Neurosurgery in the Democratic Republic of Congo: Past, Present, and Future

NEUROSURGERY IN THE DEMOCRATIC REPUBLIC OF CONGO: PAST, PRESENT AND FUTURE

Article by Ulrick S. Kanmounye email: ulricksidney@gmail.com

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

Surgical Suturing, the Checklist and more Friendships

< Adnan Šabić (National Officer on Medical Education of BoHEMSA, IFMSA), Haris Čampara (InciSioN B&H Head of Research), Ajla Hamidović (InciSioN B&H Head of Advocacy), Ahmed Mulać (InciSioN B&H member), Emina Letić (InciSioN B&H Chair) >

Suturing is one of the most used surgical procedures in the world, utilized even in non-surgical fields such as general practice. As such, it is an integral part of wound processing, which has to be methodical in order to avoid infections and reduce scarring.
In settings where healthcare professionals are not trained correctly for suturing or don’t have the necessary material, patient’s care is severely affected. The importance of learning the suturing skills is vital to all doctors whether they are going to become surgeons or not.

The “Surgical Suturing Course” was held for the first time on July, 19th, 2018  at the Faculty of Medicine of Sarajevo for students who were on an exchange (visiting students). The main objective of this project was to enable students to adequately cover all forms of wounds. Our SCOME course was realized with the help of the Department of Surgery and more specifically Dr Zlatan Zvizdić, Dr Amel Hažimehmedagić and Dr Bekir Rovčanin. The workshop was in two parts, the first part was a lecture on surgical suturing techniques – Wound, healing, suturing materials, surgical skills; given by student Rusmir Gadžo, and the second part was practical and taught students how to make surgical nodes and properly place various sutures.

Then, InciSioN B&H presented the WHO Surgical Safety Checklist to the students explaining why and how it was developed and the results of the studies which confirmed its helpfulness in the operating room. Also we presented the work of Dr. Atul Gawande (one of the founders of The Checklist) and his book, The Checklist Manifesto.

At the end of the workshop, students understood that although surgical skills are necessary for treating patients, other tools can improve patient’s outcomes and the Cheklist is a perfect example.

“The volume and complexity of knowledge today has exceeded our ability as individuals to properly deliver it to people—consistently, correctly, safely. We train longer, specialize more, use ever-advancing technologies, and still we fail” Dr. Atul Gawande in The Checklist Manifesto.

The power of the Checklist lies in enhancing and improving the communication between the members of a surgical team gathering all their abilities and knowledge to serve the patient. It brings the team together and encourages them to develop closer relationships, confidence in each other and friendships. Similarly, from now on, whenever they see a Checklist, all participants of the workshop will remember this day they spent in Sarajevo and the people they met confirming once more that the Checklist brings people together.

 

 

 

Global Surgery Day 2018

The fourth edition of Global Surgery Day on May, 25th 2018 has come to an end: a dynamic day with screaming voices around the world, a day on which access to safe surgical and anaesthesia care takes center stage, with hopes of making it an unquestionable option for everyone, everywhere, at any time of the year.

<Dominique Vervoort>

Global Surgery Day was founded by InciSioN in 2015 on May, 25th, around the passing of the Resolution WHA68.15 “Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage” to fill the lack of a global awareness day for surgery. Today, Global Surgery Day is supported by the entire Global Surgery community, uniting voices to bring access to safe surgical, anaesthesia, and obstetric care to the 5 billion people without.

After two online campaigns in 2015 and 2016, expanded with in-person events in 2017 through screenings of Lifebox’ documentary The Checklist Effect, directed by Lauren Anders Brown, and a co-hosted side-event at the 70th World Health Assembly together with the WFSA, Lifebox, Operation Smile, and the G4 Alliance, the 2018 edition set the goal of continued expansion.

Banner for Global Surgery Day 2017, highlighting the collaboration with Lifebox to translate The Checklist Effect first in 7 and now 11 different languages.

Themed “Equity in Surgery”, Global Surgery Day 2018 made its way to all corners of the world, kicking off in Melbourne, Australia, with the launch of the InciSioN National Working Group for Australia and New Zealand, through a Global Surgery Film Night supported by local faculty. A few hours later, InciSioN Somaliland launched in Somaliland with an inaugural symposium with local and visiting specialists talking about surgical and maternal care in the country. As the clock ticked on, social media was tackled by messages in 8 different languages synchronized with relevant timezones for maximal impact, whilst concurrently targeting attendees of the 71st World Health Assembly.

In Norway, the Norwegian University of Science and Technology (NTNU) in Trondheim advocated for Global Surgery Day at the forefront of a budding Norwegian National Working Group, whereas InciSioN Rwanda was committed to raise their voices for bringing equity into surgery. In the meantime, InciSioN Bosnia & Herzegovina kicked off their new National Working Group through a successful opening symposium attracting students and faculty from across the country to address disparities in accessing surgical care in Bosnia & Herzegovina.

Twitter did not stop with mere messaging, however, as the #EquityInSurgery Twitter Chat by InciSioN in collaboration with the G4 Alliance, the WFSA, and the Harvard PGSSC took Twitter by the storm. From highlighting the importance of equity and inclusion of trainees in Global Surgery to a single-tweet pitch on Global Surgery, the Chat brought food for thought for many a tweeter.

Rounding up Global Surgery Day, InciSioN’s budding group in Haiti spread the word of Global Surgery in Haiti, whereas the Canadian branch, the Canadian Global Surgery Trainee Alliance (CGSTA), launched at the Bethune Round Table in Toronto.

However, although Global Surgery Day is “celebrated” on May, 25th, advocating for the cause does not stop there. Not a day should pass without thinking about the 5 billion without access to safe surgical and anaesthesia care and we will continue to increasingly raise our voices until we reach a state of complete equity in surgery.

Next year, on Global Surgery Day 2019, we will celebrate our fifth edition – slowly time to get it officially acknowledged, UN? The world is shouting, all you have to do is listen:

 

 

The four important lessons I have learned from InciSioN and IGSS2018

<Emina Letić, student of Faculty of Medicine Sarajevo, Bosnia and Herzegovina >

It was four months ago when I first opened InciSioN-International Student Surgical Network web page and at the background read the sentence: “Nobody should be pushed into poverty for needing surgical care”

This statement made me stay on the web page and keep reading. It attracted me to the noble idea of Global Surgery and InciSioN showed me how medical students can contribute to this field.
It was destiny that pushed me further into InciSioN Network- I applied for the scholarship that InciSioN Global Surgery Symposium 2018 ( IGSS2018 – 5th and 6th May, Leuven, Belgium) offered and become one of the eleven travel scholars.
So, my InciSioN adventure started and here are the four important lessons I have learned in the last four months.

No.4 Enthusiasm is the main fuel of Global Surgery
Global Surgery is a big dream and it is not easy to achieve safe surgery for everyone everywhere but there are many examples of successful programs that implement Global Surgery in different parts of the world that encourage us all.
At IGSS2018 Dr. Lubna Samad presented the fascinating work of Indus hospital in Karachi, Pakistan, that provides free healthcare for all the people in need without administrational procedures why it is also called “paperless hospital”. The initial idea in 2007 was to establish a tertiary care hospital in Karachi but now it evolved into the Indus Health Network with many other healthcare facilities in other cities in Pakistan. This hospital developed also the Pehla Qadam program for clubfoot treatment. The good idea of Pakistani doctors just grows and spreads!

An other inspiring example from Nicaragua was presented by Dr. Yener Valle- the Surgey for the People (Cirugia para el pueblo) program in cooperation with the NGO Operation Smile (Operacion Sonrisa) provides free treatment of the cleft lip and palate. It is great example how the cooperation between international organizations and local healthcare workers can give good results.
And Dr. Yener is only 28 years old! All participants of IGSS2018 that I have met are passionate young doctors and students that want to make this world a better place. The power of a young force should never be underestimated and we have to be aware of it. As Dr Basem Higazy said “Stay eager, stay foolish, stay hungry, stay connected…”and with absorbing knowledge and experience from proficient colleagues and mentors it is with no doubts an excellent formula for achieving our dreams.

No.3 Only SAFE surgery

Performing surgery in any kind of working settings should be in the way that patients get the best possible treatment and that deaths from preventable factors are avoided. The safe surgery was one of the highlights of IGSS2018. This is more than challenging to achieve in low resource settings and a systematical approach with the governments, NGOs and surgical teams is needed.
But also some simple improvements, like the WHO Safety Surgical Checklist, that impacts communication and interconnection within the surgical team can prevent some serious conditions like surgical side infections or forgetting the instruments or sponges inside of the body. And it doesn’t require too much to implement. The simple things can achieve a lot- The Checklist Effect directed by Lauren Anders Brown is an inspiring documentary about the influence of the Safety Surgical Checklist in different countries and their hospitals.
There is no safe surgery without safe anaesthesia and the role of anaesthesia in Global Surgery is important. Dr. Rediet Shimles Workneh from Ethiopia presented at IGSS2018 a motivating story about hardworking anaesthesiologists in her country, really small number of them compared to what the population needs. She also emphasized the role of anaesthesia technicians in filling the lack of anaesthesia doctors which is an illustration of how healthcare workers can rely on each other and strengthen each other to achieve safe surgery.

No.2 Work locally and achieve globally

Many of the examples I have mentioned above started as initiatives at the local level and developed and grew up in something bigger with the support of international organizations and/or local people who fundraised the initiatives.
Local+ local + … + local equals global. This model enables countries to build up healthcare systems adjusted to the specific needs of the people living in it but also to contribute to the quality and equity in healthcare worldwide.
And the changes have to start from the local level!
InciSioN is a network connecting thousands of students worldwide and it has 27 National working groups from 27 different countries. My favourite story from InciSioN blog is “The Cargo of hope”. It describes the great success of students from Grenada who “managed to ship a boat containing nearly $400,000 worth of medical and surgical supplies to the Grenada General Hospital”. This story inspired my colleagues and I to send the request to InciSioN to establish a national working group in our country. It is a small step for us to get more involved into Global surgery and one of the small steps in making surgery in our country safer, more accessible to all and preventing the impoverishment of the people needing surgical care. We also want to bring important messages from the Global Surgery community and spark enthusiasm of the students and young doctos to be active and change things.
The InciSioN’s 23rd National Working Group is a newly formed working group from my country, Bosnia and Herzegovina.

No.1 Nobody should be pushed into poverty for needing surgical care

Nobody should be pushed into poverty for needing surgical care -this is my lesson number one. When I read it, I imagine one little family- The Mum, The Dad, The Daughter and The Son and one member of the family needs to undergo a surgical treatment. They don’t have a health insurance and they are faced with the financial issues of paying the treatment. Are they going to delay the operation? Are they going to lose one member because they can’t afford treatment? Are they going to lend the money and protect the family from losing one member but get worried after the treatment about the debts? And I truly empathise with this surrogate family because I know that in the reality many families are faced with similar situations and have to take difficult decisions.
Nobody should be pushed into poverty for needing surgical care is my lesson number one, one simple statement so right and so logical that I keep repeating it often to myself because I want to give my best to see happy and healthy families in the future, in my country and everywhere.

 

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.