InciSioN- The Netherlands first docu-evening

<Sebastiaan Van Meyel>

I am happy to announce that on the 12th of April 2018 Incision – The Netherlands hosted its first event in collaboration with Global Surgery Amsterdam (GSA) as well as the Netherlands Society for International Surgery (NSIS). Three organizations all concerned with global surgery on different levels.

The evening started off with an introduction followed by talks from all three organizations stressing the importance of surgical care in low resource settings and introducing their own respective work. Then – together with the necessary popcorn – the documentary “The Rebel Surgeon” was screened which describes the life of a Swedish surgeon operating in the outskirts of Ethiopia. A great movie which elicited both laughs and cries but was most importantly very relevant for the night’s topic. The way that the Swedish surgeon worked, doing any kind of operation, providing all possible help with low and improvised resources sparked admiration among most young students and doctors.

However, the older and experienced delegation of doctors present had its remarks on the film saying that in many parts of Africa improvements have been made and  bureaucracy have been introduced and that the absence of rules in which this surgeon worked was not representable anymore. The combination of different generations created an excellent debate that went on for the rest of the evening. Among the topics that came up, the question of whether we should bring the very developed but bureaucratic health care system from the western world to the less developed countries of the world or wheter there might be a better way of implementing a new health care system. This debate went on for some time fueled with more popcorn and moderated by the tropical and plastic surgeon Matthijs Botman and the tropical and general surgery resident Jurre van Kesteren, who both have extensive experience with working in low resource settings. Jurre was deployed from 2014 to 2016 to Sierra Leone as a medical doctor in global health. Matthijs worked as a medical officer from 2009 until 2011 in the Republic of Congo as well as Tanzania. The evening came to an end with enlightenment about the urgent need of global surgery by all attendees. All in all, the evening was a blast. We started off with extending our network and plan to organize events like this in the future. Maybe we will get some great ideas from the International Global Surgery Symposium in Leuven this May!

On International Maternal Health and Rights Day: The role of emergency and essential surgical care.

“If you want to know how strong a country’s health system is, look at the well-being of its mothers.” – Hillary Clinton

<Dr Aliyu Ndajiwo>

What is a mom, but the sunshine of our days and the north star of our nights. Of all rights of women, the greatest is to be a mother. Women are the backbone of every family and the society. On this special day – The International Maternal Health and Rights Day – we, InciSioN are standing strong along with other organizations and individuals to voice out the need for improved maternal health care and rights for all women around the globe. We believe every mother counts!

In 2014, the International Maternal Health and Rights Day was launched by the Center for Health and Gender Equity (CHANGE), along with other prominent Maternal Health organizations. It is indeed a great initiative that deserves more special attention. It is every woman’s right to have access to safe care before pregnancy, during pregnancy, in childbirth, and even after giving birth.
A woman dies in pregnancy or childbirth every two minutes, and everyday over 800 women die from complications during pregnancy and childbirth. 99% of all maternal deaths occur in developing countries, and 90% of the complications that lead to maternal death can be avoided when women have access to quality prevention, diagnostic, and treatment services.

An often-overlooked issue in improving Maternal Health Systems and rights is improving access to safe surgical care. Over 5 billion people globally lack access to safe, timely, and affordable surgical care, and anesthesia, with the majority living in lower-and middle-income countries. This staggering fact has become a common phrase on the lips of several global health leaders, advocates, surgeons, health workers and even medical students. It made the World Health Organization (WHO) pass a resolution on “Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage” at the 68th World Health Assembly in 2015. The WHO along with many other institutions, and organizations are also pushing countries, especially the developing ones, to improve their respective surgical systems by developing and implementing a National Surgical, Obstetrics and Anesthesia Plan (NSOAP).

Improving access to safe surgical care has enormous potential in promoting and contributing to maternal health and rights, maternal wellbeing, improved economic productivity, supporting Universal Health Coverage, and achieving the Sustainable Development Goals (SDG). By 2030, Low- and middle- income countries are estimated to lose as much as $12.3 trillion dollars in Gross Domestic Product (GDP) if they fail to invest in safe surgical, obstetrics and anesthesia care. Improving access to safe surgical care also has a positive feedback to the health system as services such as infrastructure, workforce, equipment’s and supplies, health information systems and policies all need to be improved to provide safe surgical care.

Each year over 136 million women give birth. 1 out of 3 of them will require medical or surgical intervention during the course of the pregnancy, and about 5-15% will require a caesarian section during birth. Over 25 million females of reproductive age require surgical and obstetric services. In 2015, an estimated 303,000 maternal deaths was reported with almost all occurring in developing countries. The Sustainable Development Goal (SDG) 3 aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births between 2016-2030.
Developing countries have a maternal mortality ratio of 230 per 100,000 live births compared to developed countries with a ratio of 16 per 100,000 live births. About one third of all global maternal deaths occur in India and Nigeria. With India producing about 17% and Nigeria producing 14%.

As of 2013, there was an estimated shortage of 17.4 million health care providers in the global health workforce as reported by the “Global strategy on human resources for health: Workforce 2030”, of which 9 million were nurses and midwives. Just increasing the coverage of midwifery-led care by 10% will result in a 27% reduction in maternal mortality in low-income countries. A recent study revealed that countries with higher densities of surgeons, anesthesiologists and obstetricians (SAO) had a significantly lower maternal mortality ratios compared to countries with a lower density. These shortages have adverse effects on maternal health outcomes. Task shifting and task sharing are strategies that could be used to manage these shortages. In Malawi, Mozambique, and Tanzania, a study revealed that Medical officers were able to perform safe caesarian section surgery when properly trained.

Improving access to basic surgical and obstetric interventions can reduce the burden of disease in maternal and newborn populations by around 40% by preventing obstructed labor. It will also help to ensure high standard of care for women and their families. It is every woman’s right to have access to interventions such as Caesarian sections, exploratory laparotomies, fistula repairs, etc. However, many women in low- and middle- income countries still lack access to such interventions, which result in high maternal mortality rates in those countries. Due to the poor state of health in developing countries, many women especially in rural areas tend to give birth at home in the presence of unskilled health workers who cannot provide life saving surgical services in cases of obstetric complications. Even pregnant women that want to deliver in the hospital find it very difficult because the hospitals are often located very far away, and are usually short staffed. In many developing countries such as Gambia and Rwanda, longer travel time between health center and district hospital was associated with poor maternal and neonatal outcomes.

One of the most disabling conditions women acquire due to poor access to emergency obstetric care is obstetric fistula. It occurs when there’s prolonged or obstructed labor for periods lasting from several days to a week, where the yet to be born baby’s head exerts significant pressure on the soft tissues around the womb, eventually creating a hole through which urine, menstrual blood, and/or faeces can leak through. Death from blood loss during childbirth, and infections are serious complications of this disabling condition. Patients with fistula usually undergo surgery. About 80-95% of fistulas can be closed surgically. Untreated obstetric fistulas are a common cause of morbidity in low-resource settings affecting 2-3 million women and resulting in social stigma and ostracisation. Women suffering from fistulas are unable to assume their normal social and marital roles, and they become more dependent on others. In Tanzania, women’s lack of decision-making power, lack of money, unavailability of transportation to and long distances to health care facilities were huge contributing factors to women acquiring this disabling condition. Perhaps if the rural areas had good emergency transportation system, skilled workers, and social and financial support there would be many more women and children alive today without any form of disability


Dr. Amina Sani Bello Founder of Raise Foundation performing Fistula repair surgery on a VVF patient in Minna, Nigeria.

Child marriage and early pregnancy are also risk factors to developing obstetric complications. A study showed that a 10% reduction in child marriage among girls could decrease a country’s maternal mortality rate by 70%. Pregnancy and childbirth complications are the leading cause of death among 15 to 19 year-old girls globally, with low and middle-income countries accounting for 99% of global maternal deaths of women ages 15 to 49 years. A study in North-Eastern Nigeria revealed that 71% of pregnant teens had experienced at least one serious pregnancy or birth-related health problem, with almost 50% being as a result of obstructed and/or prolonged labor.

There’s an increasing rate of caesarian section deliveries in the developed countries, which could be linked to improved maternal health outcomes. However, in the developing countries, majority of the women prefer natural birth to caesarian deliveries due to several personal and socio-cultural beliefs. A caesarian section is a proven life saving surgical intervention. It is listed as one of the five bellwether procedures used as an indicator in measuring surgical systems globally. Women suffering from conditions such pre-eclampsia, breech presentations, hemorrhage, prolonged or obstructed labor can be saved by this surgical intervention, yet many women don’t have access to such intervention. The rate of caesarian sections in some countries in Sub-Saharan Africa and South Asia is less than 2%, while the WHO recommends rates of at least 5-10%. An unequal coverage of caesarian section rates was discovered in Pakistan. It was noted that lower rates was seen in women that were less educated, poor, and living in rural areas, while higher rates was seen in women that were better educated, rich and living in urban areas. Several educational, financial, infrastructural and cultural barriers need to be broken in order to improve maternal health and rights.

Universal access to emergency obstetric care should be prioritized on the global health agenda. The role of emergency and essential surgical care in maternal health and rights cannot be overemphasized. There’s an urgent need to improve emergency and essential surgical care, as it is critical in reducing maternal mortality and improving maternal health outcome in cases of emergency obstetric complications. It is time to make maternal health and rights a priority, and it cannot be achieved without improving access to emergency and essential surgical care services.

UHC in Zambia – The Kutusa Intiative

Zambia is a low-and middle-income country (LMIC) with a population of about 17 million people. For a long time since the independence in 1964, the University Teaching Hospital (UTH) was the only tertiary hospital that offered most of the specialised medical services. Zambia has a specialist surgical workforce of 1.48 per 100,000 population whilst the Lancet Commission on Global Surgery has recommended attainment of close to a minimum of 20/100,000 by the year 2030.

<Jackson Chipaila>

During our training as medical students and specialists we saw many patients from all parts of the country referred to UTH for specialist management of their conditions. The greater majority was from the rural areas with little or no means to keep up in the big city as they waited to be attended to by the specialist. It is against this background that in 2014, we started an outreach programme called “Kutusa Initiative” meaning help, and whose theme is “paying back to your community.” It involves organizing our fellow doctors of various specialties in undertaking charity medical services to the less privileged rural communities biannually. This entails that these doctors commit their time, resources and skills in order to reach out to the patients in rural areas. Moreover, there is transfer of knowledge and skills in form of mentoring the medical stuff in those rural hospitals visited. The rural hospitals are responsible for the mobilisation of patients requiring specialised medical services. The core group consists of a general and an orthopaedic surgeon, a gynaecologist, a paediatrician, an ophthalmologist, and an anaesthesiologist. Since its inception, we have seen more than a thousand patients and have conducted more than 150 surgical operations which include hysterectomies, laparotomies, thyroidectomies, herniorrhaphy, open reduction, and internal fixation (ORIF) of bone fractures among others. The hospitals where these outreach services have been conducted are: Maamba District, Chikuni Mission, and Mpongwe Mission Hospitals. Each outreach has had its own stories to tell but we hereby share only three of the most recent outreach conducted in December, 2017.

The gynaecologist first found Ms X lying in bed, with a low grade fever and a history of having undergone a manual vacuum aspiration (MVA) of the uterus for an incomplete abortion. Having re-examined the patient, her blood results and abdominal ultrasound, the gynaecologist, made a clinical diagnosis of a perforated uterus. Seeing that the patient was hemodynamically stable and acquiring informed consent a mini laparotomy was done under spinal anaesthesia and this ended up into a hysterectomy because the uterus was not only perforated but necrotic. This patient recovered well before complications from sepsis could set in. Such lives are easily lost not because of negligence but the non-availability of qualified personnel to make the correct diagnosis and timely decision.

A physiotherapist technologist took advantage of the Kutusa Initiative team and presented a 9 year old girl with malunion of the right humerus with a fixed elbow deformity secondary to a supracondylar fracture. Being her dominant side, a number of activities were limited. The patient was obviously socially withdrawn and the parents were worried for their girl child. After being assessed by the orthopaedic surgeon and anaesthetist, the patient underwent ORIF to correct the malunion and elbow deformity. The patient recovered very well and this brought a smile not only to the patient but the parents as well.

We had a patient with a euthyroid goitre, pressure symptoms and a slightly low haemoglobin whose operation we postponed to either our next visit or be referred to the provincial hospital due to lack of a functioning electric cautery knife. It was obvious that the patient preferred that the operation is done from her local hospital, close to her family. Postponement of this case was cardinal as it hinged on the safety of the patient as she was mild anaemic, the electric cautery knife would have helped minimise the blood loss.

From the stories we have shared you would be marvelled at the level of commitment and team work on the part of the health workers at the rural hospitals. We conduct operations from morning till late in the night every day of the outreach period because there is usually one emergency theatre and an elective theatre. And these workers sacrifice their overtime working hours at no cost because they equally want to see that the patients in their communities are attended to. On the last day of the outreach due to time constrain we end around midday, we hurt to see that some patients are turned back because we have to drive back hundreds of kilometres to either our homes or to the next outreach site dependant on the schedule. As we celebrate World Health Day 2018, under the theme Universal Health Coverage, Kutusa Initiative highlights the fact that anaesthesia is pivotal in any surgery thus in order to reach global surgery by 2030, there is undying need to increase not only the surgical work force through specialist training but coupled with infrastructure, equipment, drugs and consumables all of which are intertwined in the delivery of safe surgery to the patient. The World Health Organisation has prescribed that in order for a country to promote health equity, the cardinal facet is moving towards universal coverage through universal access to the full range of personal and non-personal services.

Kindly follow us on our Facebook page “Kutusa Initiative“.

The cargo of hope

A group of medical students from St. George’s University (SGU), based in the Caribbean island of Grenada in the West Indies, decided to give back to the land that allowed them to make their dream of becoming a doctor come true.

They managed to ship a boat containing nearly $400,000 worth of medical and surgical supplies to the Grenada General Hospital. Those students belong to the International Student Surgical Network-InciSioN, a network bringing together medical students and young doctors from more than 50 countries. As a co-chair of this network, I was a lucky witness of their story. I have interviewed some of the main characters so that you can hear the story from them, just like I did. 

<Zineb Bentounsi>

 

Zineb Bentounsi : Hi Josh, Amanda and Kathy. So you all are medical students at St.George’s University, aren’t you?

Katayoun Seyedmadani (Kathy): Yes! Josh and I are already doing clinical rotations in the US while Amanda is still based in Grenada. Usually, students come from USA and UK to study the first 2 years (out of 4) of medical school in Grenada and then go back to those countries for 2 other years of clinical rotations as the island’s hospital can’t accommodate all the students.

Zineb: Actually, can you tell us more about the healthcare facilities in Grenada?

Kathy: Grenada is a beautiful Caribbean Island that is considered middle income by the World Bank. However, in terms of delivery of surgical care, the island is very underserved. Grenada General Hospital serves the population of over 100,000 people with 5 functional operating rooms. One is reserved for ophthalmology, one for obstetrics, and the remaining 3 are used for all other surgical procedures. There are 5 general surgeons and 4 anesthesiologists who work so hard and with great outcomes in the face of shortage of supplies and devices. When we started our global surgery group (SGU Global Surgery), we began our work by trying to evaluate the status of surgical care on the island. In spring 2016 we visited the hospital and met with the medical director, Dr. Kester Dragon, who is an orthopedic surgeon to gather more information. We were quite surprised to find out just how underserved the island was.

Zineb: And here you began to think about potential solutions…

Joshua Carlson: Indeed. While we were thinking, a great opportunity came to me. I received an email to meet with the CEO of Project Cure, Doug Jackson, in Washington, D.C. I received this email because I had previously been involved with Project Cure during the Nepal earthquake in 2015. I was going to ignore the email but then sent it to my colleague Gene Deems with whom I had started to form the charity Medicine with a Mission, who immediately told me that I should go.  Long story short, I, a lowly medical student, went to meet the CEO of one of the world’s largest and most known humanitarian groups! In our conversation and the many others that followed, I explained to him our idea to bring some surgical and medical supplies to Grenada and it turned out that he wanted to be on board! After that I was in touch with Gosia Betencourt and Michael Fry who coordinated the project with us.

Kathy: It was perfect timing.

Josh:  Indeed. I knew in my heart, that it was God’s Plan for me to meet him in order to start this project and give back to the people in Grenada after being there for nearly 2.5 years.

Zineb: So after having the support from Project Cure, how did you transform your idea into a project?

Kathy: This took 2 years of preparation and fundraising. We had a meeting with Project Cure first to understand the process of ordering the cargo and the associated costs. On the island we went back to the medical director of the hospital to see if they were interested in such aid, and what their needs were. Once we had green light from the hospital our students from SGU Global Surgery began heavily fundraising for the $20,000 cost.

Zineb: That is what you have been doing Amanda right?

Amanda Hughes: Yes, since I got involved in 2017. When Kathy had to leave the island, I stepped into her role as VP of External Affairs. At that point, the previous team had already secured $10,000. Myself and Jana DeJesus, who serves as VP of Internal Affairs worked closely together to raise the remaining funds within the SGU community. 

I  became the contact for any external organizations on the island including SGU administration, Grenada General Hospital and the Ministry of Health. I’ve worked closely with them to finalize details of the project. One of the major tasks I tackled was working with Dr. Terron Hosten, a general surgeon from Grenada General Hospital to create the manifest of supplies needed at the hospital.  Now that the supplies are en route, Jana and I are working with SGU and the Ministry of Health to make sure everything is in order for their arrival. 

 

From left to right: Jana, Amanda and Dr Hosten

Zineb: Impressive! I just want to do the counts again and really understand how your fundraising worked…

Josh: So the first $10,000 were given by both Medicine with a Mission and D’Amore Personal Injury Law, LLC.

Amanda: And the other $10,000 were collected under Kathy’s term and mine by our student group, with efforts of our entire board especially our advocacy arm lead by Daniel Tadros. We had generous contributions from several other SGU student organizations.  

Kathy: Indeed, we had all sorts of contributions. The funniest one was a 28” television that was donated by SGU Clinical Skills Department and was raffled off at the Fall 2017 Pong Tournament. Students held various fundraisers from selling crush cans for Valentine’s Day to reaching out to other student organizations and asking them to join us for support. Our VPI Ruby Vassar and I  presented at our student government meeting and they actually donated 1/5 of their budget to the cargo. This way the cargo became a campus-wide labor of love.

Zineb: Now that we talked about how the project became a reality, let’s talk about your personal experiences with this adventure. What was the most challenging obstacle that you had to overcome?

Amanda: It is always difficult learning the ins and outs of a new culture. One of the challenging aspects of this project was learning to navigate the Grenadian healthcare system. There was a bit of an adjustment period for me to really feel comfortable and confident reaching out to Grenadian physicians and Ministry of Health officials. However, we have been helped by our advisor, Dr. Subbarao, the  school’s vice provost, Mr. LaGrenade, and provost, Dr. Childers.

Kathy: The challenge was to build trust! I learned that even with the best intentions you have to first stop and learn about the culture from people, then understand their needs and wants before you jump in trying to offer help. Coming from US we were used to a different system and different timelines. We had to learn and adapt to the local flow of things. Here we were a group of medical students who were offering to do a project that is the largest philanthropic effort on our campus to this date, and speaking of bringing in a new OR and ICU, but what rapport did we have to show that we actually can deliver something like that? Underserved communities have unfortunately seen their fair share of medical dumping and aid that did not deliver what it promised etc. We built trust by striving to being always professional, always prepared, always transparent, and always keeping our focus on the goal of this project which is better surgical care for people of Grenada.

Josh: The most difficult thing I faced was having to constantly try to keep the faith, hope, and inspire the group and myself during the 1.5 year period that we tried to raise the money. We had so much momentum in the beginning, but seemed to hit one road bump after another, however I knew and believed it was going to come true. Of course there were times of doubts, but we had to keep believing and pushing forward. Students were raising money at the school and we couldn’t believe how they raised nearly $10,000 while being in medical school. This continued to inspire everyone to keep pushing forward, despite any shortcomings – and look! It all worked out for good in the end.

        Kathy and Josh

Zineb: Congratulations! Your story is really inspiring. Can you tell us what are the next steps now? As we are speaking the cargo in en route and should arrive on April 3rd to Grenada. What will happen then?

Josh: We just had a meeting with most parties involved, and need to delineate where each other supplies will go, barcode tag the supplies, make sure everything is in working order, and then make sure it will be utilized.

Amanda: Once the cargo arrives we will be tagging larger items and sorting all of the materials to be dispersed. The Ministry of Health will be assisting us with delivery of supplies to targeted destinations. We would like to have students follow up on the supplies in 3, 6, and 12 months to see how they were used and which materials were of the most benefit.

Zineb: Have you thought about the sustainability of the project?

Josh: The most important thing that we want to stress is that this is a short-term initiative with a long-term focus. We are hoping that providing these supplies now will help the people of Grenada who need the care while more sustainable partnerships are formed. InciSioN Grenada will continue to be involved in pushing initiatives on the ground in Grenada and SGU has mentioned that this partnership with Project Cure can be used in the future.

Kathy: We have identified some other possible resources and collaborators that we could work with but this is all still very preliminary. My wish is that we can use this project now as platform to highlight the needs on the island and in the Caribbean region. Grenada is not the only island in the region that is underserved, many are, especially after the recent hurricanes. I am hoping that we can come up with sustainable solutions and help empower the people of Grenada for a better surgical tomorrow.

Zineb: Now, as a final word can you tell me how this project has changed you, on a personal level?

Amanda: I am overjoyed to see our project coming to completion. It is amazing to see what our small group was able to accomplish, and I hope that other students may be inspired by our success to pursue their ideas. The Grenadian community has been wonderful to work with and I can truly say that being a part of this project has been the highlight of my time in Grenada.

Kathy: It was really amazing to be part of such a great team. Our executive board is technically divided between Grenada, US and UK, but anytime we needed a decision, it took us under 5 hours to rally everyone. From emotional support to workload support this has been such a beautiful team effort, and I truly could not have wished for a better group of passionate friends to work with. I truly wish to be able to continue on this road, I hope to become a surgeon and have the opportunity to serve those in need. My goal is to remain active in global surgery, and someday travel on surgical missions.

Josh:  I am so thankful to be a part of this incredible adventure, with the most incredible people – to be a part of something that is able to contribute to helping lives. All the glory goes to God for helping the people of Grenada with the connections and abilities we have been given.

I would like to thank Amanda, Kathy and Josh for the time they took to answer my questions. Their story illustrates once again how students can move mountains when it comes to improving surgical care. It also shows how team work, personal dedication, faith and hope can all come together to bring success. Behind those three people, there is an entire team of students who was involved. We would like to thank Ruby Vassar, Daniel Tadros, Belal Noureddine, Gabe Lavespeare, Jana De Jesus and all other members of the team.  

   Daniel Tadros

   Belal Nourredine

  Ruby Vassar

 

 

 

InciSioN- The Whole is Greater than the Sum of its Parts

I’m Stav Brown, a medical student at the Sackler School of Medicine, Tel Aviv University.

I have always been fascinated by the field of global surgery and the ability to facilitate international collaboration and share knowledge on a global level. I strongly believe that health is one of the most basic components of the human existence and that access to safe, high-quality surgical care is an integral component of every society.

I joined InciSioN’s international team in January 2018 to help make this vision a reality. Our great team is comprised of 40 members from over 30 countries with a variety of languages, cultures and backgrounds, and our main focus is building the future generation of global surgeons to make surgery safe and accessible worldwide.

Being a part of such a diverse group of people, who share the same goal and work endlessly towards it together has been a very special experience. The variety of ideas, views and perspectives is key to creativity and innovation as we unify our efforts and integrate our individual functions operating as a whole. Ultimately, I feel like we constantly learn from each other and gradually grow, both as a team and individually in our work as global surgery leaders in our countries.

This great international collaboration has made me even more passionate about global surgery, and I’m beyond excited for our upcoming projects and collaborative work as part of the InciSioN family.

Stav Brown
National Chair, “Global Surgery Israel”
InciSioN International Team member 2018

Karolinska Institute Global Surgery Course

Kampala, 12th January. After 11 intensive days in Uganda, the 3rd edition of the Global Surgery course of Karolinska Institute has come to an end. I will always be grateful for how the doctors, nurses, students and other staff at Mubende Regional Referral Hospital and Mulago National Referral Hospital, who welcomed us with open arms, who were always willing to share their impressive knowledge with us, and who always took their time to help and guide us in spite of busy schedules and difficult work.

<Jessica Zhang>

15 Swedish medical students had this honour of learning more about healthcare in low resource settings, supported by a competent team of supervisors. We had prepared for this through a number of lectures and seminars during the autumn, but of course few things can substitute observing and experiencing events first hand. During these few days, we have seen a glimpse of some health system and health financing challenges, we have seen how unequal global distribution of resources can affect the individual patients, as well as some consequences of decisions and priorities made on an international level. It’s great to hear that antimalarials, TB drugs and antiretrovirals are readily available because they have been prioritized, subsidized, sponsored or similar, at the same time it’s heartbreaking to hear how many other things are lacking.

Open heart surgery (Fallots tetrad) at Mulago National Referral Hospital (Kampala)

We have seen patients lying in hospital beds without receiving lifesaving interventions although healthcare is free because they cannot afford to buy necessary supplies such as gloves, without receiving adequate pain medication because they are out of stock, without undergoing radiological examinations that we take for granted in Sweden because the devices are not available. And the doctor says that there is no evidence supporting their choice of treatment, because research has not been done on this population. I know this is everyday life for many health workers, but for us it was a new reality.

Pediatric surgery (pyloromyotomy) at Naguru General Hospital (Kampala)

We have seen doctors, who seem to know all about everything from general surgery and orthopaedics to infectious diseases and dermatology to obstetrics and paediatrics by heart, and who are doing an absolutely amazing job with the means that they have. We have met young women with life threatening complications after unsafe abortion procedures, children with severe malnutrition, and patients with enormous T4 tumours that could’ve been cured if only they had seen a doctor earlier.

Mubende District Local Government Office 

We are constantly, and painfully, reminded of the global injustice and of our own privileges, both inside and outside of the hospital. And I keep thinking that as long as the system is unfair, whatever we do will not feel completely right. We could donate items, but will that create dependency and negatively impact the local market? We could contribute with our time or our hands, but honestly is that what is lacking and what is needed? We could provide financial support, but how will that influence other actors and stakeholders, and is that really a long term solution? Maybe we just need to change the system – if fairness even exists. And suddenly, the importance of international collaboration and policy once again becomes clearer.

Mubende Regional Referral Hospital

Talking about being fair nevertheless, it’s maybe also fair that we’ve also met a bunch of patients with similar complaints as we would find in Sweden, and participated in procedures more or less identical to what we do at home – everything from anaesthesia to cystoscopy to heart surgery. We have many things in common, in spite of the differences between our countries. Furthermore, there is so much potential to increase the availability, accessibility and quality of the healthcare with the right interventions – and with increased research as to ensure evidence based action. Most of us students would have loved to spend more time here, because we have so much left to learn. But then I’m thinking maybe it’s also good to leave with a feeling that you have not yet seen, done or learned enough; before you feel saturated, and with the hope of someday returning. I’m going home with new inspiration to become a better doctor, a better health advocate, and a better fellow human being.

UHC for a Healthier Generation

The Sustainable Development Goal (SDG) 3 aims to ensure healthy lives and promote well being for humans of all ages. Putting this in proper context means well-being before an individual is conceived – promotion of safe sexual practices, availability of contraception and the right to make informed decisions about our reproductive health; appropriate antenatal care services that go a long way to improve our present unsatisfactory global neonatal mortality rate of 19 deaths per 1000 live births in 2015. This also extends to baby care practices like vaccinations, breastfeeding and baby growth monitoring among others. Adolescent reproductive health comes next, and in the same spectrum lies mental health issues like substance abuse and adolescent response to various forms of bullying; especially in an internet age when the bullies now sleep and wake with the victim- in form of social media. The list then extends to communicable and non communicable diseases that can be found in adults, and not the least the health demands of seniors. In countries with strong militaries that make up an entire demographic, veterans health is a big concern. Achieving the aims of SDG 3 is daunting, but big progress has been made by countries and international bodies in the push towards a healthier human race.
<Alade Temidayo Qasim>
 
After the second World War, most European countries saw the mass reorganization of their societies as an opportunity to ensure health coverage for all their citizens. These were the first steps to ensure universal health coverage since Bismarck created his welfare state in the defunct German Empire in the 19th century. Many countries sought a health system that ensured all their citizens had access to health care relative to their health needs without necessarily compromising quality and exposing them to financial difficulties. Utilization relative to need, financial protection and equity in finance; and healthcare that has enough quality to be effective are the central ideas in how universal health coverage was described by the World Health Report of 2010.
 
Utilization relative to need refers to people getting the healthcare and services they require at a certain point in time. This spans through all stages of care- prevention, promotion, evaluation, treatment (either definitive or palliative), rehabilitation, and even surveillance services. This is actually quite difficult to ensure without compromising the two other core issues in UHC- financial stability and quality. Providing the best services is expensive; providing just about any service because it’s needed at that particular time may water down the quality of the care significantly. Therefore, the challenge lies not in whether governments can provide services, but whether those services will still be of the highest standards without exposing the people to undue financial risks. This unwillingness to trade off one core objective for another lies at the center of why UHC is difficult to implement. That quality healthcare cannot be cheap is a truth known to all. With that knowledge as the foundation of a push towards UHC, governments in each country can then draft specific health financing policies that are peculiar to that particular country; in a way that can guarantee quality healthcare for all.
 
Seeing UHC and health for all as a pipe dream is not pessimism, just realism that refuses to get examined. With the right steps taken to raise the funds needed to provide these services; with appropriate pooling and allocation of this scarce resources, the purchasing of the most essential services will not pose much of a problem as long as the benefit packages are designed in a very pragmatic way to favour the majority of people in the pool. UHC is possible, and will be our answer to a healthier and happier generation.

UHC Forum 2017 – Tokyo, Japan

In 1961, Japan became one of the first countries to achieve Universal Health Coverage (UHC), the key factor behind the country’s incredible improvements in health status and life expectancy of its population. 56 years later, the global health community united in Tokyo to learn from Japan’s experiences and achievements, and achieve similar goals in all countries worldwide, on a true quest for #HealthForAll. 
<Dominique Vervoort>
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“Our goal must be to protect and promote physical and mental well-being for all. Health is both an outcome and a driver of progress. It is at the centre of our vision of a more sustainable, inclusive and prosperous future […] When we invest in health – particularly of women and adolescents – we build more inclusive and resilient societies.” The United Nations’ (UN) Secretary-General António Guterres addressed the Forum with the UN’s willingness to support countries on their path towards UHC. Similar to Dr. Tedros, Director-General of the World Health Organization (WHO), he stressed the importance of political will to commit to UHC, which could yield a twentyfold return in terms of full-income growth within a generation. At the same time, Japan reaffirmed its reputation as the leading voice in UHC, pledging $2.9 billion to developing countries pursuing UHC, each in their own unique way.
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The WHO published its “2017 Global Monitoring Report”, which noted that half of the world’s population -more than 3.5 billion people- do not receive the healthcare services they need. From those that do receive healthcare, 800 million face catastrophic expenditure (more than 10% of household expenditure) and 100 million are pushed into poverty due to out-of-pocket payments for medical care.
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Just as peace is not simply the absence of conflict, so is health not just the lack of illness. Our goal is not only a band-aid or a single dose of medicine, important as those are. Our goal must be overall well-being, physically and mentally for everyone in all countries.
– UN Secretary-General António Guterres
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UHC Day
On December, 12th, the world celebrated UHC Day, which is now officially recognised by the UN. United by the UHC Coalition, over 1,000 organisations in over 120 countries joined forces to spread the word and discuss about UHC, to #WalkTogether and to #RiseForOurRight towards health for all.
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On this day, the Global Surgery community did not stay quiet either, holding an official #SurgeryUHC side event at the UHC Forum 2017, titled “The Power of Surgical Care to Catalyze Universal Health Coverage” and organised by the WHO, the governments of Zambia and Zimbabwe, the Harvard Program in Global Surgery & Social Change, the G4 Alliance and Johnson & Johnson, emphasising the essential role of surgery and anaesthesia for UHC. Global health and global surgery leaders, ranging from Jim Yong Kim (President of the World Bank) and Sania Nishtar (WHO Commission on NCDs) to Emmanuel Makasa (Permanent Mission of the Republic of Zambia to the UN) and Agnes Soucat (Director Health Systems, Governance and Financing at WHO) discussed key topics ranging from task-shifting and health workforce to health systems strengthening and health financing.
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In the other parts of the world, InciSioN’s National Working Groups held small UHC events on a local level, further advocating for UHC among the future health workers of the world. InciSioN-Rwanda believes that “healthier communities are essential for sustainable growth and development”, whereas Tanzania agreed that everyone -rich or poor- should have the right to access quality health services whenever they need it, all united to make sure that safe surgery and anaesthesia are enshrined in UHC by 2030.
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Check #SurgeryUHC on Twitter to read up on all important statements regarding Global Surgery on the UHC Forum 2017 in Tokyo, Japan.
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Read “Surgery & Anaesthesia: the Overlooked Keys to Universal Health Coverage” for more information: https://medium.com/health-for-all/surgery-anesthesia-the-overlooked-keys-to-universal-health-coverage-524bb2eeecb1

Global Neurosurgery Conference 2017 – Rabat, Morocco

After attending the Global Surgery Summer School last July in London, I became aware of how disproportionately surgical diseases affect the poorest people around the world. Currently being a second-year medical student at EUC Rotterdam, The Netherlands, I am very motivated to engage and help. Therefore, I participated in the first student-led Global Neurosurgery conference in Rabat, Morocco, organized by InciSioN and IFMSA-Morocco.

<Sebastiaan van Meyel>

In the early morning of the 11th of November 2017, everybody at the Abulcasis International University of Health Sciences in Rabat was excited about the forthcoming event where around 150 medical students participated. The main purpose of the day was to expand our academic horizons and learn how to advocate for global surgery, and neurosurgery in particular, and at the same time broaden our career options in these fields.

The programme was delivered through a combination of morning lectures, panels and highly interactive afternoon workshops. First, we started in a lecture-based-setting with different sub-themes of global surgery. After a coffee break, we enjoyed listening to the new insights into the role of global neurosurgery. These talks, especially reflecting on the African situation, enabled us to understand the challenges and opportunities of African Neurosurgery, and it also made me aware of the differences in medical education in Africa compared to that in other parts of the world. Another inspirational talk highlighted the efforts in global neurotrauma research. The morning sessions were rounded off with an interesting presentation about global anaesthesia. It was great to see how many efforts and endeavours already have been made. Subsequently, an interactive panel discussion with both Moroccan and international speakers took place.

Although the audience interacted with the panellists and created some engagement, it was the afternoon workshops that truly involved everyone. The barriers were clearly broken down and the talks became more open, with a much higher level of informality. In the afternoon, I joined the screening of the Checklist Effect, an eye-opening documentary elucidating the urgent need and shortcomings of surgical equipment and care around the world. I valued my second workshop too, being “The World of Global Surgery and Anaesthesia”. This high-level panel discussion by internationally-renowned neurosurgeons offered the opportunity to engage in a passionate exchange of ideas on the past, present and future of global surgery and global anaesthesia. We all left the room satisfied of this energizing debate, which consolidated our knowledge and left us with better understanding of the critical issues. I believe the amount of ambassadors for global surgery that day surged, or at least we got hope for positive future developments. As the icing on the cake, the national Moroccan soccer team qualified for the 2018 World Cup that day.

Overall, the first student-led Global Neurosurgery conference was a unique experience and it was great to have been part of it.

The Case for Human Resources for Health in Realizing the Sustainable Development Goals

In the past years and decades, many efforts have been made to increase access to healthcare on a global scale, yet even today, one in seven people will never see a single health worker in their entire lives. In fact, the crisis in human resources for health (HRH) has recently surpassed health system financing as the most serious obstacle to realizing the right to health within countries, calling for urgent upscaling and a drastic change in global priorities.

<Dominique Vervoort>

The World Health Organization (WHO) estimates that, globally, over 4 million additional health workers are needed to overcome the health workforce shortages in the 57 countries with the most critical needs. [1] However, the actual number is expected to be much higher (when including global disparities and countries with less critical shortages), with the deficits expected to rise to 12.9 million health workers by 2035. [2] In addition to the absolute shortages of healthcare providers, there is a severe imbalance in the distribution thereof between and within countries. Most healthcare workers, especially specialists, concentrate in urban areas, creating increasing challenges for rural populations to access healthcare services. As a result, one billion people worldwide will never see a healthcare worker in their entire lives, with the far majority residing in lower- and middle-income countries (LMICs), which are faced by (1) lower rates of training health workers, (2) fewer overall resources for health, and (3) brain-drain of trained health workers to high-income countries (HICs).


Today, modern globalization and resulting liberalization of markets lead to a complex health workforce migration pattern from LMICs to HICs. Moreover, the demand for healthcare is rising as a result of the large ageing population in more developed countries and the increase in the world’s population. Simultaneously, low-income countries continue to struggle with an unfinished agenda of infectious and non-communicable diseases. As a result, the HRH crisis is sustained and expected to worsen in upcoming years unless urgent measures are taken. To work towards the attainment of the Sustainable Development Goals (SDGs), health workforce and systems strengthening is needed on a global level.

 

Scaling up human resources for health is key in addressing the third Sustainable Development Goal (SDG3: Ensure healthy lives and promote wellbeing for all at all ages by 2030), especially with a focus on reducing global maternal mortality rates, neonatal and child mortality rates, reducing the number of deaths and injuries from road traffic accidents. The WHO estimates that at least 23 health workers per 10,000 population are needed to achieve the SDGs, yet 83 countries still fall under this threshold. [2] Of these, the African region has the highest burden in terms of workforce density, whereas the absolute shortages are highest in Southeast Asia, as a result of the larger population. [3]

 

Despite reduced maternal mortality rates in the past few years (with a 44% drop from 1990 to 2015), 830 women worldwide continue to die from preventable causes during childbirth every day, of which 99% occurs in the developing world and rural areas. [4] In LMICs, mortality rates are as high as 239 per 100,000 live births, whereas HICs face only 12 deaths per 100,000. As such, the SDGs aim to further reduce mortality rates to less than 70 per 100,000 live births, through adequate antenatal care, availability of skilled health workers during childbirth (including obstetricians or trained healthcare workers if a caesarean section is needed), and proper follow-up after birth.

In the developing world, only little over half of all mothers and children have access to skilled healthcare professionals during and shortly after childbirth, not only putting a mother’s health at risk, but also that of the newborn. [5] Neonatal (less than 28 days old) deaths account for 45% (2.7 million) of under-5 mortality, with 75% taking place in the first week after birth, and almost half within 24 hours. Of these, up to two-thirds could be prevented if access to skilled health workers was available, in order to prevent and limit complications (e.g., infections, asphyxia) and perform adequate health measures in the beginning of the newborn’s life (e.g., promote breastfeeding, keeping the baby warm).

 
When looking at all children under 5, approximately 5.9 million children continue to die on an annual basis worldwide, of which roughly half could be prevented through preventive or curative measures. [6] These rates are much higher in LMICs compared to HICs, with, for example, sub-Saharan Africa suffering from 14x higher child mortality rates compared to industrialized countries. Access to health workers is crucial in reducing child mortality, through proper education, prevention (e.g., vaccines), timely treatment and surgical care.


Lastly, every year, 1.25 million people die on the roads and another 20 to 50 million people remain injured or disabled as a result. Shockingly, 90% of road traffic mortality occurs in LMICs, especially the African region, despite having “only” 54% of the world’s vehicles. Road traffic injuries pose a major economic burden, not only for individuals and their families, but also for entire nations, costing them up to 3% of their gross domestic product (GDP). Although prevention and increased road safety should be the main focus in addressing these mortality and injury rates, timely access to health and surgical care is needed to adequately treat victims of road traffic crashes and limit morbidity and mortality thereof.

 
If we are to achieve the health-focused Sustainable Development Goals by 2030, emphasis should be put on human resources for health, which are a key component in improving access to healthcare and the delivery of healthcare services. With a rapidly increasing world population -especially in those countries needing improved access to healthcare the most- urgent upscaling is needed on a global level in order to prevent the human resources for health crisis to turn into an expanding global nightmare.

NB: This article was originally published in the 36th edition of Medical Students International (MSI36), the biannual online magazine of the International Federation of Medical Students’ Associations (IFMSA).

References:
1. World Health Organization. The World Health Report 2006 – Working Together for Health. 2006. Geneva: World Health Organization.
Available at http://www.who.int/whr/2006/whr06_en.pdf

2. Global Health Workforce Alliance, World Health Organization. A Universal Truth: No Health Without a Workforce. November, 2013. Geneva: World Health Organization.
Available at http://www.who.int/workforcealliance/knowledge/resources/hrhreport2013/en/

3. World Health Organization. Health Situation in South-East Asia Region 2001–2007. 2008. New
Delhi, India: World Health Organization.

4. Alkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet. 2016; 387 (10017): 462-74.

5. World Health Organization. Newborns: Reducing Mortality. 2016. Geneva: World Health Organization.
Available at http://www.who.int/mediacentre/factsheets/fs333/en/

6. World Health Organization. Children: Reducing Mortality. 2016. Geneva: World Health Organization. Available at http://www.who.int/mediacentre/factsheets/fs178/en/

7. World Health Organization. Global Status Report on Road Safety 2015. 2015. Geneva: World Health Organization. Available at http://www.who.int/violence_injury_prevention/road_safety_status/2015/en/