The year is not over yet

From Bogota to Kigali to Rostock, this early December has been full of surprises! 

<Zineb Bentounsi>

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!

 

 

WHO Global Conference on Primary Health Care – and Surgery?

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.

 

 

References

  1. WHO, UNICEF (2018). Declaration of Astana- from Alma-Ata towards universal health coverage and the sustainable development goals. Kazakhstan.
  2. 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
  3. 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.
  4. Pongsakul, A., Valle, Y., Chia, Y., Ndajiwo, A. and Chen, J. (2018). Surgery, rural health and primary healthcare. InciSioN- International Surgical Students Network.
  5. World Health Organisation. World Health Report 2008: Primary Health Care (Now more than ever). Available at: http://www.who.int/whr/2008/en/

Anaesthesia in the Democratic Republic of Congo

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

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.

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