As discussed in a new review by Norton and Kobusingye in the current issue of NEJM, in 2010, almost 1 out of every 10 deaths in the world — and the total number of deaths from injuries was greater than the number of deaths from infection with the human immunodeficiency virus–acquired immune deficiency syndrome (HIV–AIDS), tuberculosis, and malaria combined (3.8 million).

LMICs carry a disproportional number of injury related deaths with the number projected to increase.

Read the full article here

The talk is viewable here: http://www.youtube.com/watch?v=oGJyE5ytqD0

Dr. Wren bullet points the following facts that elucidate the scope of inequity in access to surgical care worldwide:

• 234 million surgeries are done worldwide per year- only 3.5% of those are done in low income countries
• 90% of deaths from physical injury, avertable by surgical intervention, occur in low income countries
• 2 billion people worldwide (for perspective, the US population is 313 million) have no basic access to surgical care
• 30% of the world’s population receives 75% of the world’s operations, mostly in high income countries
• The # of operations are 7x greater than the # of HIV infections (~34 million) in the world [note: while I believe it is important to compare the magnitude of diseases, it is only to emphasize the importance of surgery and not to downplay the importance of HIV)
• Surgery is not explicitly part of the Millennium Development Goals, despite playing a large role in two of the goals, Improving Maternal Health and Reduction of Child Mortality

One of the major arguments against surgery include the claim that it is not cost-effective. Dr. Wren cites data on US$/DALY (this is a metric in global health which assesses how much it would cost, per intervention or per disease, to avoid one year of disability for an individual) and shows that surgery (US$11-33/DALY avoided) turns out to be more cost-effective than condom distribution/promotion ( $19-205/DALY avoided), HIV/AIDS ($300-500/DALY avoided), and Oral Rehydration Therapy ($35/DALY avoided). The cost-effectiveness of surgery is now a well-accepted claim.

Furthermore, Dr. Wren speaks about the unbelievable disparity in the number of surgeons in African countries, many having less than 1/100,000 people (here is a fantastic article on the need for surgical task shifting in Africa). She underlines the imperative for global health programs to invest in the training of local African surgeons as opposed to doing short term mission trips where there is limited transfer of skills and no local sustainability.

Three cases from the Congo (but which really represent most of Sub-Saharan Africa) are presented in the talk– emergency c-sections during birth, bone fractures and other trauma from traffic accidents, and hernias (1/4 men worldwide will have a hernia in their life).

Ultimately, Dr. Wren’s talk focuses on the need to reject the current dogma that surgery is not part of the global health agenda. The talk was delivered roughly 6 months ago, but even since then there has been much energy in the movement toward global surgery. Several institutions, including UCSF, Harvard, UCLA, Oregon, Duke, and UW among others have established fellowships in global surgery.

Unite for Sight, an amazing non-profit for which I worked several years ago, has several free global health modules online, one of which is on surgery in the global health agenda. This is a great starting point for those interested in learning the major concepts and theories within the field.

I’ll be learning more about surgery and global health this summer while working in the Maputo Central Hospital in Mozambique studying cost, quality, and access to surgical care from a patient centered perspective, as well as conducting/partnering on a number of studies on anorectal malformations, pediatric burns, and other surgical cases.

This was originally posted at Swasthya Mundial.

See original here:
Outsourcing health care: The global explosion of medical tourism

Mortality Pattern in Surgical Wards of a University Teaching Hospital in Southwest Nigeria: A Review – Online First – Springer.

Characterizing the Global Burden of Surgical Disease: A Method to Estimate Inguinal Hernia Epidemiology in Ghana – Online First – Springer.

New York Times

<Reposted from here>

What is a hospital?  Seriously obvious question, right?

Except, when a close friend and mentor asked me that question a couple of weeks ago, I really didn’t have an answer.

I was in Conakry, Guinea, working with Mercy Ships aboard the Africa Mercy.  A completely spectacular time, as always, but that really isn’t what this post is about.

At one point, in the middle of a conversation with this friend, he raised that question, specifically in the setting of the developing world.  Why is it, he asked, that hospitals don’t just take off in these countries in which we work?  Why is it that we can’t build buildings, pump in money, train physicians and surgeons and nurses and staff, and then let the hospitals become these self-perpetuating organizations?

Why is it that, littered across the landscape of so many of these countries are shells of buildings, painted the obligate white-and-baby-blue, with screened and louvered windows, empty but for the kids playing soccer on their grounds?

My friend’s thesis was that so much of what we consider a hospital is predicated on Western sociocultural mores, and that, until things like corruption, like nepotism, and like dominant tribal allegiances change, hospital success stories will be limited.  Successful hospitals will remain insular entities, foreign impositions populated by Westerners.

As pessimistic as this might sound, I agree.  This, after all, is not an altogether uncommon theme in thinking about development.  In The Bottom Billion, a (controversial) book that has really influenced my own thinking on global health, Paul Collier identifies bad governance as a “trap” which keeps poor countries poor.  Paul Romer, a New York economist, goes even further, calling for the development of “charter cities,” run with new laws (or rules, as they are called), which enshrine concepts much closer to those we in the West live by.  His TED talk is here.

Listen, I’m no development economist.  Collier and Romer are leagues more intelligent than I will ever be, and, as much as the charter city concept feels like neocolonialism, it may really be the cure to poverty.

But is it the cure to healthcare?  Getting back to the question that started this blog post:  Maybe it is true that hospitals don’t often work in many places because, to do so, things like nepotism and conceptions of what constitutes sickness need to change.

If so, though, does that mean we need to change those things?  Or do we need to change what “hospital” means?

Is there a way to reconceptualize healthcare such that it isn’t thwarted by things like “bad governance”?  Instead of bending a culture to our necessarily foreign concepts (an endeavor that’s doomed to fail, at least in the short term), can we find a way to bend our foreign concepts to generations of culture, even if we don’t like them?

What would that sort of hospital look like?

I have no answer to this eminently unrhetorical question.

I met Sushil back in July.  At the time, he was a two-year-old boy in heart failure, malnourished, his hair thinned, his arms bony, his liver well into his abdomen.  He had already been to India, where doctors informed his parents that he needed a heart surgery they could never afford.  At the time that I met him, I thought he had Tetralogy of Fallot, a form of congenital heart disease.  Congenital heart disease affects upwards of 7 in every 1000 live births, many cases of which are fatal, but most of which are surgically correctable.  Most children around the world with congenital heart disease, however, die silent deaths in rural villages.

Nyaya had recently established two partnerships, one with the crowd-funding organization Watsi.org, and another with Tribhuvan University Teaching Hospital (TUTH) in Kathmandu.  The goal of these two partnerships is to help implement a fundamental human rights law for all Nepalis: that all individuals in need of heart surgery aged below 15 or above 65 should receive an operation free of cost. That law had largely been the result of the advocacy of Dr. Bhagawan Koirala, the cardiothoracic surgeon at TUTH who is partnering with us.  This is exactly the kind of opportunity Nyaya seeks: human rights mandates enshrined in Nepali law that require effective implementation to be realized.  In the Far West of Nepal, where Sushil is from, patients with heart disease have little hopes for their right to health to be realized.  From their failing hearts to the Kathmandu operating room stand numerous barriers: 1) primary care, with the nearest hospital to Sushil being Bayalpata Hospital, four hours away; 2) specialist care, with the nearest cardiologist being in Nepalgunj, 14 hours and many months worth of income away; 3) travel, lodging, and incidentals to get to surgical center, which is 36 hours and years worth of income away in Kathmandu; 4) follow-up care in a place without roads, electricity, or adequate food for half the year.  Nyaya’s mission is to bring together resources and partners within Nepal to break down these four barriers, and to realize the Nepali government’s mandate on the right to heart health.

I rode in the jeep together with Sushil and his mother to Nepalgunj to get his initial cardiologist evaluation at Nepalgunj Medical College.  There, an ultrasound (echocardiogram) seemed to confirm the diagnosis of Tetralogy of Fallot.  Over the ensuing months, we would get Sushil to Kathmandu to be evaluated there, would get funding through Watsi for much of his care (though we ultimately under-estimated his costs), and obtained an operating room date.  Upon review at TUTH by Nepal’s top heart specialists, his condition was found to be much more complex than our initial assessment: he had partial situs inversus, tricuspid atresia, pulmonary stenosis, an atrial septal defect, and a ventricular septal defect.

We took risks, we organized, and we got him the care that he desperately needed.  Several of our team members traveled and accompanied him across the country.  Yet after two surgeries and an extended stay in an Intensive Care Unit over the course of two months, Sushil died on December 5, 2012, in Kathmandu.  He died of complications of an extremely complicated disease, a disease that had already terrorized his small body for far too long than is medically optimal.

The silence deafens.  If we are not careful, it can consume and paralyze us.  What are we to make of failures like this?  Did we take the wrong risk at the wrong time?  Did we overstep our boundaries, or did we not act decisively enough?  Did we bring more harm than good to Sushil and his family?  The frame through which I think about this is that of the tremendous advocates, scientists, physicians, and surgeons who over the last fifty years have innovated, persisted, and transformed the silence of so many young children with heart disease into cures.  From deafening silence has come a chorus of innovation and compassion.  I think of Helen Taussig, a pediatrician who sixty years ago would walk inpatient units of dying, blue children, and whose insights led not only to several cures but to an entire field of pediatric cardiology.

Indeed, without confronting failure, without taking risks, without “failing forward” through implementation, innovation, and reflection, we will never overcome the diseases of poverty.  That is of little solace to Sushil and his family.  Congenital heart disease, like tuberculosis, cholera, and malaria, was once a disease that killed people of all social and economic classes.  Now, the mortality and morbidity of congenital heart disease is concentrated in the communities left behind by the global economy.

The innovations we develop are about systems of management and delivery that implement effective healthcare in those last-mile communities forgotten by most.  In rural healthcare delivery in settings of extreme poverty, openly talking about failure is not simply a matter of good management; it is essential to survival.  Failure is intrinsic to the work.

Still, this is of little solace to the silent world of Sushil’s mother.  Where did we fail Sushil?  The central, up-front failure was our delay in reaching him.  Note that it is not, as one of medicine’s more powerful social fictions would have us believe, about his and his family’s “delayed presentation to care.”  It is about our collective delay in creating a public health surveillance system to reach him.  The mandate of equal care is for the healthcare system to reach the patient and make care accessible, not for patients like Sushil to languish at home, fearful of fees and disrespect, only to travel four hours by foot to be greeted by a health system that gives them both.  Nyaya’s speed in expanding our community health worker program and in delivering screening for congenital heart disease has been too slow.  So, by the time Nepal’s top cardiothoracic surgeon could perform a surgery, his condition was already too tenuous, too compromised.  Complication and mortality rates are extraordinarily high in such scenarios.

So should we have offered Sushil palliative care alone?  Should we have spared him and his family the tremendous burden and added suffering of dying after several invasive procedures in Kathmandu, so culturally and geographically distant from their home?  Nearly every cure we offer patients also delivers some amount of suffering, be it the gastrointestinal upset from a course of antibiotics, pre-operative anxiety, post-operative pain, or potential death due to major surgery.  The stakes are so much higher when confronted with a life-threatening condition requiring risky surgery 36 hours from home, when back home awaits extreme poverty and food insecurity.  We have to weigh when and if such risks are worth it.  We accept the certainty of causing suffering for the possibility of alleviating it.  In Sushil’s case, we gave him a chance at life, a chance that he and his mother were willing to take.  I do believe, despite the complexities of his condition and the severity of his disease at the time of presentation, there was a chance for success.  It is, however, the devastating nature of calculated risks that sometimes we end up causing more suffering than alleviation.  But that does not mean those risks are not worth taking.

What does this say, more generally, about our approach to surgical access?  Are we, together with our partners, merely providing a stop-gap measure for a pathetically small number of patients?  Are we spending too much money for too little impact?  Sushil’s case illustrates to me again the importance of the approach that we are taking: developing and studying in-country referral, accompaniment, and follow-up systems.  Sushil has also played a part in our implementation science study, which addresses the entire system of rural surgical access that we are trying to develop.  This study seeks to answer the broader question of how to create a bona fide network of providers who communicate effectively with each other to get patients surgeries—be they orthopedic, cardiothoracic, or gynecologic.  Innovation in this type of situation requires action-oriented reflection and implementation science, and demands that we learn from each patient.  The investments we make for individual patient care provides healthcare for them while simultaneously teaching us how to build a better system.

Nights in Achham are clear, dark, crisp.  My own twin boys are 10,000 miles away.  I look out across the valley, above the mountains to the north.  The stars dotting the skyline shimmer to the beating of Anand and Umed’s hearts; hearts that I would surreptitiously listen to on quiet nights like these.  Hearts that, in their four years on earth, have each beat somewhere more than a quarter billion times.  Hearts that beat 15 minutes from a hospital that can repair most diseases that could possibly befall them.  For Sushil and so many others like him, his and his parents’ hopes for health are not met with opportunity and access to care, but rather are met with silence.

To read more, visit Nyaya Health at: http://www.nyayahealth.org/blog/when-a-child-dies/

What had brought this twenty-five-year-old man here, on this crisp, cloudless day in the hills of Achham?   His story began several weeks ago, when a scrape on his hand evolved into an infection, which produced tissue death and severely reduced blood flow, which then led to gangrene.  By the time he reached our hospital two weeks ago, our team assessed and explained that he should be transferred to Nepalgunj for an amputation of two fingers on his right hand.  The diagnosis and prescription were both correct.  Yet here he was, two weeks later, on a stretcher, on the side of the road leading to the hospital, with a gangrenous hand that had evolved into a spreading soft tissue infection.  His tenuous condition had now progressed to not just destruction of limb, but potential loss of life.  And though he was now on the road back to the hospital, he had no intention of stopping there.  He and the team of neighbors carrying him were headed to a village over an hour’s walk away from us.  He would literally pass within feet of our emergency department entrance.

Ashma Baruwal, Community Health Director and Dr. Duncan Maru discussing the case.
Photo credits: Allison Shelley. Allison is a photojournalist who recently travelled to Achham to document the health of women. More of her work can be viewed here: www.allisonshelley.com

Gas gangrene is a progressive, surgical condition.  Categorical statements in medicine are almost universally wrong, but in gas gangrene there are two fairly certain outcomes: surgery or death.   The frequency of this condition, first described by Louis Pasteur, which is caused by a pathogen of the clostridia species and which terrorized soldiers during the first world war, has decreased dramatically with advances in wound care.  Diseases of the “past”—those identified and conquered in the early twentieth century in wealthy countries—are sadly not uncommon in Achham, from tuberculosis to typhoid to malnutrition to maternal mortality.

To continue reading: http://www.nyayahealth.org/blog/fissures-in-trust-and-tissue/

A promise to save 100 000 trauma patients : The Lancet.

More at GlobalSurgery.org

A Survey of Surgical Capacity in Rural Southern Nigeria: Opportunities for Change – Springer.

Volunteer Orthopedic Surgical Trips in Nicaragua: A Cost-effectiveness Evaluation – Springer.

The UN General Assembly adopted resolution A/60/5 on 26 October 2005, welcoming the World Day of Remembrance for Road Traffic Victims, and inviting ‘Member States and the international community to recognize this day’.

Since then, the observance of the World Day has increased year by year on every continent.

WDOR.org

UN Road Safety Collaboration

Decade progress (ppt, 1.96Mb)
Global status report on road safety 2009

from the Lifebox blog

This post was originally published on Views From Beyond the OR.

Poor-quality medicines are found all over the world, and can be of poor quality for a variety of reasons: they might be made with poor-quality chemicals, they may contain toxic substances instead of the proper active ingredients, they may contain inactive or ineffective preparations, or they might be deliberately mislabeled. The World Health Organization calls them spurious/falsely-labelled/falsified/counterfeit (SFFC) medicines.

In cases of deliberate counterfeiting, the products are intended to look like genuine medicines, leaving healthcare workers uncertain as to which drugs are real (and could therefore help) and which drugs are counterfeit (and could cause harm).

In anesthesia, the stakes are high: many of the drugs that are used are given by injection, either into the veins or into the spine. When the drugs that are injected are compromised or contaminated, this could mean that bacteria or toxic substances are being injected directly into the body, causing immediate and severe harm. Anecdotally, we have heard stories of harm being caused in this way, such as pregnant women in Rwanda who received injections of contaminated spinal anesthetics for a caesarean section and became paralyzed. Several other similar stories have emerged as we have begun to talk about these issues.

Regrettably, however, there have been no major studies of anesthetic drugs in low- and middle-income countries that might help us to identify the sources of these problems. Our colleagues are thus left to hope for the best, knowing that the drugs they are using might be of poor quality and, as a result, might cause harm when they administer them.

We want to fix this. Counterfeit medicines are a huge problem around the world that we don’t know enough about, and worse – don’t yet know how to fix. We want to work with our colleagues in Zambia to try and tackle this problem and improve safe surgery and anesthesia. So, we have applied for funding from Grand Challenges Canada to do exactly this. But, we need help to vote for our project and make sure that we get the funding to support our work against counterfeit anesthetics. We need you to register and vote for our project on the Grand Challenges Canada website.

Our proposal is straightforward: We want to figure out the cause of poor-quality anesthetics in public hospitals and see if we can use existing technologies at the point-of-care to identify medicines that are likely to cause harm.

How will we do this?

We want to use an existing device called the TruScan to test medicines in public hospitals in Zambia for their authenticity. The TruScan is a handheld Raman spectrometer (for the science fans, here’s the Wikipedia page) that allows the user to essentially point-and-shoot at a drug, through the packaging, to determine its authenticity as compared to the device’s database. Basically, a front-line health worker can hold a vial up to the device and have it tell them if it is authentic, or not.

Because we don’t know much about why injectable anesthetic drugs are of poor-quality, we need to validate the use of this device in the field before we can say that this is an effective way of preventing harmful drugs from reaching patients. There are a range of other problems that we hope to be able to detect and eliminate – bacterial or fungal contamination, for example – that might not be responsive to this approach. That’s why every drug that we test at the point of care will also be tested in a lab in Canada, to make sure we haven’t missed anything. Once we know and understand the issues, we can figure out how to go about solving them.

What do we hope will come from this project?

We hope that we will be able to show that handheld devices like the TruScan can be used by front-line health workers to identify poor-quality medicines before they are delivered to patients. If our project is a success and we have a high rate of detection, we think that this could save lives and provide us with enough evidence to support integrating this kind of device into other health facilities where we know poor quality medicines are a problem. By empowering local health workers, particularly anesthesiologists, we hope to be able to show that better control of the drug supply chain can be attained by local staff.

If our project is a success, then this gives us solid evidence to support scaling up this kind of intervention. Furthermore, it also will provide us with valuable information on the drug supply in anesthesia: something that we know relatively little about in low- and middle-income countries. Of course, preventing counterfeiting at the source is always preferable, and there are a number of initiatives doing just that, which compliment the work that we are undertaking (like mPedigree or Sproxil.

How can you help?

First, watch our Grand Challenges Canada video, register, and VOTE for us.

Second, share our video with your friends and colleagues and encourage them to do the same.

Surgical care is an integral component of a strong, functioning health system. Regrettably, millions of people are denied access to safe surgical care around the world. There is a growing momentum to strengthen the quality of surgical care available, and ensuring access to safe and effective anesthetics is a critical component of these initiatives. But, we need to know more about what the problems in the anesthetic supply chain are and how to fix them. This project is an important part of this work and we hope that you will support us.

via Normothermic perfusion of donor lungs for preservation and assessment with the Organ Care System Lung before bilateral transplantation: a pilot study of 12 patients : The Lancet.

via TheLancet.com.