Smiles or Residents: Improving Global Surgery Capacity

The following two tabs change content below.
Mark Shrime
Mark is a head and neck cancer and reconstructive surgeon in Boston, currently getting PhD in health policy from Harvard. He also works regularly in West Africa and writes on topics in global surgery.

surgery sinkIt’s a tough question: Given the limited resources, thorny politics, and weak infrastructure in low- and middle-income countries, how do you develop surgical capacity?

In January’s issue of the World Journal of Surgery, Javeria Qureshi and her colleagues from the University of North Carolina, Chapel Hill reported on their experience in Malawi. Their solution was placing a senior surgical resident in his or her research years at Kwamuzu Central Hospital, in Lilongwe for two years as part of a surgical disease assessment project.

In their model, this resident would be supervised “by fully trained surgeons at KCH as well as UNC surgical faculty” and would primarily serve in an epidemiologic role, assessing the local burden of surgical disease. At the time of publication, one resident had finished his two years in Lilongwe. Importantly, in the course of his tenure, his role had expanded to include the training of clinical officers and district health officers.

This month, also in the World Journal of Surgery, Jonathan Pollock and his colleagues report on the Pan-African Academy of Christian Surgeons, which, in its nearly decade and a half of service, has trained 18 surgeons and is in the process of training 35 more. The academy has applied for accreditation with the West African College of Surgeons and the College of Surgeons of East, Central, and Southern Africa. It consists of five general surgery programs and one pediatric surgery fellowship in Cameroon, Ethiopia, Gabon, and Kenya.  According to Bruce Steffes, its CEO, 100% of its graduates have remained in practice in Africa.

And finally, last week, the New York Times reported on the merger of Operation Smile and Smile Train, two organizations at the forefront of what others have called “surgical tourism”— short-term trips to developing countries, with limited surgical focus.

These three solutions to the problem of surgical infrastructure in developing countries couldn’t be more different. Each has its supporters and detractors.

Take, for example, Smile Train and Operation Smile. These are multimillion-dollar outfits with their own public relations departments. In 2010, the net assets of the two charities approached $180 million. In contrast, PAACS operates on a yearly budget of $460,000.

Can surgical tourism be the solution to the problem of surgical capacity? Many people don’t think so, but as Olayinka Ayankogbe, a surgeon in Lagos, Nigeria, said on the topic: “It is a great relief that ‘surgical tourism’ is coming on stream. At last we are getting something, however small and transient.”

But can we do better? And how do we do better?  Is surgical task-shifting the answer? Is it the PAACS model?  Is it the mid-term NGO model that organizations like Mercy Ships have adopted? Where do we start?

It’s a tough question.


  1. Anselm Tintinu
    Posted Sep. 04, 2011 at 00:07 | Permalink

    Any individual surgeon or group of surgeons who go out to Africa with the aim of biting a chunk out of the surgical disease burden deserves my applause and I say – GOD BLESS YOU. The old adage of – it’s better to teach a man how to fish than to give him fish – comes in to play. I believe training African doctors to become surgeons is priceless! These wonderful volunteer surgeons do operations as a means of teaching and the trained surgeons inturn help thousands of patients and will likely train other doctors.
    This is why PAACS is so apealing to me and I believe they’re doing a wonderful job

    Surgical Resident

  2. Adam Kushner
    Posted Jul. 12, 2011 at 15:20 | Permalink

    I agree with you that there are probably more efficient models. Also, you wrote about the $460k for PAACS and the millions for Op Smile/Smile Train but didnt note the costs for Mercy Ships (which if i remember being told about the mission in Liberia was not insignificant either.)

    I guess that’s one of the reasons we have been working with the local surgeons and MoH in Sierra Leone and also in Liberia to help them start their own surgical residency programs. I dont think it will necessarily be any cheaper in the long run, but at least they wont be so dependent on external volunteers etc.

    Anyway, i’ll be at Connaught Hospital from 1 Aug to 12 Sept. If you are still around, it would be great to meet up.



  3. Posted Jul. 11, 2011 at 17:25 | Permalink


    Thanks for the very thoughtful comment!

    I agree strongly that there doesn’t necessarily need to be one right answer and one right away. I do believe that there are many ways to deliver surgery, and all (most?) have their place. However, I also think that there may be much more efficient ways of building surgical infrastructure than what we currently have. The shotgun, I’ll-do-it-my-way-and-you-do-it-yours approach could be improved upon—and if we do so, we might find that some of the models of surgical delivery are not as useful as we initially thought.

    That said, I agree that recognition of the importance of surgery and anaesthesia in building global healthcare infrastructure is an extremely important first step.

    Thanks again for reading!

  4. Adam Kushner
    Posted Jul. 11, 2011 at 09:15 | Permalink

    Mark, Congrats on the good work and teaching. I must say though, I dont think there needs to be only one answer and one right way. I think all have value.

    However, one way to start (really continue) would be to try and get a World Health Assembly resolution on the importance of Surgical Care and Anesthesia. Without that, I think it will be more difficult to really gain the support and resources needed to improve global surgical care.

    Adam L. Kushner, MD, MPH, FACS
    Founder & Director
    Surgeons OverSeas (SOS)

One Trackback