– UN Secretary-General António Guterres
After attending the Global Surgery Summer School last July in London, I became aware of how disproportionately surgical diseases affect the poorest people around the world. Currently being a second-year medical student at EUC Rotterdam, The Netherlands, I am very motivated to engage and help. Therefore, I participated in the first student-led Global Neurosurgery conference in Rabat, Morocco, organized by InciSioN and IFMSA-Morocco.
<Sebastiaan van Meyel>
In the early morning of the 11th of November 2017, everybody at the Abulcasis International University of Health Sciences in Rabat was excited about the forthcoming event where around 150 medical students participated. The main purpose of the day was to expand our academic horizons and learn how to advocate for global surgery, and neurosurgery in particular, and at the same time broaden our career options in these fields.
The programme was delivered through a combination of morning lectures, panels and highly interactive afternoon workshops. First, we started in a lecture-based-setting with different sub-themes of global surgery. After a coffee break, we enjoyed listening to the new insights into the role of global neurosurgery. These talks, especially reflecting on the African situation, enabled us to understand the challenges and opportunities of African Neurosurgery, and it also made me aware of the differences in medical education in Africa compared to that in other parts of the world. Another inspirational talk highlighted the efforts in global neurotrauma research. The morning sessions were rounded off with an interesting presentation about global anaesthesia. It was great to see how many efforts and endeavours already have been made. Subsequently, an interactive panel discussion with both Moroccan and international speakers took place.
Although the audience interacted with the panellists and created some engagement, it was the afternoon workshops that truly involved everyone. The barriers were clearly broken down and the talks became more open, with a much higher level of informality. In the afternoon, I joined the screening of the Checklist Effect, an eye-opening documentary elucidating the urgent need and shortcomings of surgical equipment and care around the world. I valued my second workshop too, being “The World of Global Surgery and Anaesthesia”. This high-level panel discussion by internationally-renowned neurosurgeons offered the opportunity to engage in a passionate exchange of ideas on the past, present and future of global surgery and global anaesthesia. We all left the room satisfied of this energizing debate, which consolidated our knowledge and left us with better understanding of the critical issues. I believe the amount of ambassadors for global surgery that day surged, or at least we got hope for positive future developments. As the icing on the cake, the national Moroccan soccer team qualified for the 2018 World Cup that day.
Overall, the first student-led Global Neurosurgery conference was a unique experience and it was great to have been part of it.
In the past years and decades, many efforts have been made to increase access to healthcare on a global scale, yet even today, one in seven people will never see a single health worker in their entire lives. In fact, the crisis in human resources for health (HRH) has recently surpassed health system financing as the most serious obstacle to realizing the right to health within countries, calling for urgent upscaling and a drastic change in global priorities.
The World Health Organization (WHO) estimates that, globally, over 4 million additional health workers are needed to overcome the health workforce shortages in the 57 countries with the most critical needs.  However, the actual number is expected to be much higher (when including global disparities and countries with less critical shortages), with the deficits expected to rise to 12.9 million health workers by 2035.  In addition to the absolute shortages of healthcare providers, there is a severe imbalance in the distribution thereof between and within countries. Most healthcare workers, especially specialists, concentrate in urban areas, creating increasing challenges for rural populations to access healthcare services. As a result, one billion people worldwide will never see a healthcare worker in their entire lives, with the far majority residing in lower- and middle-income countries (LMICs), which are faced by (1) lower rates of training health workers, (2) fewer overall resources for health, and (3) brain-drain of trained health workers to high-income countries (HICs).
Today, modern globalization and resulting liberalization of markets lead to a complex health workforce migration pattern from LMICs to HICs. Moreover, the demand for healthcare is rising as a result of the large ageing population in more developed countries and the increase in the world’s population. Simultaneously, low-income countries continue to struggle with an unfinished agenda of infectious and non-communicable diseases. As a result, the HRH crisis is sustained and expected to worsen in upcoming years unless urgent measures are taken. To work towards the attainment of the Sustainable Development Goals (SDGs), health workforce and systems strengthening is needed on a global level.
Scaling up human resources for health is key in addressing the third Sustainable Development Goal (SDG3: Ensure healthy lives and promote wellbeing for all at all ages by 2030), especially with a focus on reducing global maternal mortality rates, neonatal and child mortality rates, reducing the number of deaths and injuries from road traffic accidents. The WHO estimates that at least 23 health workers per 10,000 population are needed to achieve the SDGs, yet 83 countries still fall under this threshold.  Of these, the African region has the highest burden in terms of workforce density, whereas the absolute shortages are highest in Southeast Asia, as a result of the larger population. 
Despite reduced maternal mortality rates in the past few years (with a 44% drop from 1990 to 2015), 830 women worldwide continue to die from preventable causes during childbirth every day, of which 99% occurs in the developing world and rural areas.  In LMICs, mortality rates are as high as 239 per 100,000 live births, whereas HICs face only 12 deaths per 100,000. As such, the SDGs aim to further reduce mortality rates to less than 70 per 100,000 live births, through adequate antenatal care, availability of skilled health workers during childbirth (including obstetricians or trained healthcare workers if a caesarean section is needed), and proper follow-up after birth.
In the developing world, only little over half of all mothers and children have access to skilled healthcare professionals during and shortly after childbirth, not only putting a mother’s health at risk, but also that of the newborn.  Neonatal (less than 28 days old) deaths account for 45% (2.7 million) of under-5 mortality, with 75% taking place in the first week after birth, and almost half within 24 hours. Of these, up to two-thirds could be prevented if access to skilled health workers was available, in order to prevent and limit complications (e.g., infections, asphyxia) and perform adequate health measures in the beginning of the newborn’s life (e.g., promote breastfeeding, keeping the baby warm).
When looking at all children under 5, approximately 5.9 million children continue to die on an annual basis worldwide, of which roughly half could be prevented through preventive or curative measures.  These rates are much higher in LMICs compared to HICs, with, for example, sub-Saharan Africa suffering from 14x higher child mortality rates compared to industrialized countries. Access to health workers is crucial in reducing child mortality, through proper education, prevention (e.g., vaccines), timely treatment and surgical care.
Lastly, every year, 1.25 million people die on the roads and another 20 to 50 million people remain injured or disabled as a result. Shockingly, 90% of road traffic mortality occurs in LMICs, especially the African region, despite having “only” 54% of the world’s vehicles. Road traffic injuries pose a major economic burden, not only for individuals and their families, but also for entire nations, costing them up to 3% of their gross domestic product (GDP). Although prevention and increased road safety should be the main focus in addressing these mortality and injury rates, timely access to health and surgical care is needed to adequately treat victims of road traffic crashes and limit morbidity and mortality thereof.
If we are to achieve the health-focused Sustainable Development Goals by 2030, emphasis should be put on human resources for health, which are a key component in improving access to healthcare and the delivery of healthcare services. With a rapidly increasing world population -especially in those countries needing improved access to healthcare the most- urgent upscaling is needed on a global level in order to prevent the human resources for health crisis to turn into an expanding global nightmare.
NB: This article was originally published in the 36th edition of Medical Students International (MSI36), the biannual online magazine of the International Federation of Medical Students’ Associations (IFMSA).
1. World Health Organization. The World Health Report 2006 – Working Together for Health. 2006. Geneva: World Health Organization.
Available at http://www.who.int/whr/2006/whr06_en.pdf
2. Global Health Workforce Alliance, World Health Organization. A Universal Truth: No Health Without a Workforce. November, 2013. Geneva: World Health Organization.
Available at http://www.who.int/workforcealliance/knowledge/resources/hrhreport2013/en/
3. World Health Organization. Health Situation in South-East Asia Region 2001–2007. 2008. New
Delhi, India: World Health Organization.
4. Alkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet. 2016; 387 (10017): 462-74.
5. World Health Organization. Newborns: Reducing Mortality. 2016. Geneva: World Health Organization.
Available at http://www.who.int/mediacentre/factsheets/fs333/en/
6. World Health Organization. Children: Reducing Mortality. 2016. Geneva: World Health Organization. Available at http://www.who.int/mediacentre/factsheets/fs178/en/
7. World Health Organization. Global Status Report on Road Safety 2015. 2015. Geneva: World Health Organization. Available at http://www.who.int/violence_injury_prevention/road_safety_status/2015/en/
About 200 students from medical schools around Boston joined in the HMS Amphitheater on August 28th for the screening of the Checklist Effect documentary. The screening was hosted by the Boston chapters of the Global Surgery Student Alliance (GSSA) and sponsored by the Kletjian Foundation. Students came from Harvard, Boston University, and Tufts medical schools as well as other undergraduate colleges around the Boston area. The focus of the screening was to impress upon the importance of quality, safety, and ethics in global surgery.
The screening began with opening remarks from Kris Torgeson, Global CEO of Lifebox, who described to the audience what brought upon the idea of the Checklist effect. The Lifebox partners for years have been helping to deliver safer surgery projects across the world. However, delivering stories of these projects and experiences has not always been an easy task. The Checklist effect, based off the development of the Surgical Safety Checklist by surgeon, author, and Lifebox founder Dr. Atul Gawande, allows for an impactful story to be told to audiences across the world. Thus, accomplishing a crucial step in creating safer access to surgery globally.
The documentary screening itself discussed the quality, safety, and ethics in global surgery, especially in low-resource countries. It focused on the implementation of the surgical safety checklist under different settings, and how this implementation changed the lives of not only the doctors and nurses running the OR, but also the patients and their family. The documentary not only lets the audience into OR’s across the world, but also gives insight into the struggles faced by doctors and patients alike when proper resources are not provided.
Following the hour long screening of the documentary, audience members were able to attend a panel discussion on global surgery. The panelists included Dr. Atul Gawande, Chairman of Lifebox and Executive Director at Ariadne Labs, Dr. Brian O’Gara, Global Anesthesiologist at Beth Israel, Dr. Sabrina Sanchez, Global Trauma Surgeon at Boston Medical Center, and Dr. Victoria Mui, Global OB/GYN at Tufts Medical Center. Discussion revolved around the future direction of the surgical safety checklist, the experiences as a global surgeon, and how medical students can become advocates for change. The final keynote was given by Parisa Fallah, a second year medical student at Harvard Medical School and National Chair of GSSA, who gave a wonderful closing to the event and provided information regarding similar future events.
“Undoubtedly it is within your power to contribute significantly to shaping the societies of the coming century; youth can move the world.”- Paris Fallah
SLEMSA held its 3rd national general assembly on the 22nd -23rd August, 2017 at the Bank Complex in Freetown. The GA is a conference that brings together medical students in the country. It is aimed at building the capacity of medical students in various subject areas including soft skills that they will need in the future as healthcare providers. The theme for this year’s conference was “Safe Surgery and Universal Health Coverage”. Access to safe surgical care is crucial for the population of Sierra Leone, yet the vast majority of the population has no access to skilled surgical care, largely due to high cost and because of shortages of staff equipment, drugs and supplies.
<Mohamed Bella Jalloh>
Over 350 medical students were in attendance and had the honor of hearing Professor Temidayo O. Ogundiran as the keynote speaker. He gave an insightful presentation on global surgery and the challenges of safe surgery in low- and middle-income countries like Sierra Leone. We also had the privilege of listening to the Director General of the National Social Security and Insurance Trust, where he talked about the Sierra Leone Health Insurance Scheme. There is a need for a reliable and sustainable domestic financing model to increase universal health coverage in an efficient and equitable way.
With surgical ailments being significant contributors to the global burden of disease, efforts to increase the interest and understanding in global surgery amongst medical students must be expanded. One crucial avenue toward achieving surgical workforce needs to involve exposing, educating and motivating medical students to participate in global surgery initiatives.
The second day of the conference offered unique training opportunities for students. We organized six sessions including global surgery and primary trauma care. The sessions were very much educative, interactive and fun-filled.
On August 12th, the Global Surgery Student Interest Group (Singapore) organized the very first student-led Global Surgery Workshop in Singapore, held at Lee Kong Chian’s Clinical Sciences Building.
<Jason Huang Juncheng>
Approximately 80 students from the three medical schools of the country came together to explore their passion for Global Surgery.
They were lucky to have Professor Russell Gruen, a commissioner of the Lancet Commission on Global Surgery, as a speaker.
Professor Gruen shared invaluable insights on how Global Surgery is an emerging concern and how Singaporeans medical students have a role to play in the Asian region.
InciSioN is happy to announce their latest partnership with CSurgeries, providing educational and research possibilities for students and surgeons alike, everywhere, in every setting.
CSurgeries: The Only Peer-Reviewed Surgical Video Journal
CSurgeries is an online surgical video journal dedicated to creating a centralized source of brief, peer-reviewed medical videos that are accessible to a wide audience, including students and professionals in all surgical disciplines. Created by surgeons for surgeons, CSurgeries aims to be a useful resource for teaching basic and complex surgical techniques, and a venue where surgical innovations can be shared across specialties. Enhance your learning by getting video publications delivered directly to your inbox.
Contact for questions: firstname.lastname@example.org
Many global surgery leaders from around the world joined in Ottawa from June 1-3rd for the Annual Bethune Round Table global surgery conference. Researchers came from Rwanda, Uganda, India, Zambia, Nigeria, South Africa, Bangladesh, Zimbabwe, Ethiopia, Canada, and the U.S. This year’s theme was “Evidence-Based Global Surgery.” The focus was to raise the standard of research being done in global surgery and to improve the way results are implemented in LMICs.
The conference began with a presentation from Dr. Ed Fitzgerald, a general surgery registrar in England. Dr. Fitzgerald runs GlobalSurg, an exciting research collaborative comprised of thousands of students and clinicians from 60 countries around the world. Rather than doing multiple smaller studies, GlobalSurg involves simultaneously collecting professionally crowd-sourced data from various sites worldwide, leading to large-scale studies that capture important trends in surgical care. Their most recent work includes developing a surgical instrument set for the bellwether procedures in global surgery.
One of the highlights of the conference was the Ab Guha Lecture given by Dr. Nobhojit Roy, who gave a talk titled, “Global Surgery 2030: What is Missing in the Discourse?” Dr. Roy filled in many of the gaps that exist between global surgery research and the way global surgery efforts are being implemented. He talked about topics that some have been more hesitant to discuss and left the audience with a lot of salient points to consider.
Other keynote speakers included Dr. Stephen Ttendo, who is working to build anesthesia capacity in Uganda, and Dr. Rachel Spitzer, who talked about equipping OB/Gyn trainees with the skills to participate in global surgery. The final keynote was given by Dr. Nadine Caron, who gave an incredible talk on the challenges to evidence-based indigenous health care in Canada and the importance of remembering that global can mean local as well.
Beyond the research presentations and keynotes, there were several workshops including: Innovation Development, Developing a Curriculum, Research in LMICs, Working with the World Bank, Advocacy for Political Change, Preparation for Successful Partnerships, and Getting Published in Global Surgery. There was also a banquet, where screenings of “The Checklist Effect” were shared and where director Lauren Brown talked about the value of media in enacting change. The conference ended on the final evening with multiple locally-hosted dinners that facilitated more conversations on global surgery.
From left to right: Dr. Laurence Bernard (Ob/Gyn resident), Dr. Adriana Ramirez (general surgery resident), Stacey Giles (nurse), Parisa Fallah (medical student), Dr. Andrew Giles (general surgery resident)
Several members of the Global Surgery Student Alliance (GSSA) leadership team were present, including Parisa Fallah, Dr. Andrew Giles, and Dr. Adriana Ramirez. Dr. Giles, one of the VPs for Residents/Trainees, presented his research on “Predictors of Obstetric Fistula Repair Outcomes in Lubango, Angola.”
As the InciSioN’s National Working Group (NWG) for the U.S., GSSA was able to have many conversations with key global surgery players at the conference and is now working towards partnering with Canadian medical students to help them develop their NWG in the coming year.
Look ahead to May 2018, when the Bethune Round Table will be held in Toronto. The theme is “The Role of Trainees,” so many will be listening closely to learn how they can support students and trainees in their localities who want to join the field of global surgery.
Najwa Nadeem (Final Year M.B.B.S.)
It was a different world when she woke up. Blinking and coughing, the woman looked around only to find herself surrounded by anxious, inquisitive faces, staring at her in disbelief. Not her exactly, but a part of her. Her feet. Words seemed gibberish and the whole crowd a blur when the pain hit her. She shrieked, catching everyone’s attention. The surgeon bandaging her fractured tibia, her lacerated foot hanging on to her leg, asked her to calm down, all the while telling the medical students around him that she’ll definitely lose her right foot due to the extent of the damage in the accident. She kept screaming in pain, lying on the stretcher she came in, all covered in blood. The nurse waited as soon as the other surgeon filled her chart to maintain her IV line and give her the necessary pain-killers. The rest of the treatment would have to wait until all necessary investigations were done and she was moved to Bay-1 of the ER, still on the stretcher. She screamed one last time as the analgesics kicked in, looking at the room she was in, surrounded by strangers, old and young alike and then finally falling unconscious. Her husband was asked to take her samples to the lab for tests and also to arrange blood so that surgery can be started. He wanted to ask so many questions but the ER is a busy place, with everyone yelling around and he was pushed away, still confused about the whole procedure.
This is not an unusual scenario at a tertiary hospital in Pakistan. If the woman and her husband lived in a village, she would have been taken to a Basic Health Unit (BHU) first where the doctor would suggest her to be taken to the city for surgery and in the meantime during transport (if available), she could lose not just her foot but her life as well. Barriers to optimal surgical care in Pakistan affect surgical access to the patients, which we will discuss here in more detail.
In 2011, the World Health Organization (WHO) Alliance for Health Policy and Systems Research brought out their report “Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries.”  The barriers which the paper mentioned included:
Pakistan being a low- and middle- income country (LMIC), faces similar barriers to optimal healthcare conditions for its population, majority of which belongs to rural areas. With the ever increasing population, Pakistan is yet to address these problems. The specialist surgical workforce density is 5.53 per 100,000 population. Risk of impoverishing expenditure for surgical care is 62.8% and that of catastrophic expenditure for surgical care is 75.2%. 
A study conducted in 2011 addressed many such variables :
“Patient-related variables included age (elderly), gender (female), preferential use of alternative health providers (Hakeem, traditional healers, others), personal perceptions regarding disease and potential for treatment, poverty, personal expenses for healthcare, lack of social support, geographic constraints to accessing a health facility, and compromised general health status as it relates to the development of surgical disease. Environmental barriers include deficiencies in governance, the burden of displaced or refugee populations, and aspects of the medicolegal system, which impact treatment and referral. Barriers relating to the health system include deficiencies in capacity (infrastructure, physical resources, human resources) and organization, and inadequate monitoring. Provider-related barriers include deficiencies in knowledge and skills (and ongoing educational opportunities), delays in referral, deficient communication, and deficient numbers of female health providers for female patients.”
Surgery is described as an “indivisible, indispensable part of healthcare.” Unfortunately, in Pakistan, where the country is in a usual political turmoil, with only 2.6% of the GDP spent on healthcare, the situation is far worse. The government does provide some support to hospitals in urban areas but rural areas suffer from a lack of trained doctors and health facilities to treat major surgical ailments.
Patients in urban areas have access to emergency care and ambulances provide transport to the nearest care center. However those in rural areas reach a Basic Health Unit (BHU) first where only first aid and minor care can be provided (according to the competency of the duty doctor and the meager facilities available). They then have to travel miles away to a tertiary care center in urban areas to treat their ailment. Many lose their lives in the transit. Others can’t afford the treatment. Then there’s the issue of bed availability.
Emergency surgical procedures are done in a less than ideal setting where the patient is prone to all kinds of hospital-acquired infections. Even after the procedure the risk of surgical site infection is high. Patients’ families have to arrange blood on their own and are mostly seen running through the hospital looking for a referral or a familiar to doctor to help them out. Blood screening is another problem. Public hospitals don’t always provide a clean environment for the patients in general wards as those in private hospitals. Surgical waste once removed from the bedside is often heaped up outside, leading to environmental pollution.
A majority of the Pakistani population resides in rural areas and is illiterate which is another factor that affects treatment. Patients often have the wrong ideas about their illness (reinforced by the elders in the household) and avoid a visit to a medical practitioner. Instead, they seek help from hakims and quacks to heal. This worsens their condition. By the time they reach the doctor, it is already too late. The security threats pertaining to a BHU discourages female doctors to practice in distant rural areas and hence the female patients in the area suffer indirectly as the social setup discourages them to visit a male doctor.
The specialist surgical workforce density faces an imbalance as most specialists are concentrated in the urban areas and so people from villages have to travel a long way. Most avoid the transit and “wait it out”, unless it is absolutely necessary to go. Travel expenses, residence and arranging an appointment all add up to the patient and his family’s worries. Patients often refuse surgery and resort to medicines as they’re either afraid of the outcome or simply cannot afford it.
Government funding, proper planning and improvement in health facilities can help alleviate the situation. There’s a need for proper research into all these factors, development of policies and ensuring their implementation so to improve surgical access and its safety in Pakistan.
- Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Jacobs B. et al. Health Policy and Planning 2011;1–13. Available online at http://www.who.int/alliance-hpsr/resources/alliancehpsr_jacobs_ir_barriershealth2011.pdf
World Development Indicators, The World Bank. Available online at http://data.worldbank.org/data-catalog/world-development-indicators
Barriers to Accessing Surgical Care in Pakistan: Healthcare Barrier Model and Quantitative Systematic Review. Irfan, Furqan B. et al. Journal of Surgical Research , Volume 176 , Issue 1 , 84 – 94