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Operation HealthSusan Hale Thomas

Operation Health (continued)

The Father of Global Surgery

In the world of global health surgery, everybody who’s anybody knows Colin McCord, MD.

He developed a successful program in Mozambique in the early 1980s to train non-physicians in surgery, with a focus on obstetrical emergencies. Today, the curriculum remains essentially the same and its graduates perform more than 80 percent of the obstetrical surgeries in the country, as well as a number of other basic surgeries. They work mainly at hospitals in rural areas, called district hospitals, where the need for surgical services is most acute.

Equally important, McCord, 84, a School faculty member in the 1970s, has authored several studies to document the quality of care of such task-shifting programs that train clinicians without medical degrees to provide essential obstetric surgeries. (“I consider him to be the father of surgery in global health,” says Perry.)

McCord is also responsible for some of the first research on the cost-effectiveness of surgery at small district hospitals. In a 2003 study, he found that the cost-per-year of a life saved through surgical care at a Bangladesh district hospital was comparable to preventive measures such as a measles vaccine or oral rehydration therapy.

A heart surgeon in the U.S. in the early years of the specialty, McCord transitioned to the international health field in 1971. When he began working in Mozambique in 1981, government health officials made their expectations clear, telling him, “We’d like to have you, but you have to do surgery.”

“We were only doing 2 percent of the C-sections that needed to be done,” says McCord, retired and living in Oxford, England. “The only way that Mozambique was going to solve the problem was to train people that weren’t doctors.”

He patterned the program after a similar initiative in Tanzania, which began in 1962.

With only 15 to 20 medical school graduates annually in Mozambique, McCord says he sought to train providers ranked a level below doctors—assistant medical officers (AMOs)—to deliver surgical care.

Based at Central Hospital in Maputo, the students received three years of training on top of the three-year AMO program, completing approximately 100 C-sections. By comparison, says McCord, licensed doctors in district hospitals typically perform only a handful of the procedures in medical school and internships.

The AMOs usually practice at hospitals in rural areas that are less likely to have experienced surgeons. There’s another reason for training AMOs. Their qualifications are not recognized by wealthy nations so they’re less likely to become part of the “brain drain.” While doctors often seek better pay in the West or in urban areas in their own country, AMOs generally spend their careers in their home countries, says McCord.

In a 2009 analysis in Health Affairs, McCord and colleagues found no measureable differences between physicians and non-physicians in the quality of obstetrical surgical care in Mozambique, Tanzania and Malawi. They reported a case fatality rate between 1 and 2 percent, meeting or approaching the UN target of 1 percent.

According to the researchers, most African countries have not approved similar non-physician models to provide emergency obstetric surgeries because of concerns about the quality of care.

The study notes, “If women could reach hospitals where these providers operate, maternal mortality could fall by 75 percent or more.”

Comments

  • Keith Apelgren, MD

    United States 05/21/2013 09:42:53 AM

    Surgical and anesthesia care are as important as vaccination programs or prenatal care.

  • Bruce Steffes, MD

    Kenya 06/04/2013 12:00:29 AM

    The Pan-African Academy of Christian Surgeons is training over 40 national physicians in a COSECSA approved five-year general surgery program. Thus far, we have had 100% retention in Africa and almost all in rural areas. Our website is www.paacs.net.

  • James Militzer

    Michigan 06/05/2013 11:08:21 AM

    Great post, and a topic that deserves more attention. One complication to making surgery accessible in low-income countries is the lack of infrastructure - especially reliable electricity. We recently covered this issue on NextBillion Health Care, with an overview of an innovative anesthesia machine that can work even when the power goes off: http://nextbillion.net/blogpost.aspx?blogid=3327. I hope to see more innovations like this, and more attention in general to this issue.

  • Amanda Slagle

    HeartGIft, Austin TX 07/12/2013 01:48:11 PM

    Increasing the number of trained surgeons throughout the world is by far the best way to create a sustainable workforce. However, specialty surgeries, like pediatric cardiac, cannot always be completed in the developing world. HeartGift provides lifesaving heart surgery to disadvantaged children living in developing countries where specialized medical treatment is scarce or nonexistent. Please refer to our website for more information, www.heartgift.org, and contact us if you feel you know of a child who is in need of lifesaving heart surgery!

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