscopic Skills Development Using a Low-Cost Trainer Box in Tanzania. Journal of Surg Ed 2014; 71(1): 85-90

Reply
says:

16 April, 2014 at 4:47 am

Bangladesh is a developing country – try to coming out from the list of low income country to middle income country. Health sector develop in Bangladesh is mostly primary health care level & preventive communicable diseases by this way reduce the mortality & morbidity of neonate & child bearing mother. Above achievement Anesthesiologists is a great role by providing anesthesia service in emergency obstetric program.
With the development country huge burden of non communicable diseases most of them need surgical interference, resuscitation & artificial support treatment.
On the demand of the suffering people & the development medical science different surgical subspecialty is develop & expand without developing appropriate infrastructure & supporting manpower specially anesthesiologists.
Obs. & Gynecological surgery are increasing tremendously due to most female doctor are gynecologists & 50% population are female. Other branch of the surgery subspecialty or super specialty also expand but not up to demand of the people. In Bangladesh Anaesthesiologists are not only confined within the operating theater and they also provide the ICU service, with the expanded to emergency and trauma resuscitation, pain management and palliative care.
With the surgical expansion & also other services is very much limited due to the lack of skills anesthesiologists. In Bangladesh it is essential to improve our health service in secondary and tertiary level. In this level anaesthesiologists among the physicians have great role to provide modern medical service to the people.
Shortage of skill anesthetic manpower is major obstacle to quality health service delivery. Young physicians have a little interest to doing their carrier in this special medical branch like Anesthesiology. Because there is lack of carrier infrastructure, post, national & social recognition & remuneration compare to medical & surgical specialties.
International health organizer must suggest to the Government & private health care provider (NGO) to maintain equality of medical science by giving the special attention to anaesthesiology. They improve the carrier infrastructure for anesthesiologists, providing more post & position for anaesthesiologists & give them special incentive. By this way to overcome the shortage of skill manpower in anaesthesiologists. Hopefully anaesthesiology would get the first priority.
Without improving anaesthesia service we cannot provide safety of surgical patients, for this reason better anaesthetic management is essential & that facilitate the surgeons to perform highly complicated and innovative operations, leaving patient’s life in good condition.
If above mention facilities can provided than anaesthesiolgists have to extend their services beyond urban areas and come to serve the poorer section of the nation living in villages. Spectrum of anaesthetic services has been expanded considerably in this modern era. To meet the demand of growing population, skill and increased manpower, instrumental support in this relatively neglected subject like anaesthesiology is of outmost importance.
International organization & government health policy can change this scenario without much financial involvement. They can provide training facility abroad for more skill development & knowledge to achieve the international standard safety in the patients.

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Dr Teshufin Naidoo says:

23 April, 2014 at 9:25 am

To what extent should the suffering of others impact on the welfare and projects of an individual surgeon or anaesthetist? What are the limits of our professional obligations, specifically to the poor? How can we access the benefits of economic competition and maintain professional ethical obligations when medical services are traded on a free market?

I would like to highlight the need for a resurgence in applied ethics education across all professions, particularly specialist medical personnel in developing countries. The field of professional ethics offers current thinking regarding the value in codes of ethics, character based approaches and the renaissance in the specific value of honesty, trust and integrity. When applied to some of the challenges to health care delivery in LMIC and dealt with as an a priori concern, solutions to challenges of sustainability, maintaining professional standards, resource distribution, skills retention and continued medical education, will be arguably more effective in achieving the desired ends of access to, and a high quality of, health care for all.

Is traditional deontological based teaching is adequate? Is medical ethics about more than just duty?
To answer many questions and challenges faced in the delivery of health care in LMIC. Consider these examples:

A tourist, while visiting a national game reserve in South Africa, is involved in an MVA and sustains fractures to his legs. He is airlifted to a private hospital casualty within a short time where he is told that unless he pays a deposit of $6000 he will not be seen. After handing over his credit card he meets the orthopaedic surgeon who says his fee is $ 10000 and he can arrange for the procedure to be done the same day. The Anaesthetist quotes a fee of R 20 000 ( $2000). The patient, in his current state, agrees to all of this. As he is going off to sleep, the Anaesthetist tells him that he can also offer him a nerve block which will provide superior analgesia post op, but this will cost him a further R 5000 ($500).

This highlights the efficiency of the private sector in Africa and perhaps any part of the world, but raises questions of ethical pricing behaviour. How do we know that this is a fair price for the services offered? Why should the doctors even consider ethics in a “willing buyer-willing seller” transaction? Is this exploitation?

A new orthopaedic surgeon, recently registered with the council ( 4 years postgraduate training and completion of examinations in our country) enters private practice with dreams of driving a Porsche within the year. The private hospitals offer him subsidised office space, a named parking bay and off he goes. His first private patient with shoulder pain gets admitted for arthroscopic acromioplasty and repair, a procedure he has never performed alone nor witnessed as part of his training. He instead has arranged with a rep from the surgical equipment company to assist him in theatre, the same rep that will be sending him on an all expenses paid business class trip overseas to a shoulder surgery conference.

If everybody is benefitting- the patient gets an operation, the hospital bills for theatre time, the doctors are paid their respective fees and in the process gain some education- why is this a problem?
Is this an abuse of the patients trust? How ought indications for surgery, choice of technique and choice of equipment in the private sector be regulated ? What is acceptable training and where should post-specialization training occur ? How do we deal with barriers to professional regulation? Can professional regulatory bodies do more to monitor accreditation of super-specilaty procedures? Is there a way to encourage ethical practice from within the professions?

The government hospital intensive care unit gets a request from a rural area clinic to admit a patient with respiratory failure. She is HIV positive with a Cd4 count of 84, on treatment for pulmonary tuberculosis and pneumocystis pneumonia. Her blood gases and clinical condition suggest mechanical ventilation and organ support is necessary. She is 35 with 3 dependants. The consultant on call for the ICU finds her clinical condition to be severe and denies admission stating that with the limited number of ICU beds, it is not in the interests of social justice to accept this patient. The vacant beds should be reserved for someone with a better prognosis.

In a system overrun with infectious diseases and the complications thereof, how ought we to make ethical decisions regarding resource utilisation ? What are patients entitled to in the interests of “social justice”? In a rapidly evolving global society, do our doctors make socially acceptable decisions? Is there any value for dignity, even in LMIC? Does social justice support or refute a right to access health care facilities when one is sicker than the status quo? Do doctors compromise basic human rights to dignity when denying access to care, or are they absolved on the basis of preventing further suffering?

The paediatric ICU at the government hospital is full and current policies do not allow for transfer of patients to the private sector. A child with advanced liver disease requires intensive care following a mishap in theatre. The young school going mother did not want surgery for the child. She and the elders in her family had decided to accept the child’s eventual demise as part of their cultural beliefs. Doctors removed the child from parental custody and operated regardless. There was an arrest with prolonged hypoxia at induction and the procedure was abandoned.

Is medical ethics suitably appraised of cultural value systems in the developing world? How ought we to balance conflict between cultural values and medical obligations? Is it reasonable for the medical manager at a state hospital to place a moratorium on “buying” a bed in the private sector ? Should there be an independent multi-disciplinary panel that weighs all relevant considerations, medical, cultural and ethical, before decisions are taken?

Practical, applied ethics ought to be a primary concern in all health care settings, particularly where there are gross discrepancies in social classes and the difference between good and bad decisions lies with the ethical behaviour of the individual professional. The field of applied ethics incorporates thinking from diverse spheres in order to assist with difficult decisions. Increasing awareness of and consideration for these principles and models will affect the professional behaviour of individual practitioners, professional bodies and health care regulators in order to provide a greater access to high quality care.

Any model or process ought to incorporate current ethical thinking regarding the value of trust, honesty and integrity in individual professionals as well as in professional organisations. New thinking regarding the ethical value in professional codes of conduct, ethical business practices, developments in effective continued education is paramount to any venture in LMICs.

Sincerely

Dr Teshufin Naidoo
MBChB (Natal) DA (SA) FCA (SA) MA APE (Leeds)
Specialist Anaesthetist
Private practice Ethekwini Metro Area
Sessional Consultant King Edward Hospital Intensive Care Unit

Reply
Evelyn Nguyen says:

23 April, 2014 at 10:10 am

Pediatric Surgery in Sub-Saharan Africa: An Unmet Need Although surgery has been increasingly recognized as an important component of global health, pediatric surgery has not been given much individual attention [1]. It is important to recognize that children have surgical needs distinct from that of adults, and many developing countries are in dire need of this care [2]. Sub-Saharan Africa is one region comprised of such countries. Although the proportion of pediatric surgical burden has not been assessed [1], there are some estimates for certain conditions requiring surgical care. For example, injuries are the most frequent cause of surgical conditions in Africa [2], with sub-Saharan Africa possessing the highest rates for injury-related childhood disability-adjusted life years (DALYs) [3]. Also, congenital diseases that are surgical conditions affect 543 of 10,000 children between 0 and 14 years of age, with the aggregate risk of surgical treatment necessity at 85% [4]. In sub-Saharan Africa, major congenital abnormalities have an exceptionally high mortality rate [4]. One of the main issues of this burden is clearly the lack of manpower. South Africa has a severe shortage of pediatric surgeons, with merely one pediatric surgeon per two million people [5]. Amongst the countries surveyed, a recent study found that of these few surgeons, an overwhelming majority (90%) of them practice in large tertiary hospitals clustered in major cities [6]. This exacerbates the shortage problem because over two-thirds of the African population reside in rural areas [6]. Some of these unmet needs can be aided by surgical volunteerism [7]. The Global Pediatric Surgery Network is one way of coordinating these efforts [1]. However, it is important to realize that sporadic aid from foreign pediatric surgeons is insufficient for lasting results [4]. Sustainable solutions that can be adapted to the local conditions are critical for long-term effects [4]. Improvements include a greater health care budget from African governments, enhancements in medical facilities, incentives to help retain African medical school graduates, greater involvement of pediatric surgeons in Africa in mentoring trainees, and collaboration amongst African pediatric training institutions for maximal use of resources [6]. In addition to resources, a change in mindset regarding pediatric surgical care is a necessity. In developing countries, surgical care is often seen as a luxury rather than as a vital part of child health care [2]. It is imperative that communities realize that proper surgical care can benefit their child’s health when the applicable situation arises [2]. There also needs to be a change in the political environment. In their research, Bickler and Rode stated that there is no government agency health action plan that focuses on pediatric surgical care needs [2]. It is clear that many things must be done to ameliorate the insufficiency in pediatric surgical care in sub-Saharan Africa. In addition, greater attention must be given to the imperative issue of pediatric surgical care needs. Otherwise, progress in addressing these needs will remain stunted, and millions of children will continue to either suffer with their surgical conditions or perhaps succumb to their ailments. Evelyn T. Nguyen Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA References [1] Ozgediz, D., and Poenaru, D., 2012, “The Burden of Pediatric Surgical Conditions in Low and Middle Income Countries: A Call to Action,” Journal of Pediatric Surgery, 47(12) pp. 2305-2311. [2] Bickler, S. W., and Rode, H., 2002, “Surgical Services for Children in Developing Countries,” Bulletin of the World Health Organization, 80(10) pp. 829-835. [3] Deen, J. L., Vos, T., Huttly, S. R., 1999, “Injuries and Noncommunicable Diseases: Emerging Health Problems of Children in Developing Countries,” Bulletin of the World Health Organization, 77(6) pp. 518-524. [4] Calisti, A., Belay, K., Mazzoni, G., 2011, “Promoting Major Pediatric Surgical Care in a Low-Income Country: A 4-Year Experience in Eritrea,” World Journal of Surgery, 35(4) pp. 760-766. [5] Elhalaby, E. A., Uba, F. A., Borgstein, E. S., 2012, “Training and practice of pediatric surgery in Africa: past, present, and future,” Seminars in pediatric surgery, Anonymous Elsevier, 21, pp. 103-110. [6] Chirdan, L. B., Ameh, E. A., Abantanga, F. A., 2010, “Challenges of Training and Delivery of Pediatric Surgical Services in Africa,” Journal of Pediatric Surgery, 45(3) pp. 610-618. [7] Butler, M. W., 2010, “Fragmented International Volunteerism: Need for a Global Pediatric Surgery Network,” Journal of Pediatric Surgery, 45(2) pp. 303-309.

Reply
Roger Eltringham says:

28 April, 2014 at 9:15 am

Lancet Commission on Global surgery.
Suggestions for advancing surgical care by improving anaesthesia services.

Roger Eltringham Medical director of the charity `Safe Anaesthesia Worldwide`
former member of Education Committee of WFSA

In recent years I have visited, together with colleagues from the WFSA, anaesthetic departments in more than 30 countries throughout the developing world .Here is a brief summary of our findings and some recommendations for improvements. These improvements could easily be achieved –not by spending more money but by spending much less, by focussing on the causes of their problems and identifying ways of eluding them.
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1. The standard of anaesthesia outside the main teaching hospitals is frequently unsatisfactory largely due to problems of equipment and training

2 A great deal of money has already been spent on aid. Unfortunately much of this has been misdirected and wasted on equipment which is totally in-appropriate. For example, the latest anaesthetic machines complete with electronic monitoring have been donated at huge expense without consideration for the local circumstances and additional requirements.

3 The type of anaesthetic machine commonly used in UK is unsuitable for use in poor countries with limited facilities, as they are dependent on uninterrupted supplies of both oxygen and electricity as well as regular servicing by highly skilled electronic engineers. Without these, they cannot function and are discarded..

4 Although this form of aid is both expensive and ineffective it has continued unchecked for many years. This is partly because many have vested interests in maintaining the status quo and partly because, until recently, little research was directed at the needs of the poorest countries.
This has recently changed and there are now on the market` state of the art` anaesthetic machines, such as the Glostavent, which have been specifically designed to cope with the additional problems encountered in isolated hospitals in poor countries

5.To be suitable for use in these conditions an anaesthetic machine needs components not found in standard machines, these include;
-a draw over breathing system to enable inhalational anaesthesia to be administered safely even when oxygen is unavailable
-a gas driven ventilator that can function in the absence of electricity
-an oxygen concentrator which can produce oxygen from atmospheric air at a fraction of the cost of cylinder oxygen

An anaesthetic machine with these components can continue to function without interruption if the oxygen fails, if the electricity fails, or indeed if they both fail simultaneously, occurrencies that are all too common in developing countries.. Furthermore it does not require regular visits by highly trained electronic engineers to undertake the maintenance and servicing.

6. Not only are these purpose built machines now readily available, they are much less expensive than the standard anaesthetic machines used in UK hospitals. Furthermore the running costs are greatly reduced since the need for the purchase and transport of a constant supply of cylinders of oxygen is greatly reduced and even eliminated. They can deliver safe anaesthesia for any type of surgery and can provide long term ventilation if required in an intensive care or recovery unit.

7. If emergency anaesthesia is required in situations where local facilities are completely non-existent , for example following terrorist activity or natural disasters, a portable version weighing under 10 Kg is available and has been shown to be completely satisfactory .

8 Concientious clinical monitoring is less expensive and more satisfactory than reliance on complex electronic monitors which require electricity and regular servicing. These skills should be emphasized in every teaching program.

9 Adequate instruction must be given in the correct use of equipment, its care and maintenance, as well as the avoidance of extravagance and waste. Arrangements for an after- sales service are essential in order to deal with questions and problems.

10. There needs to be a recognised source of information on minimal standards of equipment required for use in difficult situations..It should be a completely independent of commercial influence and prepared by a respected international organization. The current guidelines recently published by the WFSA fulfil these criteria and are now available.

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WFSA says:

29 April, 2014 at 8:03 am

Lancet Commission on Global Surgery and Anaesthesia

WFSA comment

The World Federation of Societies of Anaesthesiologists (WFSA) welcomes the Lancet Commission on Global Surgery. Anaesthesia providers are a core staff of every modern hospital providing expertise for patients undergoing surgery, critical illness and acute pain.

In many countries anaesthesia services have advanced to ensure a highly qualified, well resourced specialist clinician cares for each patient before, during and after surgery. Developments in anaesthesia have improved opportunities for surgeons to operate on patients safely during surgery to such a level that now in the best centres only around 1:200,000 patients die as a complication of the anaesthetic.

Contrast this with countries working under difficult conditions where anaesthesia services are poorly developed; here mortality rates 100-1000 times higher have been reported. [1,2]

The reasons for such high mortality rates are related to a lack of infrastructure providing the essential equipment, monitoring and drugs to perform safe anaesthesia, a shortage of a trained workforce and inadequate training and experience of those practicing anaesthesia. It is still common to hear of anaesthesia being administered by untrained personnel (Trained on Job).

The tragedy is that providing basic, safe anaesthesia is not complicated, but it requires an investment in workforce, training, facilities, drugs and equipment.

Workforce and Training
In countries with adequate numbers of medical graduates, anaesthesia is often a medical based service. However, where doctors are scarce, anaesthesia nurses, clinical officers or technicians have provided anaesthesia services for many years. This is often termed task-shifting. The anaesthesia provided by this group of dedicated healthcare workers is often very high quality, but only provided adequate resources are put into their training and continuing professional development.
Anaesthesia training requires a good knowledge of physiology, pharmacology, equipment, medicine and surgery integrated with a range of practical skills that have been taught and assessed throughout training. This takes time to accomplish and expertise rises with experience. Higher risk patients, operative delivery and paediatric patients need enhanced expertise.

Facilities and Equipment
Surgery requires an operating theatre; anaesthesia requires equipment to administer drugs and gases (particularly oxygen) to patients. Both require access to an electricity supply and water to allow basic infection control.

An increasing gap is developing between the richer and poorer nations in terms of equipment design, development and specification. In many settings, patient-contact equipment (airway, oximeter probes etc.) is disposable; this is unaffordable for other settings.

Investment in equipment by manufacturers follows the market place, which is most predictable in wealthier healthcare systems. In anaesthesia terms LMICs represent an unpredictable, and often viewed as insignificant, market for manufacturers to invest in. This limits the development of appropriate level technology which is long lasting and thus safer for more challenging environments.

The WFSA has published International Standards in this area and are concerned to raise the issue of equipment design and investment with the Commission. We hope that the importance of minimum standards will be stressed to MoH and others. [3]

Drugs
Basic anaesthesia drugs are inexpensive but essential. The WFSA Standards provides insight into these. [3] A particular problem is developing with ketamine, the mainstay of rural anaesthesia provision for many millions, perhaps billions of people. As it is also a drug, which is capable of being abused, there is a move to reclassify ketamine, which will limit its availability and the provision of anaesthesia from many centres because of complications developing within supply chains. Some anaesthesia drugs require refrigeration to remain active. Other agents such as halothane require specific vaporisers. Many pieces of anaesthesia apparatus are specific for certain drug use so if a drug is changed then apparatus must be purchased to enable its administration to patients.

Pain control postoperatively is an area that the Commission needs to consider. Simple, cheap drugs such as morphine are often unavailable.

As the Commission has realised, this is the time for an informed debate about the place of global surgery and anaesthesia. The WFSA is delighted to contribute to the Lancet work, hoping that development in these critical areas will follow.

Dr David Wilkinson
President

1. Walker IA, Wilson IH. Anaesthesia in developing countries–a risk for patients. Lancet. 2008;371:968-9
2. Ouro-Bang’na Maman AF, Tomta K, Ahouangb.vi S, Chobli M. Deaths associated with anaesthesia in Togo, West Africa Trop Doct 2005; 35: 220–22.
3. Merry AF, Cooper JB, Soyannwo O et al. International standards for a safe practice of anesthesia 2010. Can J Anesth 2010;57:1027-34

Reply
Eric Vreede says:

30 April, 2014 at 4:18 am

Dear Commissioners,
I congratulate the Lancet for the launch of this Commission which is long overdue. For those of us who spend a career in LMICs, it has been incomprehensible that Global Surgery/Anaesthesia has often been so completely overlooked and misunderstood. Below I outline a few of the issues that I believe the Commission should report on, placed in some order of priority although parallel initiatives are welcome.
1. Acknowledge the problem of Global Surgery/Anaesthesia
There must be an acceptance that surgery/anaesthesia rightfully belongs at the top table of public health and that it forms an essential part of combating a number of significant public health issues. Some of the comments above allude to this and there is increasing literature to underpin this statement. Since the 1978 WHO Alma Ata declaration specialist hospital care has been pushed off the agenda. Unfortunately Surgery/Anaesthesia owes much of this to itself; it has not done enough to publicise good and relevant operational research and data go counteract the misconceptions about Surgery/Anaesthesia that exist with public health officials and donors.
2. Have the political will to address the problem
Second, there must be the political will to take the need for (basic) Surgery/Anaesthesia seriously and to address the shortages in resources that exist. This is not a position against primary health care and non-medical public health measures, but a position in favour of a balanced approach to public health and health care. The understanding and acceptance that investing in health makes economic sense is important.
3. Make funds available
With political will health budgets must be made sufficient to allow for increase in salaries and incentives, spending on training and infrastructure. Accepting that investing in Health creates Wealth, every LMIC needs to determine what realistic spending on recurring costs it can afford for the next 20 years to maintain a functional health service including training, maintenance of equipment and infrastructure as well as timely renewal (and I suggest that this must increase considerably if their political will is genuine). The backlog in infrastructure and training can be picked up by donor funding for a sufficiently prolonged time to ensure sustainability. Provided each LMIC has a clear long term funding plan donors are much more likely to fund the backlog.
4. Innovative ideas
Innovation rather than following the old pathway that high income countries have done, may lead appropriate and affordable solution. There should be emphasis on the availability of certain specialist skills (rather than necessarily full blown specialists) in all locations so as to ensure access for all. Since specialists tend to prefer to work in towns and cities thereby leaving the rural and remote areas devoid of specialist services, task shifting should be encouraged (not really innovative anymore!). A three tiered system for the delivery of specialist services is an example; specialised nurses/technicians mainly working in rural and district hospitals supported by GP specialists; specialists initially in the larger and teaching hospitals and some regional centres.
5. Training
The shortage of health care workers can only be filled by a sustained effort to train the appropriate cadres in the right context; this means training in the region where they will practice and if training institutions do not exist they should be established possibly on a regional basis yet maintaining sufficient learning time in the context that they will practice in. In view of the shortage of teaching staff in many locations, outside assistance may be effective and efficient until more workers have been trained including in “how to teach/train”.
6. Monitor
The inputs, projects etc. must be monitored to be able to adjust, be flexible and achieve the best results possible for the populations of LMICs.
7. Miscellaneous points
(Clinical) governance and systems, appropriate technology, maintenance of equipment and infrastructure, safety, quality improvement

Eric Vreede, Consultant Anaesthetist
Hospital Nacional Guido Valadares, Dili, East Timor

Reply
Henry Rice says:

30 April, 2014 at 8:29 am

I applaud the expansive agenda that the Commission has undertaken to give clarity and concrete recommendations to policymakers about addressing fundamental global surgery priorities. However, what I don’t see in this organizational schema is inclusion of the general topic of barriers to surgical care. Although most experts appears to recognize that global surgery is hindered due to a lack of clearly defined metrics of success (i.e. it is easier to assess success of vaccination rates compared to what makes an effective surgical system), it is similarly hampered by ill-defined methods to study, measure, and address barriers to surgical care. There are many examples of where global surgery initiatives fail simply because a community does not accept surgical care, even if affordable, for a variety of reasons which are often difficult to identify. Before developing specific recommendations for policymakers of how to improve surgical systems, it is essential to develop a more robust methodology and taxonomy of how to measure successful access and acceptance of surgical care.

I would suggest that Healthcare Management and Infrastructure Working Group include within their discussions a critical assessment of barriers to surgical care. Specifically, it may be helpful to define optimal qualitative and quantitative tools to assess barriers to care, metrics of success for interventions, and optimal methods to minimize barriers to care for developing surgical systems. Only with this robust data can policymakers effectively develop programs and priority structure frameworks to optimize access to surgical care.
Henry E. Rice, M.D.
Professor of Surgery, Pediatrics and Global Health (Affiliate)
Duke University Medical Center

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Eric Vreede says:

30 April, 2014 at 8:13 pm

This is particularly true for fracture surgery in my experience. Patients come to hospital with a (fresh) fracture of e.g. the femur which needs fixing (in our eyes), patient says yes, but next is nowhere to be found because s/he has gone home (to traditional healer?). I have seen this both in Africa and now again Timor Leste. It appears less of a problem with e.g. hernias.
Eric Vreede

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Patricia Houston says:

5 May, 2014 at 10:51 am

Re: Lancet Report on Global Surgery

Thank you very much for your request for review and feedback re the Lancet Commission Report on Global Surgery

The CAS has collated feedback from our membership and has the following comments/recommendations re this report:

• Partnership models between institutions in high-income countries and those in low and middle-income countries be developed to support educational programs (postgraduate medical, clinical officer and nursing), build capacity and support the development of safe systems of care

• Safe mother and infant care should be a priority. The SAFE project is one model that might be emulated. It has been and is a major sustainable educational effort involving three medical specialties: surgery, anesthesia and obstetrics and nursing.

• Implementation of a trauma registry and organization of trauma teams where surgery and anesthesia have a strong presence is desirable in many jurisdictions. The burden of trauma is very high and a trauma registry is not available in many sub-Sahara countries.

• Collect data on surgical mortality, this should be supported by the WHO. Surgery and anesthesia need to be part of the “What comes after 2015?”. National Governments need to be made aware of the public health aspects of surgical care.

• None of the initiatives to improve world health will succeed without the full commitment of the local Government as the institution who is primarily and ultimately responsible for health delivery of that country. Health care must be a priority – GDP contribution to health care should be an average of 10% in all countries.

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Keith Vowles says:

9 May, 2014 at 11:58 am

Retiring from my NHS surgical work in 1987 I was free to travel and worked for spells as a locum in India, Kenya, Zambia and Thailand in 1987-92. I would say that anaesthesia was the main problem in primitive hospitals and so relied on spinal and local for the main part. The main threat to coping surgically is our now increasing super-specialising, as such work may require all the skills acquired during a very general training process.

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Fiemu says:

15 May, 2014 at 3:24 pm

A significant barrier to safe surgery and anesthesia in LMICs is the relatively outdated training in modern surgical and anesthesia knowledge and scarcity of skills. The Lancet Commission can use it’s brand to bring stakeholders (including industry, professional organizations and NGOs) together in LMICs, supported by business and management expertise, to define small scale interventions to improve surgical knowledge and skills in LMICs.

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Eric Vreede says:

19 May, 2014 at 7:13 pm

Dear Commissioners,
A further comment on the human resource situation.
The global shortage of surgical and anaesthesia health care workers, which is particularly acute in LMICs, can only be solved by a significant and sustained effort to train the appropriate cadres of health care workers. To do this, one should look at the surgery that needs to be done at the various levels of health care as well as the skills of the providers to respond to these needs. Important to differentiate between skills needed and those who provide them i.e. non specialists can provide specialist skills. This means two things; first, for the foreseeable future (say 50 years), there is a need for task shifting without which poor patients in remote areas will not have the access to services they need. One can see a pyramid of several tiers (this is only an example and other models are possible; this depends on various factors in each country) for example; a large base of nurse/technician/clinical officer providing the basic services in rural and district hospitals supported by smaller number of generalist doctors with specialists skills (GP surgeons/obstetricians/anaesthetists). The top of the pyramid is formed by an even smaller group of specialists who should lead the specialty and its training. Although aspirational to have doctors and specialists at all levels, it is unrealistic to expect highly qualified specialists to settle in areas where only part of their skills is used and where additional income is limited; this is a problem in high income countries with remote areas (e.g. Australia) and there is evidence form LMICs that this indeed the case there as well . Second, a sustained effort must be made to train the different cadres to the level that they can deliver the required services. It is likely that to achieve this, both outside funding and expertise may be needed. New graduates will become the teachers of the future thereby sustaining the initial investment
However, solving the human resource shortage is in itself not sufficient if the conditions to deliver the services in the remote areas are not up to standard; no or intermittent water and electricity, shortage of drugs and consumables, failing or absence of maintenance of plant and equipment. In addition, salaries and allowances (e.g. remote area bonus, housing allowance etc.) must be made attractive to retain staff. It is thus imperative that remote facilities are made functional and working there attractive for the staff. This loops back to task shifting; having the right cadre of health care worker, with links to the community and appropriately trained and remunerated, will have a greater chance of success than placing “specialists” in areas they don’t really want to practice in.

Eric Vreede, Consultant Anaesthetist
Hospital Nacional Guido Valadares, Dili, East Timor

1. Evolution of the demography of anesthesia practitioners in French speaking Sub-Saharan Africa.
Sanou I1, Vilasco B, Obey A, Binam F, Chobli M, Touré MK, Adnet P. Ann Fr Anesth Reanim. 1999 Jun;18(6):642-6.

2. Anesthesiologists’ demography in French-speaking Sub-Saharan Africa: the impact of fifteen years of Belgo-Beninese cooperation.
Zoumenou E1, Lokossou T, Assouto P, Chobli M, de Waroux Ble P, Baele P. Acta Anaesthesiol Belg. 2013;64(2):81-9.

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Eric Vreede says:

24 May, 2014 at 8:37 am

A brief submission about financing for global surgery.

Eliminating the backlog in training of surgical/anaesthetic service providers through establishing national and regional training institutions will take a significant input of resources including finances. A World Health Assembly’s resolution on Essential and Emergency Surgical Care and Anaesthesia will aid recipient and donor countries to include these services in national health AND development assistance policies and thus making financing of these activities a greater priority than they have hitherto been. It may be useful to divide the budget into the recurring budget and the “catch-up” one. The recurring budget should include all recurring costs including investment for the future. The “catch-up” budget covers the investment to increase the training capacity and if necessary improve physical infrastructure on an agreed country specific basis. LMICs should ideally cover the recurring budget including the possibility to expand into the future. The costs to catch-up may need to be covered by donor institutions, countries and possibly public private partnerships.

Eric Vreede
Consultant Anaesthetist
Hospital Nacional Guido Valadares, Dili, East Timor

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Eric Vreede says:

29 May, 2014 at 4:51 am

Dear commissioners,

Quality improvement of essential surgical (including obstetrics, anaesthesia, orthopaedics and urology) services needs a culture of safety and will partly result from training more providers and training them better, but this will not be enough. Significant improvement will only be achieved when appropriate international standards and consequent local protocols are developed AND adhered to. Developing the curriculums around these standards will significantly increase success. Significant and sustainable quality improvement is also determined by systems, leadership, working conditions and the tools to provide services (drugs and consumables, and maintenance of plant and equipment). In short, staff, governance/systems and logistics. To achieve the change towards a culture of quality and safety, an understanding of the political and personality powers, that influence certain actions and decisions, is needed; without high level support it will not be achieved.

Eric Vreede, Consultant Anaesthetist
Hospital Nacional Guido Valadares, Dili, Timor Leste

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James Bernstein says:

29 May, 2014 at 6:02 pm

As many of the above commenters have illuminated, infrastructure deficiencies are a major challenge to surgical care in LMICs. The application of standard surgical practices from wealthy countries is impossible in places without reliable access to electricity, water, or other essential resources. It is clear to all of us that these infrastructure problems are too great to be addressed by current development efforts, and therefore new innovations in surgical care must be specifically designed to work within these resource limitations.

Anesthesia delivery and human resources have already been mentioned as areas where solutions are sorely needed if access to surgery is to be expanded. However, no one has mentioned sterilization of surgical instruments, without which any surgical procedure is likely to result in infection. It is not enough to simply make surgical procedures available to those who need them in LMICs, we must also ensure that these procedures do not cause further morbidity or mortality.

Having visited numerous clinics, health centres, and hospitals throughout East Africa in the last year, I can attest to the fact that their existing sterilization methods are completely unsuitable for their environments. Autoclaves purchased for thousands of dollars from Europe or China lay long broken, used as storage containers instead of sterilizers. As a result, most procedures are performed with instruments that have been disinfected with chemicals or boiling water instead of being sufficiently sterilized. Disinfection is inadequate for invasive procedures, as it does not kill spores that can easily be activated in the body and cause infection. Even in wealthy countries with strictly regulated sterilization practices, hospital-associated infection is a major problem. Although data on healthcare-associated infection in LMICs is limited, the rates are undeniably higher. The lack of sterilization capability has been a major factor in the proliferation of the use of disposables for surgical care, but this solution is unsustainable in terms of cost and environmental impact (generates huge amounts of hazardous waste).

In response to this huge gap in surgical care in LMICs, we have developed a sterilization system specifically designed to operate in low-resource healthcare settings. It uses a proven nitrogen dioxide gas technology to sterilize instruments without electricity or water, is portable, and is drastically less expensive than an autoclave. With the support of local Ministries of Health and private healthcare providers, the Eniware Portable Sterilizer is set to be pilot tested by Jhpiego in 5 sub-Saharan African countries in fall 2014.

We urge the Commission on Global Surgery to recognize sterilization capability as one of the three essential requirements for surgical care along with anesthesia delivery and trained personnel. Innovation in these three areas must be supported, implemented, and scaled to enable global surgery no matter the resource limitations. To be successful in LMIC’s, Essential Surgical practice and the three key legs of its stool must be locally designed and adapted to ensure acceptance and advocacy.

James Bernstein, MD
CEO, Eniware
http://www.EniwareSterile.com

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Eric Vreede says:

2 June, 2014 at 2:48 am

In addition to sterilisation we should also not forget laboratory, imaging, histology, microbiology etc., each at a level appropriate to the level of care.

Eric Vreede

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Stephen says:

5 January, 2015 at 9:57 pm

I believe there are at least two key issues in enhancing the quality and accessibility of surgery globally: education and efficiency.
Education of young surgeons is best done in their home country, but I was astonished two decades ago when a number of ophthalmology residency programs in New York City were closed. These programs took care of many poor folks, often with residents from outside the US. The excuse for closing the programs was that there were no effective methods for getting the graduating residents to return to their home countries! This is a problem we should be able to fix, for a win-win solution. We also need more incentives and more opportunities for High Income Country surgeons to spend time in educational situations in Low and Middle Income Countries, who should be the drivers and owners of such experiences. Again, a win-win.
On the efficiency side, there are many good and bad examples in global surgery. In China, the price of cataract surgery in recent decades has tripled while the volume has remained flat. No surprise, the blindness rate has risen. In Madurai in south India, the Aravind Eye Hospital has been a model of high-volume, high-quality surgery for decades. Most places in the developing world can achieve the same success, with mentorship and determination. For elective surgery, the most efficient care is often specialized care in a central place, like Aravind or the Shouldice Hospital. Timely access to trauma surgery is a more difficult issue, but can follow from establishment of teaching hospitals and improved surgical capacity in developing country locations.
My own focus is recent years has been establishing eye banks in developing countries. Corneal blindness is often the second most common cause, after cataract. LMICs can sustain an eye bank, but creation requires a series of mentor visits to teach the surgery, assist the host country to obtain the equipment, help the locals to establish appropriate policies and legal support, encourage a favorable local climate for eye donation. Building this capacity enhances other ophthalmologic care and accessibility to care. Together, we can bring excellent surgical solutions to all.

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