What effect can surgeons have on world health?

Ross Elledge BChD(Hons) MFDS RCPS(Glasg) Final year medical student, University of Birmingham, UK

Thinking globally

• • • 2 to 3 billion people have no access to surgical care Around 11% of disability adjusted life years (DALYs) are due to surgical diseases (similar to communicable diseases): • Injuries 38% • Malignancies 19% • Congenital anomalies 9% Despite this, rates of surgery in LMIC lag behind those of richer countries – Africa has 25% of the disease, 3% of the health care workers

Who cares?

• • • • • Poorly researched problem Surgery is often “the neglected stepchild of global public health” regarded as not cost effective WHO Commission on Macroeconomics and Health (2001) “Minimum package” for healthcare US$34 per capita Failed to include any surgical services beyond emergency obstetrics

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Is there a surgeon in the house?

The scale of the problem

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5 million people worldwide die from traumatic injuries each year, equivalent to deaths from HIV/AIDS, malaria and tuberculosis combined

– –

90% of these occur in developing countries For each person who dies 3 to 8 are permanently disabled

Still waiting......

• Estimated 2.8million children/adults worldwide with untreated CLAP – – – Death from feeding difficulties, dehydration and malnutrition Infanticide by an unenlightened community A lifetime of social abandonment potentially extended to the entire family unit

Your flight is about to depart

• In Uganda, there are 20 orthopaedic surgeons, 3 cardiothoracic surgeons, 3 paediatric surgeons, 3 plastic surgeons, 3 urologists and

27 million people

in the waiting room

What are the answers?

• • • Surgery needs to be recognized as a concern Better reliability in data gathering to give a clearer picture of “gaps” in research so far Safety practices such as the WHO Guidelines for Safe Surgery following the second Global Patient Safety Challenge 2007-2008 – 5-10% mortality in major surgical procedures in the developing world the majority of which were preventable – safety of anaesthesia (1 in 150 mortality in Togo) – need for preventive strategies to reduce infection and other post-operative complications e.g. antibiotic prophylaxis

What are the answers?

• • Improving access to healthcare – – Increasing manpower Correcting the rural/urban divide • 70% of doctors in Ghana work in 2 major cities with only 30% in rural outreach areas Adequately funded and resourced hospitals – Early detection of surgical diseases e.g breast cancer through public awareness and screening infrastructure – Cost effective alternatives in standard surgical procedures e.g. sterilised polyester mosquito net for hernia repairs!

What are the answers?

• Education – building local surgical services – Interdepartmental partnerships such as UCSF and Makere University, Uganda in paediatric surgery • Beneficial to visiting trainees as well resulting in research projects, masters degrees, scholars programs – University of Toronto and two centres Botswana • “Teleconference teaching” – Texas Heart Institute and Tbilisi, Georgia • Gradual reduction in the visiting team to allow independence

What are the answers?

• • ATLS-style courses, WHO IMEESC toolkit – 81% of trauma patients die before reaching hospital in Ghana – Trinidad reduced its mortality from 67% to 34% The “Sandwich fellowship” model – Successful pilots in ophthalmology and orthopaedics by the University of Ottawa – May need retention clauses?

Money makes the world go round

• Surgery may reap $11-77/DALY averted compared with vaccination programmes at $5/DALY averted – Cleft palate repair added between $152,372 and $375,414 to lifetime earnings in a study by Corlew – For all patients operated on in a single calendar year by a single surgical outreach programme, this was a combined lifetime earning of $22,881,627 to $57,631,770

Is it worth it?

References

• • • • • • • • • Semer NB, Sullivan SR, Meara JG. Plastic surgery and global health: how plastic surgery impacts the global burden of surgical disease. J Plast Reconstr Aesthet Surg 2009 Jul 28 [Epub ahead of print] Corlew DS. Estimation of the impact of surgical disease through economic modelling of cleft lip and palate care. World J Surg 2009 Aug 22 [Epub ahead of print] Aziz SR, Rhee ST, Redai I. Cleft surgery in rural Bangladesh: Reflections and experiences. J Oral Maxillofac Surg 2009;67:1581-8 Ozgediz D, Jamison D, Cherian M, et al. The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bull World Health Organ 2008;86(8):646-7 Ozgediz D, Kijjambu S, Galukande M, et al. Africa’s neglected surgical workforce crisis. Lancet 2008; 371(9613):627-8 Hodges S, Wilson J, Hodges A. Plastic and reconstructive surgery in Uganda – 10 years experience. Paediatr Anaesth 2009;19(1):12-8 Kingham TP, Kamara TB, Daoh KS, et al. Universal precautions and surgery in Sierra Leone: the unprotected workforce. World J Surg 2009;33(6):1194-6 Quansah R, Abatanga F, Donkor P. Trauma training for non-orthopaedic doctors in low and middle-income countries. Clin Orthop Relat Res 2008;466(10):2403-12 Mock C, Cherian MN. The global burden of musculoskeletal injuries: challenges and solutions. Clin Orthop Relat Res 2008;466(10):2306-16

References

• • • • • • • • • Taira BR, Kelly McQueen KA, Burkle FM Jr. Burden of surgical disease: does the literature reflect the scope of the international crisis? World J Surg 2009;33(5):893-8 Mock C, Joshipura M, Goosen J, et al. Overview of the Essential Trauma Care Project. World J Surg 2006;30(6):919-29 McQueen KA, Hyder JA, Taira BR, et al. The provision of surgical care by international organizations in developing countries: a preliminary report. World J Surg 2009 Aug 15 [Epub ahead of print] Bickler SW, Rode H. Surgical services for children in developing countries. Bull World Health Organ. 2002;80(10):829-35 Azzie G, Bickler S, Farmer D, et al. Partnerships for developing paediatric surgical care in low-income countries. J Paed Surg 2008;43:2273-4 Velebit V, Montessuit M, Bednarkiewicz M, et al. The development of cardiac surgery in an emerging country: a completed project. Tex Heart Inst J 2008;35(3):301-6 Kassam F, Damji KF, Kiage D, et al. The Sandwich fellowship: a subspecialty training model for the developing world. Acad Med 2009;84(8):1152-60 Anderson BO, Braun S, Carlson RW, et al. Overview of breast health care guidelines for countries with limited resources. Breast J 2003;9(Suppl 2):S42-50 Clarke MG, Oppong C, Simmermarcher R, et al. The use of sterilised polyester mosquito net mesh for inguinal hernia repair in Ghana. Hernia 2009;13(2):155-9

Any questions?