Sutures for the Future

Women in India receive blankets and financial support from the district administration after their eye cataract operations.
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Women in India receive blankets and financial support from the district administration after their eye cataract operations. © 2007 Anil Gulati, Photoshare

It might seem a bit incongruous at first: Isn’t surgery more about medicine than public health—helping one patient at a time rather than intervening at the population level?

A panel of surgeons and a journalist, however, used data on the staggering unmet need and stories about individuals to argue for surgery’s centrality to public health during the Johns Hopkins-Pulitzer Center Symposium on Wednesday.

Consider the 3-year-old Pakistani boy with Hirschsprung’s disease who had to travel 325 miles to get a rectal biopsy. Or the young girl in Pakistan, turning blue; traditional healers thought she had asthma but in fact she had a heart murmur and needed surgery—a condition worsened by the treatment. Describing these children, Amber Mehmood, an assistant scientist with the International Injury Research Unit at the Bloomberg School, explained that her native country has an estimated deficit of 18 million surgeries per year.

Across low- and middle-income countries (LMICs), the story is familiar: At least 2 billion people globally do not have access to safe surgery.

Adam Kushner, founder and director, Surgeons OverSeas (SOS) riffed on the surgeon’s common saying, “A chance to cut is a chance to cure” by saying, “… what I started to learn is that it’s also a chance to prevent, diagnose, and treat and palliate.” Surgery is foundational to many critical public health interventions—maternal health, c-sections, circumcisions, etc., according to Kushner, an associate with the Bloomberg School’s International Health department.

Answering the vast unmet need will require more trained personnel. In Pakistan, as in many LMICs, Mehmood said that the lack of skilled surgeons is a key obstacle. Health professionals concentrate in towns and cities, and surgical facilities are inadequate in rural areas.

Pakistan’s cultural fabric also plays a role in who gets treated, Mehmood said. While women account for 53% of the population, the surgical workforce is 80% male. “Surgery is still seen a male-dominated field … a macho specialty,” with female surgeons steered toward breast surgery, or gynecological surgery. “We have to change that culture,” Mehmood emphasized.

In her reporting in Mozambique and Uganda, Bridget Huber, a journalist supported by the Pulitzer Center on Crisis Reporting, described creative solutions to the surgeon shortage. Mozambique, a country of 26 million, has just 20 surgeons, Huber said. As in many LMICs, the country has filled the gap with surgical technicians. They may not have medical degrees, but they are front-line health care providers, performing many tasks that surgeons would elsewhere—and often in far more challenging circumstances.

But it isn’t just a question of staffing and training. Kent Stevens, an assistant professor of Surgery, Johns Hopkins School of Medicine pointed out. Improving trauma systems, he said, involves addressing everything from equipment, to standards of care, to infrastructural needs like ambulances and trauma bays. The disparities are stark, as Stevens illustrated with images of ambulance bikes in rural Bangladesh and a Kenyan trauma care center’s only ambulance—missing its wheels for months. But it’s hard, he said, to know where to concentrate efforts.

Asad Latif knows one area in need of attention. If surgery is the neglected stepchild of global health, anesthesia is often the neglected stepchild of global surgery, he said.

And anesthesia’s central role must not be underestimated: it “allowed surgery to evolve from a treatment of last resort to mainstream therapeutic option,” said Latif, an assistant professor of Anesthesiology and Critical Care Medicine at Hopkins Medicine.

But the challenges to delivering anesthesia care in LMICs are vast. It’s partly a human resources question; Latif highlighted the US ratio of 25 anesthesia providers/100,000 patients. Compare that to the Ivory Coast, with 0.17 anesthesia providers/100,000 patients. The solution is really a multifactorial problem, he said, including access to the right drugs and safe electronic monitoring equipment.

The panelists explored the problem of surgeon shortages—and brain drain—in greater depth in a follow-up Q&A session. Adam Kushner offered a paradigm-crushing response: we should stop using the phrase ‘brain drain,’ and reframe the problem. How do we persuade people to stay and work in rural hospitals? The answer, he said, is that we pay them: “If there was money available to pay clinicians $100,000 a year, you would have people lining up to work in these places.” But absent a pool of funds to pay salaries, it becomes a question of how to prioritize needs, and encourage in-country capacity building. It’s also up to local countries to help foster the right conditions and help build capacity and optimize local use, he added.


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