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What did Global Surgery Amsterdam teach us on the challenges of foreign surgical interventions in Africa?

Western healthcare workers only really contribute to LMIC healthcare if they stay abroad for several years.

This statement by Tom Gresnigt, a medical superintendent at Masanga Hospital in Sierra Leone stuck with me through the entirety of the Global Surgery Amsterdam symposium. An afternoon was dedicated to sharing stories, giving advice, and discussing on and off-the-job training strategies to achieve the vision of: “One world, One Standard of Care – Improving Skills in Global Surgery.” The focus, however, lay on short and long-term foreign surgical interventions in low- and middle-income countries (LMIC), particularly in Africa.  Truth be told, a topic that I, as an aspiring med student, had a lot to learn about.

Surgical need

At the start of the symposium, we were reminded that the poorest third of the world’s population receive only 3.5% of the 235 million surgeries that take place over the world (Ologunde, 2014). Of these 8 million surgeries, only a fraction are recorded, and statistics gathered, leading to significant lack of knowledge about the burden and distribution of surgical conditions, the unmet surgical need, the missing resources (human, clinical, financial.), and the impact that foreign surgical intervention might have. (WHO, 2008).

While truly little is known about the burden of surgery in Africa, the limited data have shown that cleft lip, appendicitis, obstructed labor, clubfoot, cataracts, hernia, and trauma, such as burns are some of the direst unmet surgical necessities (Bickler et al., 2015). Most of these problems have rare long-lasting effects in the western world, for example in the Netherlands where the density of specialist surgical workforce is 47,1 per 100,000 people (Gawande, 2015). However in a place such as Sierra Leone,  with a population of 7.557 million people, a specialist surgical workforce of 0.2 per 100,000 people (Gawande, 2015) is shocking.

The ever-increasing number of international healthcare workers that travel to LMIC’s to volunteer their surgical skills and expertise reflects the acknowledgment and understanding of the challenges to the health system and the discrepancies between continents and countries (Ahmed, 2017). With this increase, however, comes the necessity for adequate training, ethical coherence, and cultural fluency, as due to the lacking evidence and outcomes of such foreign surgical intervention, the exact impact of these missions is difficult to quantify (Casey, 2007).

The impact

The impact of foreign surgical intervention is so complex you must weigh the individual benefit of the surgeries, the detrimental effects of potential complications, the training, and advice that is given to these communities and local doctors against the ethical dilemma of surgical trips to vulnerable communities (Ahmed et al., 2017) These problems are not solved by merely staying an extended period of time. The greatest challenge lies in measuring the outcome of these missions and the accompanying accountability of the surgeons, pediatricians, anesthesiologists, and the other healthcare workers. The benefits therefore of combining these trips with proper data collection and management is increasingly showing its value on validating practices and providing information on areas needing improvement (Sykes, 2014).

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Looking back at the statement of Dr. Gesnigt, I now understand why it stood out against the rest. He mentions this idea of contribution, of successful help in a small area, a district hospital, yet it does not encompass the importance of also contributing to a global database on the outcome of the surgical interventions. The desperate need for empirical evidence of activities done there needs to be of sufficient and reliable quality. The surgical disparities, even within countries can be reduced by being able to quantify the burden of surgery through information on the need for, access to, and outcomes of surgical care. Furthermore, a greater understanding of the iatrogenesis expenditure related to surgical care, the availability and use of surgery-related resources, such as human resources, equipment and supplies can lead to more cost-effective solutions. So lastly, the coverage, quality, and effectiveness of interventions are beyond valuable to effective long-term help for their improvement (Luboga et al., 2009).

Making data actionable

At the conference, Sister Avelina Temba from Korogwe Hospital in Tanzania shared her experiences as the only surgeon in her district. She talked about the struggles she has not having another doctor to talk to you, to discuss possible cases, advice, or future complications. She is one of the only female surgeons in her country! This extreme pressure and the massive influx of patients she treats daily is further evidence of the necessity for simple secure and reliable data collection. The management of such will allow her to monitor her patients better, assign thresholds for various conditions to alert her or other personnel, and will enable her to predict how the patient will react or develop to surgery or a specific treatment. The benefits continue, through access to a database of millions of recorded surgeries, Sister Avelina will no longer need another specialist to talk to, she can consult previous data on such surgeries, the necessary personnel, materials, and skills. These outcomes are measured and help research and studies into these surgical discrepancies, allocating foreign interventions better and promoting training in necessary surgeries where such conditions occur more frequently.

Tom Gresnigt finished his presentation with a last strong statement, ‘surgery is not a luxury, it is basic care.’ If this care can be better quantified, better recorded and managed, the need and current lacking mechanisms will be a thing of the past.

References

  1. Ahmed, F., Grade, M., Malm, C., Michelen, S., & Ahmed, N. E. (2017). Surgical volunteerism or voluntourism–Are we doing more harm than good?
  2. Bickler, S. W., Weiser, T. G., Kassebaum, N., Higashi, H., Chang, D. C., Barendregt, J. J., ... & Vos, T. (2015). Global burden of surgical conditions. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN. Disease control priorities in developing countries, 1, 19-40.
  3. Casey, K. (2007). The global impact of surgical volunteerism. The Surgical Clinics of North America, 87(4), 949-60.
  4. Gawande, A. (2015). Global surgery. The Lancet, 386(9993), 523-525.
    Luboga, S., Macfarlane, S., Von, S., Kruk, M., Cherian, M., Bergström, S., . . . Bellagio Essential Surgery Group (BESG). (2009). Increasing access to surgical services in sub-Saharan Africa: Priorities for national and international agencies recommended by the bellagio essential surgery group. Plos Medicine, 6(12), 1000200. doi:10.1371/journal.pmed.1000200
  5. Ologunde, Rele, Mahiben Maruthappu, Kumaran Shanmugarajah, and Joseph Shalhoub. "Surgical care in low and middle-income countries: burden and barriers." International Journal of Surgery 12, no. 8 (2014): 858-863.
  6. Sykes, K. J. (2014). Short-term medical service trips: a systematic review of the evidence. American journal of public health, 104(7), e38-e48.

Image source: Staff Sgt. Shejal Pulivarti (CC BY 2.0)

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Tiago Beck

As long as I can remember medicine, and in particular neurology has been my fascination. I am currently a pre-med student at the Erasmus University in Rotterdam. I have been exploring countries and medical fields my whole life and it has ultimately lead me to the Netherlands where next to uni, I work as an assistant researcher at the Erasmus Medical Center and write blogs here and there. And this is just the beginning...


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