Surgery is public health? Researchers argue that the quintessential clinical intervention deserves an essential place on the global health agenda.
The 2-year-old girl arrived at Phebe Hospital in rural Liberia barely alive.
Her abdomen had been ripped open, and her intestines spilled out of the gaping wound. She had been attacked while playing with her village’s pet monkey.
“Something happened to upset the monkey, and it literally tore the child’s abdomen open,” says Johns Hopkins surgeon Fizan Abdullah, MD, PhD. The girl likely had an umbilical hernia that the monkey grabbed, allowing the animal to easily tear open the abdomen, he says.
“The mother thought that the baby was dead and immediately abandoned the child,” Abdullah explains. Then a neighbor—who had seen a visitor in a pickup truck earlier that day—picked up the baby and ran a mile-and-a-half to find the truck’s owner. They drove the child over 30 miles of bad roads to reach the hospital.
“We helped the local surgeons put IV fluids in, put her intestines back in and close up the abdominal cavity,” says Abdullah, who was in Liberia leading a medical education program to train surgeons in a cost-effective and efficient hernia repair technique.
The toddler survived. She was lucky. Many in the developing world—especially its rural areas—are not. Women who need Cesarean sections die in childbirth. Surgically repairable conditions like clubfoot, hernias, cataracts and abdominal complications become disabling and even fatal. Injury victims needing emergency or orthopedic surgeries often don’t survive the trip to a distant hospital or receive subpar surgical care.
“You’re talking about a major burden of disease that is not being addressed by global health through funding or policies or development of new training procedures or supportive, innovative programs where effectiveness can be documented,” says Henry B. Perry, MD, PhD, MPH ’71, a senior associate in International Health.
For decades, the former surgeon and primary health care expert has maintained that closing the global surgical gap is a public health issue.
“If a kid in Sierra Leone, Liberia or Sudan falls out of a tree and breaks his arm, he’s potentially disabled for life,” adds surgeon Adam L. Kushner, MD, MPH ’99, an associate in International Health.
Worldwide, the surgical imbalance is staggering.
Of the 234 million major surgeries performed in 2008, only 3.5 percent took place in the poorest countries, whose people account for 35 percent of the world’s population. The World Bank estimates that 11 percent of the global disease burden is treatable by surgery. Two billion people have no access to surgical care.
The issue will only become more acute because of the growing number of injuries related to increased vehicle traffic in developing countries and unsafe roads.
“Obviously it’s not feasible to think about heart transplants or complicated cancer surgeries,” says Perry, “but where the global health agenda has missed the boat is in looking at low-cost ways to provide access to hospital care for lifesaving or life-changing surgical services… It’s bringing a public health vision to surgery.”
Signs of Change
Traditionally, public health and surgery have lived at opposite ends of the spectrum.
One deploys inexpensive, prevention programs for populations. The other is a one-to-one intensive clinical procedure. The separation becomes even more pronounced in the developing world. Surgeons are scarce, training is often limited, hospital capacity is insufficient and supplies and equipment are in short supply or unaffordable.
From a public health perspective, surgery has historically been viewed as expensive, time-consuming and generally not a good investment. It saves and changes individual lives, not populations. These assumptions, say global surgery advocates, are wrong and have contributed to surgery’s low ranking among public health priorities.
The past decade, however, has brought signs of change. “There’s an increasing recognition of the global burden of disease that can be addressed with surgery,” Perry says.
In 2006, Disease Control Priorities in Developing Countries, a World Bank publication, included for the first time a section on surgery in low-income countries. The chapter will be substantially expanded in the 2015 edition. In recent years, some U.S. medical schools and hospitals have established global health surgery programs, including the Johns Hopkins Global Surgical Initiative. And, the American College of Surgeons is offering more opportunities for international work.
“There is no doubt that expanding access to even routine surgical procedures holds the potential to prevent disability and save lives,” says Bloomberg School Dean Michael J. Klag, MD, MPH ’87. “Procedures that we take for granted, such as incision and drainage of an abscess or repair of a laceration, can be lifesaving.”
As surgery gains more attention, interest in global health among younger surgeons and surgeons-in-training has clearly evolved. Julie Freischlag, MD, chair of the Department of Surgery and Surgeon-in-Chief at Johns Hopkins Hospital, remembers being surprised several years ago when a student told her that she wanted to work in global surgery. Things are different today. “In 10 years I think we’ll see more and more surgeons trained to perform more sophisticated interventions for both diagnosis of diseases and multimodality treatment of cancer in the global setting,” Freischlag says.
On the first day of the School’s fourth term, Adam Kushner stands before 15 students to debut his course, Surgical Care Needs in Low- and Middle-Income Countries.
At 5:30 in the evening, the students’ collective energy level is low. Kushner, however, is eager to get started, and congratulates the class for enrolling in the School’s first course on the global surgical imbalance.
“Just by being here, you guys are already at the forefront of global surgery,” he says. Early in the class, Kushner shows a large, close-up photo of a 3-year-old Malawi girl. It was taken two days after he had removed a blood clot from her brain at Kamuzu Central Hospital.
Eyes look up from smart phones and laptops.
Kushner, who worked at the hospital after completing his surgical residency in the U.S., first saw the little girl about an hour after she had fallen from a balcony. She was paralyzed on one side and seizing on the other.
“I looked at her, made the diagnosis and 20 minutes later drilled holes into her skull and evacuated the clot,” he said, adding that the country did not have a single neurosurgeon and that the hospital—which served 5 million people—did not have CT-scan capability. “I saw cases like this over and over again and said, why aren’t we doing more?”
Kushner has lived at the intersection of surgery and public health for 13 years. A faculty member with the School’s Center for Refugee and Disaster Response and founder of Surgeons OverSeas (SOS), he’s worked as a surgeon and teacher in 15 low-income countries.
Kushner shakes his head at the notion that traditional surgery is not a good public health investment.
“I’m a surgeon and I understand public health,” he says. “In Malawi I’ve seen patients come in with a perforated appendix or a hernia. I’d operate and they’d go be a productive member of society.”
In addition to his clinical work, Kushner is committed, as a researcher, to building the meager evidence base on surgical deficiencies in low-income countries. “It needs the legitimacy that it’s an important problem, and you need data to measure the magnitude,” he says.
To that end, last year Kushner and colleagues in Sierra Leone undertook a population-based survey to determine the prevalence of untreated surgical conditions in a country of 6 million, approximately 10 formally trained surgeons and 30 medical school graduates annually. Investigators deployed 16 local medical and nursing students to the country’s 14 districts.
The researchers found that 25 percent had a condition that needed surgical attention, and 25 percent of deaths in the previous year might have been averted by timely surgical care, primarily for pregnancy complications, injuries and abdominal conditions. The article on the study was published online in The Lancetin August 2012.
Based on the Sierra Leone results and findings from a similar study in Rwanda, SOS estimates that 56 million people in sub-Saharan Africa currently need surgery.
“That starts to put things in perspective—the volume of surgery that’s needed,” Kushner says.
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.”
Placing surgery in the hands of non-physicians isn’t the answer for certain surgical procedures.
That’s what Bloomberg School Dean Emeritus Alfred Sommer, MD, MHS ’73, determined after leading a project to address the need for cataract surgery in sub-Saharan Africa, where half of blindness today is caused by cataract formation.
Sommer, whose groundbreaking research has saved millions of children’s lives and eyesight through vitamin A supplementation, initially thought that task shifting might be effective. However, after investigating similar programs, Sommer concluded that non-physicians required close supervision by an ophthalmologist to sustain high-quality work.
So he came up with a Plan B.
“I took a Wilmer resident and we spent a month roaming around Africa to understand the dynamic and discovered a startling statistic,” he says. In a region with a critical need for cataract surgery, most ophthalmologists only work 60 percent of the time.
One reason, according to Sommer, is patients’ dissatisfaction with the level of vision restored by their surgery, as well as cost, lack of transportation and supplies, and equipment shortages.
He approached the problem by locating ophthalmologists in Ethiopia, Kenya, Nigeria and Zambia who performed high-volume, high-quality cataract surgery. Under Sommer’s proposal for the Hilton Foundation, these doctors would train committed younger ophthalmologists. Every two years or so, the senior ophthalmologists would train another small group of young doctors and either add them to their own practices, or support them in establishing satellite surgical centers.
The Foundation, Sommer says, is looking into funding a pilot program to test his proposal.
“It has to be sustainable and indigenous and not a solution that’s dependent on outside cataract surgeons flying in and doing a couple hundred cases,” he says.
“It’s finding local people who have a proven track record and building on them.”
The View in 10 Years
Although the magnitude of unmet surgical need is gaining some visibility on the global health agenda, experts say that real progress depends on donor support and commitments from local governments to expand surgical capacity as part of a comprehensive health system.
“On my first trip to Ghana in 2007, my intention was to help and teach surgeons, but I realized very quickly that the focus has to be on surgical strengthening as part of national health plans at the ministry of health level,” says Abdullah, an associate professor of Surgery at Johns Hopkins School of Medicine.
Still, in his recent experiences training surgeons in a low-cost procedure to repair inguinal hernias using a piece of plastic mesh, he’s found that education to improve their surgical skills is what they want, even more than supplies and equipment.
With an inguinal hernia, for example, in which abdominal tissue protrudes through an abdominal muscle, Abdullah says that a simple, one-hour outpatient surgery can repair the problem. But left untreated, the hernia can become disabling, and possibly fatal. “Because patients don’t have access to surgeons who can do these simple operations … a lot of people are dying from this,” he says.
Experts in surgical care in developing countries hope that in the next decade the momentum continues toward a greater acceptance of basic surgery as a public health intervention.
Moving forward requires funding commitments to back robust research and the development of innovative and cost-effective training, education and surgery programs. On Kushner’s wish list: 20 endowed global surgery chairs at top U.S. universities, trauma centers in developing countries, residencies and international exchanges.
“I think in 10 years we’ll look back and be surprised that all this stuff wasn’t being done a lot earlier,” says Kushner.