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Operation HealthSusan Hale Thomas

Operation Health (continued)

Plan B

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.


  • 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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