By Gail Rosseau, MD, Clinical Professor of Neurosurgery, George Washington University of Medicine and Health Sciences, Washington, D.C.
During the pandemic, virtual meetings have become commonplace and have even allowed medical trainees in remote parts of the world to share how the pandemic has affected their training. In this brief interview, two future neurosurgeons connect over their shared interest in Neurosurgery and Russian language.
Nathan Shlobin (nathan.shlobin@northwestern.
edu)is a first year medical student at Feinberg School of Medicine, Northwestern University, Chicago, Illinois. His interest in neurosurgery started when he realized that he wanted to pursue his interest in neuroscience while being engaged in operative care. He learned Russian as a first language, as his grandparents and parents immigrated to the United States from Ukraine and Belarus.
Manuel De Jesus Encarnacion Ramirez (dr.encarnacionramirez@gmail.
com) is a second year resident in Neurosurgery at Peoples’ Friendship University of Russia, Moscow, Russia. His interest in neurosurgery started in his native Dominican Republic, and led him to pursue a neurosurgery residency in Caracas, Venezuela. When political instability threatened his hospital, he moved to Moscow to pursue his training. He learned Russian while learning neurosurgery, and is learning to appreciate the Russian language and culture through his Russian wife and young daughter.
They were recently interviewed by Dr. Rosseau (firstname.lastname@example.org)of the World Federation of Neurosurgical Societies Global Neurosurgery Committee.
Gail Rosseau, MD, Clinical Professor of Neurosurgery, George Washington University of Medicine and Health Sciences, Washington D.C., USA
Nathan Shlobin, first year medical student at Feinberg School of Medicine, Northwestern University, Chicago, USA
Manuel de Jesus Encarnación Ramírez, second year resident in neurosurgery at Peoples’ Friendship University of Russia, Moscow, Russia
Gail: These are challenging times. The COVID-19 pandemic has necessarily focused the attention of medical professionals on the clinical care of patients, hospital workers and communities. This scourge has also disrupted medical education and residency training throughout the world.
How has the current situation affected your schooling / training?
Manuel: Our academic program has been reduced, and we only go to the hospital 3 days/ week for on-call duty,only we attend emergency surgery
Nathan: While our lectures have been moved to an online platform, we also have a reduced and incomplete academic program. Sessions for our longitudinal care care clinics were moved to telemedicine visits, which has limited my ability to practice the clinical exam. Clinical skills sessions were postponed to at least June.
What has been the largest limiting factor on your education due to the social distancing requirements?
Manuel: Suspension of all the scheduled surgeries means I am not learning how to perform elective surgery. Only emergency surgeries, such as neurotrauma(fractures,subdural and epidural hematoma, etc.) are performed. The hospital provides us with personal protective equipment
Nathan: A lack of on-site clinical exposure has limited my ability to practice skills at a young stage in my education.
What have you done to manage limitations on your education during this time?
Manuel: I am using my time to improve my neurosurgical didactic education, with online educational courses ( Neurosurgicaltv, Skullbase week. neurocirurgia.online and PNS Webinar) and increased the reading of neurosurgical texts and journals.
Nathan: I have watched the online lectures created by professors at my medical school, thought about how I would conduct patient visits, and continued to engage with my professors and classmates via the online platform. Engaging with my professors and peers has helped bring some semblance of normalcy.
What attitude are you taking to:
Manuel: Receiving online classes everyday also and increase the reading time, At the same time, every day I go to the hospital I have to be more careful, without letting fear and stress prevent me from doing my job in the best possible way, and after I leave the hospital I must go home very carefully.
Nathan: I feel fortunate that I am able to continue my education during this time because events such as these show how important physicians are. Purely online classes have not been too much of an adjustment because a lot of the curriculum was already online. I do not think that the time I have spent on school work has increased. My class schedule has changed a bit, but that has not been too much of a problem. The most difficult part of this has been engaging with my classmates in an online setting. It is easier and more natural to work together on problems or discuss cases face-to-face, but the online platform has still allowed those discussions to continue to occur.
Have you felt stress? If so, how has this changed your education?
Manuel: Yes. I feel that I must increase my hours of reading about neurosurgical topics, as well as learn everything I can about COVID-19.But also information overload creates more stress and uncertainty.
Nathan: It was a bit difficult to maintain focus at the beginning of the pandemic due to the stress of hearing about the number of people affected, and I continue to worry about loved ones. Unfortunately, this has become the new normal. We have to continue what we are doing now for the sake of our current or future patients.
What are your expectations about how this will change your education post-quarantine?
Manuel: The academic year will be prolonged. We don’t know if students and residents will graduate on time. There will be a post-quarantine period of uncertainty in health care and education.
Nathan: In the short term, the start and end dates of our academic year might get shifted. In the long term, it is difficult to say. Many of my classes were already pre-recorded and placed online or placed online after lecture prior to quarantine.
Gail: You both have said that you expect that your training will continue to include much more virtual learning in the future. Medical educators are predicting significant changes to medical school and residency curricula that will reflect lessons learned from the profound increase in online learning necessitated by social distancing.
What are your suggestions for other trainees during this time?
Manuel: I have found online educational resources to be very useful. For residents who have operating loupes, they can practice microsurgical techniques, like suturing, at home.
Nathan: It is particularly important that you continue your education, perhaps now more than ever. Stay connected with your friends and family. Even though we cannot be with some of them in person, it is important to support each other. And if you are struggling mentally, that is ok. There are resources to help us get through this safely, with our physical and mental health intact. It is a difficult time, and we are united to help each other through this.
What can faculty do to support you?
Manuel: A suggested reading list or other learning guides from faculty would be helpful, as well as continuing departmental educational conferences via online platforms.
Nathan: Instructors should assess our needs and work closely with us. Fortunately, administrators in the office of medical education at my medical school have been very helpful. They send out a weekly email detailing any updates they have to share with us and have been responsive to student concerns.
Map of path from Chicago to Moscow
Aswan Tai (Junior Doctor, Royal Melbourne Hospital, Australia)
Tim Hall (Trainee Intern, Auckland City Hospital, New Zealand)
Global Surgery Day (May 25th) aims to spread awareness and recognition regarding the inequity in surgical access and outcomes for patients around the world. Access to health care can be defined as ‘the timely use of personal health services to achieve the best health outcomes’.1 It is a basic human right and is critical for public health, safety and economic security, which may not be provided by some countries around the world.
It is estimated that over 5 billion people worldwide lack basic access to safe surgical care, resulting in around 17 million preventable deaths each year and further responsible for ~30% of the global burden of disease.2 Moreover, the landmark Lancet Commission on Global Surgery reported that at least 4.2 million people worldwide die within 30 days of surgery every year making post-operative deaths the third leading cause of mortality (see figure below).3
Universal health coverage (UHC) has been set as an umbrella target for key global health objectives in the post-2015 Millennium Development Goal framework.4 Without the presence of surgical, obstetric, and anaesthesia care as part of Universal Health Coverage (UHC) commitments, we will never achieve quality and safe health care for all. Surgical care has been an essential component of health care worldwide for over a century. As the incidence of traumatic injuries, cancers and cardiovascular disease continue to rise, the impact of surgical intervention on public health systems will continue to grow.
Recently, the 72nd World Health Assembly (WHA) was held in Geneva and focused on the theme ‘Universal Health Coverage: Leaving No-One Behind’. Global Surgery is and should be a significant component of the health care system in every country and the importance of it has been emphasized in the WHA72 progress report.5
Although significant developments have been made in certain areas, it is vital that safe and affordable surgical, obstetric, and anaesthesia treatment remains a global priority. InciSioN hopes that through continued research, advocacy, and educational efforts we can unite and foster an international community of future healthcare professionals who are passionate about Global Surgery and motivated to help achieve timely access and safe surgical care to everyone, everywhere, by 2030.
 Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to Health Care in America. Millman M, editor. Washington, DC: National Academies Press; 1993.
 Meara JG, Leather AJM, Hagander L, et al. (2015). Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386(9993):569-624.
 Nepogodiev D, Martin J, Biccard B, Makupe A, Bhangu A, on behalf of the National Institute for Health Research Global health Research Unit on Global Surgery. (2019). Global burden of post-operative death. Lancet 393(10170):401.
 Vega J (2013). Universal health coverage: the post-2015 development agenda. Lancet 381(9862):179-80.
11 April – The International Maternal Health and Rights Day
Written by: Pokam Feunou Ornella and Rebecca Mwambegele under supervision by Aswan Tai, InciSioN Education team, 2019.
Every mother every child: our future
Every child comes from a mother, and every mother was once a child. Maternal health is the peak of a reliable health system, and with proper care results in a better health outcome.
Surprisingly enough, while 62% of women worldwide receive at least four antenatal care visits worldwide, the rates are much lower in regions with the highest rates of maternal mortality, with urban women far more likely to receive antenatal care than their counterparts (1). Antenatal care should include identification of pre-existing health conditions, early detection of complications arising during pregnancy, health promotion and disease prevention as well as birth preparedness and complication planning (2). In South Asia for example, 46% of women receive the recommended antenatal health care visits (1). This means that 5 in 10 women do not, and inadvertently, might result into having birth complications which would have been avoidable.
More to that, access to healthcare for mothers is a key health determinant and is still a big challenge for many low- and middle-income countries. This pitfall has also contributed to increasing maternal mortality as portrayed in Cameroon where in 2016, a 31-year-old mother of twins arriving with labour complications at a public hospital was denied care for hours because she could not afford treatment which precipitated the death of her and her twins (3). There is no excuse for this act and it is impossible to think of her death as a mere medical accident.
Denying care to pregnant women because they cannot afford their medical bills may contribute to increasing maternal death and consequently neonatal death as seen in the above scenario. For every pregnant mother we must consider two lives and we must protect the dignity of human lives. The aforementioned also reflects obstetrics violation. Obstetric violence is a Human Rights violation, as WHO (4) expresses in its statement “The prevention and elimination of disrespect and abuse during facility-based childbirth”.
Another major and unfair situation contributing to maternal death is unsafe abortion. The WHO defines unsafe abortion as a procedure for terminating a pregnancy that is performed by an individual lacking the necessary skills, or in an environment without the minimal medical standards, or both conditions (5). Approximately 50% of all abortions performed around the world are unsafe, and this proportion has increased in the past decades. This account for 8% of all maternal death worldwide; at least 22800 women die each year between 2010-2014 from complications of unsafe abortion, reported by Guttmacher (6).
A big gap in mortality rate is also seen between first and third world countries. The maternal mortality ratio in developing countries in 2015 is 239 per 100 000 live births versus 12 per 100 000 live births in developed countries. About 830 women die from pregnancy- or childbirth-related complications around the world every day. It was estimated that in 2015, roughly 303 000 women died during and following pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented (7). However, that is about to change as more governments reevaluating their decisions and prioritizing maternal health care, and the construction of multiple BEMOC (Basic Emergency Obstetric Care Centers). With countries such as Tanzania creating strategic health plans to make sure these plans are implemented (8), provision of mobile health technology in Ghana (9), removal of user fees in Lesotho (10) and mobile health interventions (11), a better future is guaranteed.
As InciSioN, our major focus is in creating a safe space where students can contribute to matters such as this. We firmly believe that better maternal health care will be a great starting point in creating better health care. We support all efforts being done to promote maternal health care worldwide, and are looking forward to work together with all major stakeholders in achieving better health for all.
We acknowledge that the young population is at a higher risk for complications and death as a result of pregnancy than other women. We also consider 3 obstetric delays; delay in seeking care, delay in accessing care and delay in receiving care to address maternal mortality thus advocate for better healthcare before, during and even after the pregnancy to safeguard both the mother’s and child’s health. This does not necessarily have to be limited to hospitals but more of extended programs to reach the community at large, including seminars and in-school projects.
All women should have full access and autonomy over the range of their reproductive and sexual rights, including safe obstetric care, safe abortion, access to family planning. These services should be affordable, legal and free of stigma and discrimination yet we see that many countries especially LICs (low income countries) have not put this to reality.
And this is why we believe advocating and increasing awareness on this matter can make the quantum leap we desire with mitigating maternal mortality in LICs. Beginning from educating the healthcare personnel ranging from midwifery, nurses, nursing students, medical students, general practitioner on valuing a mother health and the child and understanding importance of humanized birth and empowering women during pregnancy. Humanized birth is putting the woman giving birth in the center taking into account cultural, social and ethnicity aspects, thus it is not limited to technical skills and the birth.
We would also like to advocate for proper mental health support through the pregnancy, as well as encourage them to attend clinics on agreed dates, stressing on why proper clinic attendance is important for both her health and the baby’s. Not forgetting encouraging community and hospital access to family planning services, counselling on abortion implications for every sexually active woman with no stigma and discrimination of age, religion, marital status and others. This is in line with the fact that we strongly believe every woman has a sexual and reproductive health right that is to choose when and how to reproduce and to prepare physically socially and mentally for it, hence promoting health of a woman.
As it is the 21st century, it is our desire that no more women die because of trying to bring a new life. #no death for life, we are at a position where we don’t have to see things get much worse before we decide to do better. We support any and all legal efforts that target promoting maternal healthcare worldwide and we hope that tomorrow, a different story will be told.
- Antenatal care – UNICEF DATA [Internet]. [cited 2019 Apr 4]. Available from: https://data.unicef.org/topic/maternal-health/antenatal-care/
- Number of facilities per 500,00 providing basic and comprehensive emergency obstetric care — MEASURE Evaluation [Internet]. [cited 2019 Apr 4]. Available from: https://www.measureevaluation.org/prh/rh_indicators/womens-health/sm/number-of-facilities-per-500-00-providing-basic
- Nehsuh Carine Alongifor, Women Deliver Young Leader, Maternal Mortality in Cameroon: An Urgent Need for Action, April 4, 2016. Available at https://womendeliver.org/2016/maternal-mortality-in-cameroon-an-urgent-need-for-action/
- World Health Organization. The prevention and elimination of disrespect and abuse during facility-based childbirth, 2014. Available from:http://apps.who.int/iris/bitstream/10665/134588/1/WHO_RHR_14.23_eng.pdf?ua=1&ua=
- World Health Organization, Safe abortion: technical and policy guidance for health systems – 2nd ed., 2012. Available from:http://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf;jsessionid=C1CCA6FFD1BE18DD3F4B2E2D50A775E3?sequence=1, accessed on December 2nd, 2018.
- Guttmacher Institute, Factsheets/ Induced Abortion Worldwide, Global incidence and trends. March 2018, Available from:https://www.guttmacher.org/fact-sheet/induced-abortion-worldwide
- 7. World Health Organization, News/Fact sheets/Detail/Maternal mortality. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
- 8. United Republic of Tanzania Ministry of Health and Social Welfare. The National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania [Internet]. 2008 [cited 2019 Apr 4]. Available from: https://www.who.int/pmnch/countries/tanzaniamapstrategic.pdf
- Laar AS, Bekyieriya E, Isang S, Baguune B. Assessment of mobile health technology for maternal and child health services in rural Upper West Region of Ghana. Public Health [Internet]. W.B. Saunders; 2019 Mar 1 [cited 2019 Apr 4]; 168:1–8. Available from: https://www.sciencedirect.com/science/article/pii/S0033350618303731
- 10. Steele SJ, Sugianto H, Baglione Q, Sedlimaier S, Niyibizi AA, Duncan K, et al. Removal of user fees and system strengthening improves access to maternity care, reducing neonatal mortality in a district hospital in Lesotho. Trop Med Int Heal [Internet]. John Wiley & Sons, Ltd (10.1111); 2019 Jan 1 [cited 2019 Apr 4];24(1):2–10. Available from: http://doi.wiley.com/10.1111/tmi.13175
- 11. Dol J, Campbell-Yeo M, Tomblin Murphy G, Aston M, McMillan D, Richardson B. Impact of mobile health interventions during the perinatal period for mothers in low- and middle-income countries. JBI Database Syst Rev Implement Reports [Internet]. 2019 Feb [cited 2019 Apr 4];17(2):137–46. Available from: http://insights.ovid.com/crossref?an=01938924-201902000-00003
Written by Ioanna Dimasi MBBS, MSc
Women face discrimination and obstacles when pursuing a career, specifically in male dominated jobs such as surgery. The reasons why women might not choose a surgical specialty in the first place or make the conscious decision to drop out (Forel et al., 2018), is multifactorial in origin. There are many additional obstacles women have to face compared to their male colleagues. Starting with the more obvious societal stereotypical pressures to being the recipients of sexism and abuse in their workplace (Wirtzfeld, 2009). In a lot of cultures women are expected to stay at home or do a job that will allow them to care for their children, however, a surgical job is demanding, with long operating hours and on calls. Women do not get enough support; from home and/or work, and frequently resort to quitting.
Moreover, women are expected to be childbearing at some point during their careers, which results in them having to take time out of their training or their work, which can delay or hinder their progression. Women in surgery also tend to be perceived as less competent compared to the their male colleagues. Despite this, research has shown that if women are given equal opportunities and support they can be as successful in surgical training (Thomas, 2006) (Pico et al., 2010).
Many things need to change in order to see a shift in the number of women that pursue a surgical specialty and those that remain within it. In order to achieve this we need to:
I “Identify” the reasons why women are facing these obstacles
N “Necessitate” taking actions towards changing these problems
C “Cultivate” an environment where women can feel safe and can equally reach their potential
I “Indicate” different ways we can achieve these changes
S “Support” women through their surgical pathway
I “I” Change starts with ourselves. We need to make it our problem
O “Offer” our help to all women and especially the ones that struggle the most
N “Nurture” confidence in women
InciSion will continue to support all females globally that are striving to pursue a career in surgery or those that are already in training. We stand by your side every step of the way. Our purpose is to ensure equal opportunities are given to women in surgery. Supporting them in their pursuits and equipping them with leadership skills in order to deal with the difficulties and pressures they face in their working environment. There are a lot of female surgical role models and in the recent years women in surgery are coming together to show to their female junior colleagues that they have a support network. By working and empowering women, we aim to achieve equality within our operating theatres.
FOREL, D., VANDEPEER, M., DUNCAN, J., TIVEY, D. R. & TOBIN, S. A. 2018. Leaving surgical training: some of the reasons are in surgery. ANZ journal of surgery, 88, 402-407.
PICO, K., GIOE, T. J., VANHEEST, A. & TATMAN, P. J. 2010. Do men outperform women during orthopaedic residency training? Clin Orthop Relat Res, 468, 1804-8.
THOMAS, W. E. 2006. Teaching and assessing surgical competence. Ann R Coll Surg Engl, 88, 429-32.
WIRTZFELD, D. A. 2009. The history of women in surgery. Can J Surg, 52, 317-320.
INNOVATION IN GLOBAL SURGERY
Remarkable social and economic developments that have been attained in the last decades have engendered novel challenges in global healthcare. Nowadays, the scientists and professionals have to think of finding more comprehensive methods in order to bring new solutions that would make a progress for the improvement of life in the future. This essential need to improve the quality of life of global citizens has brought together medical and non-medical professionals from all around the world with the aim to emphasize the importance of improving surgical-care by defining key messages, indicators and recommendations for advancing Global Surgery. The next challenge has been setting priorities of Global Surgery, and this could have not been possible without an innovative approach because innovation is the key solution to new challenges as it comprises creation of something new and accomplishing the essential needs.
The importance of innovation in Global Surgery can be easier understood if we focus on the aim of Global Surgery to provide safe and affordable surgical care as part of universal health coverage (UHC). Innovation is a very important component towards creation of potential strategies for scale-up of Global Surgery through integration of information and communication technology as it promotes new learning methods, delivery of care, management schemes that contribute to the improvement of healthcare arrangements and governance, economics and finances and implementation strategies. Consequently, there is an inevitable need for cooperation between Global Surgery institutions and those of innovation as both of them aim to improve the quality of life. Moreover, innovation institutions/centers are very welcoming places that encourage inter-disciplinary collaboration; thus, integration of innovative centers in the strategy of Global Surgery paves the way towards advancing the actual situation of UHC.
Once we understand the importance of integrating innovation in Global Surgery, we will be able to determine the innovative mechanisms that will enable us to overcome the obstacles of global healthcare. Global Surgery workers will be able to integrate innovation in Global Surgery only when they understand that both of the abovementioned fields share a common goal. On the other hand, it is important to understand that innovation should always be perceived as a solution and not only as an option for achieving UHC and this can be possible only if we incorporate innovation as a core component of our ideas and thoughts since the beginning. Innovative approaches help us achieve a long-term sustainability in the field of Global Surgery, especially if we develop it within four domains of global surgery that are health-care delivery and management; workforce, training, and education; economics and ﬁnance; and information management.
Based on these principles, our InciSioN branch in Kosovo GSOK-Students’ Committee organized its first session together with Innovation Centre Kosovo (ICK). The organization of the meeting of our global surgery enthusiasts in an innovative center has encouraged quality of discussion within attendees and has increased the interest of other students to join our committee as well. The renowned ICK has built a great reputation in Kosovo for supporting new ideas through innovation and technology, and this great reason has inspired us to organize our first meeting with ICK as their work has been very inspirational to us as it resonated with the vision and mission of our students’ committee. The experience of collaboration with ICK has been unique as it offered us the chance to understand that innovation centers are willing to support Global Surgery.
Therefore, we highly recommend every National Working Group on Global Surgery to follow our example and contact their nearest innovation centers and think of including innovation as part of their strategy because inclusiveness is definitely the right path towards achieving our goals of universal health coverage by 2030.
Head of GSOK – Students’ Committee
By Anisa Nazir
The Global Neurosurgery symposium was held on January 18th and 19th at the Weill Cornell Medical School in New York City, USA, attended by representatives from 5 continents. Dr. Walt Johnson from WHO Emergency and Essential Surgery led the keynote, speaking about the role of neurosurgery in global surgery, the progress it has made over the years and the dire need for surgical commitments.
Throughout the meeting, there were captivating discussions about different challenges encountered, progress made, and most importantly, what still needs to address. The presenters focused on advocacy, resolution development, service delivery and accessible health systems. Various examples of current programs included the development of neurosurgical services available in Tanzania, evaluations with a focus on formal training programs in Hanoi, Vietnam, as well as the use of new diagnostic technology to diagnose life-threatening neurosurgical conditions. Specifically, studies commented on the global burden of neurosurgical conditions including stroke, traumatic brain injury, and pediatric conditions such as hydrocephalus. On a larger scale, conversation leaned towards the importance of national and regional strategic planning and its implementation in lower and middle-income countries.
The InciSioN delegation was in attendance with 14 students and represented the student and trainee perspective on global neurosurgery. Sara Venturini (InciSioN-UK) presented her and her team’s research on the effects of legislation on helmet use in Cambodia, emphasizing the importance of local buy-in as well as policy-making for impactful change in communities.
From Bogota to Kigali to Rostock, this early December has been full of surprises!
On December 2nd, InciSioN was present at the BVMD (german medical student’s association) Bundeskongress in Rostock, Germany where our member Emina Letic, who is the chair of InciSioN Bosnia and Herzegovina, conducted a workshop to introduce Global Surgery to medical students attending the congress. The workshop was a success and more global surgery events will happen in Germany in 2019, we will keep you posted!
Emina Letic with german medical students
On December 7th and 8th, InciSioN Rwanda organised a surgical hackathon at the University of Rwanda, with the support of the Harvard Program in Global Surgery and Social Change. During those 2 days, medical students and young doctors worked in teams on challenging healthcare problems and tried to come up with innovative solutions while having fun!
InciSioN Rwanda team with Dr Claire Karekezi
Then, our Rwandese members were invited to attend the College of Surgeons of East Central and Southern Africa (COSECA) Meeting that was held this year in Kigali. It was an inspiring experience for them to meet with colleagues and senior surgeons from the continent and beyond.
At the same time, in Colombia, our newly established InciSioN Colombia led by Angelica Clavijo were organising their first global surgery conference. They had national and visiting speakers and had the chance to cover a wide range of topics from National Surgical Plans to Obstetrical care in the context of Global Surgery.
InciSioN Colombia with speakers
Do you also want to engage in InciSioN activities? We have a couple of opportunities for you coming up this December. First, do not miss the abstract submission deadline for our next InciSioN Global Surgery Symposium IGSS2019 that will be held in Kigali on April 20th and 21st, 2019. Second, please join us on December 12th online to celebrate Universal Health Coverage Day and use the hashtag #SurgeryUHC. And last but not least, on December 16th we are opening the call to recruit the InciSioN international team for 2019. Stay tuned on our facebook page and don’t hesitate to apply. We are waiting for you!
By Dylan Goh
The Astana declaration, from Alma-Ata towards universal health coverage and the sustainable development goals, was adopted on the 25th of October, following from the original declaration of Alma Ata 40 years ago (1978). This declaration reaffirmed the international community’s goal of providing Universal Healthcare Coverage (UHC) for all, with primary healthcare (PHC) serving a fundamental role in achieving UHC. Health and well-being of the population should be achieved through a combination of primary care and essential public health as core health services, addressing broader determinants of health through better policy across all sectors and the empowerment of communities. (1)
Drawing up on the experiences from the Alma Ata declaration, the new declaration describes PHC composed of three different components. First by meeting people’s health needs through a healthcare system with primary care and public health at its core to deliver comprehensive healthcare that is promotive, protective, preventative, curative, rehabilitative and palliative provided over the lifetime of individuals and family within populations. Secondly, the declaration calls for multisectoral collaboration and evidence-based policy to systemically address the broader determinants of health (social, economic, environmental, including individual characteristics and behaviour). Lastly, the final component includes the empowerment of individuals, families and communities to optimize their health, being advocates for factors that contribute to better health and well-being, to co-develop health and social services and finally as self-carers and caregivers. (2) Ted Chaiban summed this up perfectly during the Astana declaration calling for a healthcare system that is “people-centered, population-focused, integrated, coordinated, continuous, accountable, participative, evidence based, and technology enabled.”
WHO describes its reasons behind the push for PHC at the core of health systems. PHC allows for health systems to adapt and respond to the health challenges of the world. Placing the population at its center allows greater efficiency and better division of resources and creates a robust health system that is able to face future threats to the health of the system. It is also essential to keep in mind that even though primary care is central to PHC, that PHC should also include other stakeholders that may contribute to or take away from health. Studies have also shown the impact that non-health interventions have on the general population, signifying the importance of a focus outside of healthcare as well. (2)
Throughout the conference, many leaders of their countries describe the steps that they have taken towards UHC, including the various examples on the empowerment of the populations such as in Argentina, and Indonesia where policies have allowed for the responsibilities of the care of populations to be decentralized and placed on the populations themselves. Similarly, in Brazil and Namibia, community health teams have been assigned the role of taking care of the health of a defined community.
Although PHC is essential in achieving UHC, there are limitations in what it can do; the role of surgery is irreplaceable and essential to achieve well-rounded and complete healthcare. It is important make the case for surgery within UHC. Essential surgeries, defined as surgical intervention for neoplasms, injury, neonatal and obstetric care and gastric surgery, also contribute to the provision of UHC. The Lancet Commission on Global Surgery 2030 has illustrated the lack of surgical access- 5 billion people in the world lack access to safe surgical care, with 143 million additional surgical procedures required to save lives and prevent disability. Financially, more than 33 million individuals face catastrophic financial spending due to surgical costs. Surgery is an irreplaceable component of healthcare and similar to healthcare, investment in healthcare can yield potential financial gains from reduced financial losses. (3)
InciSioN supports the Astana declaration and the need for quality and affordable healthcare for all. However, we also call for the integration of essential surgical services within PHC through both the better access to surgical care and task sharing and task shifting of aspects of surgery. (4,5) Going back to the definition of UHC, surgery often acts in preventative, curative and sometimes palliative health services. Surgery an indivisible part of healthcare, and to achieve the vision of UHC by 2030, the inclusion of surgery is required.
- WHO, UNICEF (2018). Declaration of Astana- from Alma-Ata towards universal health coverage and the sustainable development goals. Kazakhstan.
- A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2018 (WHO/HIS/SDS/2018.X). Licence: CC BY-NC-SA 3.0 IGO
- Meara, J., Leather, A., Hagander, L., Alkire, B., Alonso, N., Ameh, E., Bickler, S., Conteh, L., Dare, A., Davies, J., Mérisier, E., El-Halabi, S., Farmer, P., Gawande, A., Gillies, R., Greenberg, S., Grimes, C., Gruen, R., Ismail, E., Kamara, T., Lavy, C., Lundeg, G., Mkandawire, N., Raykar, N., Riesel, J., Rodas, E., Rose, J., Roy, N., Shrime, M., Sullivan, R., Verguet, S., Watters, D., Weiser, T., Wilson, I., Yamey, G. and Yip, W. (2015). Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet, 386(9993), pp.569-624.
- Pongsakul, A., Valle, Y., Chia, Y., Ndajiwo, A. and Chen, J. (2018). Surgery, rural health and primary healthcare. InciSioN- International Surgical Students Network.
- World Health Organisation. World Health Report 2008: Primary Health Care (Now more than ever). Available at: http://www.who.int/whr/2008/en/
Article by Ulrick S. Kanmounye email: email@example.com
Group picture of Congolese physician anaesthesiologists and non-physician anaesthesiology technicians
Concepts of task-sharing and task-shifting in Congolese anaesthesiology date back to the early 1960s. These were implemented since the post-colonial period in order to solve the shortage of physician anaesthesiologists. As such, this non-physician workforce either works in collaboration with physician anaesthesiologists when the former are available or have complete autonomy when physician anaesthesiologists are not present. In most francophone countries, these healthcare staff are known as “State Registered Anaesthetic Nurses” or “Infirmiers Anesthésistes Diplomés d’Etat – IADE” in French. However, it is important to note that while in most francophone countries this appellation has evolved from that of “Anaesthesia and Resuscitation Technician” (Technicien Anesthésiste Réanimateur – TAR), this body is still known as TAR in the Democratic Republic of Congo (DRC).
Prior to the colonial period, the Congolese population went to traditional doctors for matters of health, finance, religion and bad luck. However, on their arrival, the colonial masters banned the practice of traditional medicine which was thought to be a pagan practice. As a result, most traditional doctors went into hiding and their patients went on to seek care from the colonial doctors. Later on during the early sixties, the balance of power was redefined as the country achieved independence. It is during this period that the first TARs were trained by American and Swiss physicians at the Kinshasa Provincial and Regional Hospital (known then as Mama Yemo), the Kinoise Clinic (known then as the Danish Clinic) and Kintambo Reference Hospital.
Back then, these TARs were trained for a year and they earned a certification known as “Capacité”. This contrasts with the three and five year courses that are currently available nationwide to future TARs giving them the titles of “Gradué” and “Licencié” respectively. In the Congolese higher education system, “Graduat” is the equivalent of a Bachelor while “Licence” is the equivalent of a Masters. The wide availability and popularity of these courses has helped the growth of this workforce and as a result, as of 2018 we register 656 gradués and 46 licenciés. In 2017, 729 TARs were registered by the Society of TARs in the DRC with a mean age of 50 years, 35% of TARs were female and 54% of TARs worked in the private sector. Despite this apparently encouraging figures, half of the regions in the DRC do not have TARs whereas Kinshasa alone has more than 500 TARs.
On the other hand, the medical workforce’s evolution has been different. Less than a decade after independence, the first Congolese Anaesthesiologists were trained at the Department of Anaesthesiology of the Kinshasa University Clinic. Since it was created, the Department has had four Department Heads: first was Dr Gribomont (Belgium), then Dr Fares (Egypt), followed by late Pr Nathalis Bele (DRC) and finally Pr Kilembe Manzanza (DRC). Together, they have trained and are training a total of 109 doctors (34 anaesthesiologists, 40 senior residents and 35 junior residents). Sadly, the female gender makes up just 28 of the 109 doctors, the number of residents keeps rising each year and the Department is still the only training site nationwide.
To make matters worse, there are only five of the 26 provinces of the DRC that have anaesthesiologists, 13 anaesthesiologists have immigrated abroad, and Pr Kilembe remains the only professor of anaesthesiology in the DRC. In order to solve some of these problems, the Department decided to create an entrance examination into its residency programme and to send their senior residents to other hospitals in the capital city that have senior anaesthesiologists and an important workload. These decisions have helped control the number of admissions into the residency programme and increase the work experience of senior residents respectively. Finally, the Faculty of Medicine of the University of Kinshasa and the Congolese Society of Anaesthesiology and Resuscitation, have decided to support the professorships of five candidates at the Malagasy and African Higher Education Council – CAMES (Conseil Africain et Malgache d’Enseignement Supérieur) by 2023.
Dr Wilfrid Mbombo (far right and standing), President of the Congolese Society of Anaesthesiology and Resuscitation at the 4th Congress of the society
In conclusion, despite the long history and experience of task-sharing in the field of anaesthesiology in the DRC there are still many patients that do not have access to anaesthesiologists and non-physician anaesthesiology technicians. One of the main problems is the uneven distribution of the anaesthetic workforce. If we want to achieve the global surgery, obstetrics and anaesthesia objectives set by 2030, we need to encourage anaesthesiology staff to relocate in other regions than Kinshasa. In the same vein, if we want to increase the anaesthetic workforce, we need to stop the brain drain from the DRC and to encourage those that are abroad to come back home.
NEUROSURGERY IN THE DEMOCRATIC REPUBLIC OF CONGO: PAST, PRESENT AND FUTURE
Article by Ulrick S. Kanmounye email: firstname.lastname@example.org
According to the Lancet Commission on Global Surgery, more than two thirds of the global population do not have access to safe and affordable surgical care and most of them live in Low and Middle Income Countries (LMIC). There are many reasons that explain this: first, patients from these regions lack geographical and financial access to specialist surgeries. Secondly, surgeons in LMIC do not have access to equipment necessary to practise complex surgery. A typical LMIC example that illustrates this is the Democratic Republic of Congo (DRC). The DRC is a central African country with a population of 77.8 million people of whom 50 million earn less than $ 1.90, no universal health coverage system, a surface area of 2,3 million square kilometers and a low surgical workforce. All of these factors make it difficult to financially and physically cover most regions. This is especially true for neurosurgery as the neurosurgical workforce is made up of 16 surgeons: of which 7 are locally based neurosurgeons, 4 are neurosurgeons based abroad and 5 are general surgeons dedicated to neurosurgical practice. This has not always been the case. In fact, up until 10 years ago there was only 1 neurosurgeon in the DRC.
Members of the Congolese Neurosurgical Society
The history of Congolese neurosurgery dates back to 1979 with the return to the DRC of late Pr Shako Djunga after he had completed training in the United States and in Belgium. From the time he returned in 1979 to 1983, Pr Shako took Dr Antoine Beltchika then a general surgeon, under his wing. Later on, from 1983 to 1987 Dr Beltchika went to Toulouse, France where he was a resident under Pr Yves Lasorte. When Dr Beltchika returned, he practised at the Kinshasa University Hospital and at the Neuro-psychopathologic Centre. From 1987 to 2008, Dr Beltchika, current president of the Congolese Neurosurgical Society, served as the only neurosurgeon nationwide. During this time, he would receive help from diasporan neurosurgeons – Pr Kalangu Kazadi (Zimbabwe) and Pr Jean-Pierre Kalala (Belgium). Between 2008 and 2013, the surgical workforce gained a helping hand when late Dr Mudjir Didier set up practice at the Ngaliema Clinic. Since 2010, there have been 6 new neurosurgeons: Pr Glennie Ntsambi, Dr Jeff Ntalaja, Dr Charles Kashungulu, Dr Safari Mudekereza, Dr Trésor Ngamasata and Dr Adalbert Shweka. In addition to these six, two more diasporan neurosurgeons have been lending a helping hand to their homebased counterparts – Dr Orphée Makiese (France) and Dr Lubansu (Belgium). Finally, in the next three to six years, there will be a total of 9 new Congolese neurosurgeons. These future neurosurgeons are currently in neurosurgery residency programmes in Zimbabwe, Morocco, Senegal, Brasil and South Africa.
Given the rapidly growing workforce and the numerous problems they faced, Congolese neurosurgeons decided in 2015 to create the Congolese Neurosurgical Society (SCNC). The SCNC has been working to provide global neurosurgery in the DRC by advocating for the training of neurosurgeons, advancement of neurosurgical research and the treatment of neurosurgical patients indiscriminate of their social status or geographical location. In order to cover the neurosurgical demand, the SCNC decided to divide the country into 4 neurosurgical zones with headquarters in Kisangani (North), Lubumbashi (South), Kinshasa (West) and Bukavu (East). The most active zone is currently in the west where the capital of the DRC, Kinshasa, is located. This is because the western zone has more than half of the SCNC’s workforce, two major public hospitals (Kinshasa University Clinic and Ngaliema Clinic) and better equipment including: microsurgical equipment, clips, Mayfield skull clamps, and hypophyseal surgery equipment. With this new equipment, the SCNC has increased the scope and number of neurosurgical interventions across all subspecialty fields. While most of this equipment is currently at the Ngaliema Clinic, the SCNC has planned to equip each zone equally.
Neurosurgical Zones of the Democratic Republic of Congo
In the future, the SCNC hopes to offer advanced techniques (skull and spine neuronavigation, scoliosis surgery, ultrasonic surgical aspiration, functional neurosurgery…) and to increase the number of neurosurgeons locally. Unfortunately, very few medical students have picked up neurosurgery because till date, those aspiring to become neurosurgeons have to be trained abroad which usually implies high costs and separation from loved ones. Another deterrent has been the lack of neurosurgical equipment in most facilities. Fortunately, most of these issues are been solved by the World Federation of Neurosurgical Societies (WFNS), the Continental Association of African Neurosurgical Societies, the SCNC and other partners. For example, they have made it possible to train future neurosurgeons on scholarships in Morocco and China with a clause stating that on completion of their training, neurosurgeons have to return home. Also, the WFNS has helped the SCNC in the acquisition of most of its current and future equipment.
Clipping of an aneurysm at the Ngaliema Clinic by a Moroccan and two Congolese neurosurgeons