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Operation HealthSusan Hale Thomas

Operation Health (continued)

Value Investing

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.

“Just by being here, you guys are already at the forefront of global surgery.”
                  —Adam Kushner to students in his global surgery course

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 Lancet in 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.


  • 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

  • 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: 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,, and contact us if you feel you know of a child who is in need of lifesaving heart surgery!

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