@fanusdreyer chairs the International Development Committee of ASGBI, is a member of Edinburgh University’s Global Health Academy and of the WHO’s Global Initiative on Essential and Emergency Surgery.
What is the primary care of obstructed labour, or a cleft lip, an imperforate anus or other birth defect? In the mid-1980s I worked in a small mission hospital at Nkhoma, Malawi as a medical officer. One day a boy was born with imperforate anus. It was the rainy season and there was no way he could be sent to the city. So I looked in the book how to do a defunctioning colostomy in a newborn, gave him ketamine and did the operation. Afterwards he stopped breathing every few minutes but started again when we flicked the soles of his feet. Our few incubators were all in use, each with three prem babies inside. So, over lunchtime and while the nurses kept our baby breathing, I built a wooden incubator, with plastic sheeting as a transparent top. That way we could give him oxygen, put two warm water bottles next to him and keep watch. I sat with our boy through the night, stroking him and flicking his soles so he would breathe, until the ketamine had worn off by the early hours of the next morning. He left hospital a few days later, ready to wait for the Canadian paediatric surgeon who was visiting a few months later. And I learnt that surgery can be primary care …
The declaration of Alma Ata (1978), which is a cornerstone of WHO healthcare states in section VII.3 that primary health care “includes at least: education concerning prevailing health problems,…maternal and child health care, …appropriate treatment of common diseases and injuries.” What place then for surgical conditions within “prevailing health problems”?
Of the global disease burden 11% needs surgery, mainly due to injuries (38%), malignancies (19%), congenital anomalies (9%), complications of pregnancy (6%) and peri-natal conditions (4%). Only 3.5% of 234 million annual surgical procedures worldwide are performed on the poorest 33% of people, but 80% of surgical deaths occur in low and middle income countries (LMICs). About 800 women die every day due to complications of pregnancy and childbirth e.g. obstructed labour, haemorrhage, sepsis, uncontrolled high blood pressure and unsafe abortion, i.e. mostly conditions that can be managed surgically. A significant complication for mothers who survive obstructed labour is obstetric fistula, which means that they are continually wet, smell badly and are ostracised by families and communities. With appropriate training fistulae can be repaired by non-doctors.
In non-communicable diseases (NCDs), the diseases of “rich countries” e.g. diabetes, vascular disease, hypertension and cancer, the highest incidences and mortality are in LMICs. The WHO expects 16million cancer deaths by 2020; 70% of these will occur in LMICs. Worldwide 5.8 million people die yearly from injuries, which is 32% more than from malaria, TB and HIV/AIDS combined. That means that 2300 children die daily from injuries. Road traffic crashes are responsible for 23% of all injury deaths, with 20 injured patients per fatality, reaching epidemic proportions in sub-Saharan Africa (50/100000 vehicles compared with 1.7/100000 in high income countries).
Household surveys in Rwanda and Sierra Leone have shown that the immediate surgical need is higher than the HIV rate, that 15-25% of respondents had a surgical need in the previous year that affected their ability to earn a living or their quality of life significantly, and that 25% of household deaths in the preceding year were due to surgical conditions.
The Millennium Development Goals (MDGs) have to report in 2015. At present there is a worldwide review of what global goals should replace the MDGs, with the WHO, the Gates Foundation and other philanthropic institutions all recently asking for submissions. The problem is that only MDG 1 (eradicating extreme poverty and hunger by >50%) is expected to be achieved worldwide by 2015. There has been some progress with MDGs 4, 5 (Child and Maternal Health) e.g. in Ethiopia through the work of community health workers, but in sub-Saharan Africa it might be that Rwanda is the only country to achieve all targets. The question can rightly be asked “Did the MDGs fail because these were drawn up in a room by rich countries for poor countries?”. For development to be real and sustainable it needs to be based on indigenous knowledge and solutions, not donor-led philanthropy.
What role then for global surgery after 2015? I have no doubt that the provision of safe and effective surgery should form part of the post-2015 development goals, and surgeons have a responsibility to contribute to this global debate. How can this be achieved? When we started our critical care teaching programme in Africa, now under the name of Alba CC Course Design, we first went to Hawassa in rural Ethiopia to teach health officers (non-doctors) who were doing an MSc course in emergency surgery. With funding from the Clinton-foundation they are taught to do 12 operations well and look after these patients; this covers 85-90% of surgical emergencies in rural Ethiopia e.g. Caesarean section, ectopic pregnancy, incarcerated hernia, debridement of open fracture. When I asked the first intake of students in Hawassa “Why are you doing this course?”, 6 of 8 answered “Because I have seen women in obstructed labour die”. When we went back for a second visit 18 months later, one of those same students had already done 70 Caesarean sections, under spinal, alone in theatre except for a midwife and a scrub nurse. Now that is public health worth fighting for.
Cost studies in surgery provision in Bangladesh and Sierra Leone have shown that the cost per disability life-year (DALY) averted is equivalent to the costs of a measles vaccination programme. Providing essential and emergency surgery saves more than it costs.
With various other groups we are proposing a programme called “15-by-15”, which will aim to teach 15 essential and emergency operations to the same minimum standard worldwide by 2015, to decrease the physical, psychological, social and economic burdens of untreated surgical disease in even the poorest communities. Everyone has “the right to heal” (http://vimeo.com/59388957).
Next weeks blog will be by Penny Halliday, Non-Executive Director of NHS Dumfries and Galloway and is titled “Woman Interrupted”