News Meeting the need for surgery Surgical provision falls far short of what is needed in developing countries, but recent initiatives aim to correct this deficit. Carolyn Mahoney and Fiona Fleck report. Malawi’s health system relies heavily on ficer Surgical Training in Africa (COST) close,” Mahler told the World Congress clinical officers. In eastern and southern initiative. of the International College of Surgeons Africa countries, these professionals This year, Chiumia graduates with in Mexico in that year, making access to are qualified to provide specialized his bachelor of science degree in gen- surgery a social justice issue. and general medical services that in eral surgery and will be qualified to do Writing in the World Journal of other countries would be the preserve additional surgical procedures, such as Surgery in 2008, Dr Paul Farmer and of physicians. hydrocele or hernia repairs. He is also Dr Jim Kim made an impassioned plea Clinical officers like Calistus Chi- trained to recognize cases that need re- to strengthen surgical care in these umia can diagnose and treat disease ferral to the central hospital for surgery. countries, calling surgery in Africa “the and injury, perform routine medical For Dr Stephen Ogendo, who recently neglected stepchild of global health”. and surgical procedures and, often, run stepped down as president of the College But today little has changed in district hospitals because there are so of Surgeons of East, Central and South- terms of access to surgery in developing few physicians in his country. ern Africa (COSECSA), sub-Saharan countries. “There is a great need for surgery Africa countries will not meet the need The volume of surgery increased in my community. Our central hospitals for surgery without training more clini- globally between 2004 and 2012, but are very far from our district, but they cal officers as surgeons. wide disparities persist between rich are still congested with patients because and poor countries, according to a study so many of them need surgery,” says Chi- published in this issue of the Bulletin of umia, who works in Mangochi District the World Health Organization. Hospital in southern Malawi. There is a great An estimated 288.2 million people “If the surgical expertise were need“ for surgery in my in the poorest 48 countries are in need available on a district level, it would be community. of surgical care, according to one of a different,” Chiumia says. Calistus Chiumia series of studies published for the Lancet Like so many other clinical officers ” Commission on Global Surgery in 2015. in Africa, Chiumia was initially trained The Lancet Commission estimates in pregnancy-related surgical proce- “Half of the countries in sub-Saha- that five billion people lack access to dures such as caesarean sections. He also ran Africa already use non-physician safe, timely and affordable surgery. Ac- acquired other surgical skills on the job surgeons,” says Ogendo, a professor of cording to Disease Control Priorities in at the district hospital. surgery at Nairobi University in Kenya. Developing Countries, third edition, an Four years ago, he started his “They provide basic, low-cost es- estimated 1.5 million deaths per year specialized training in surgery with a sential surgical interventions in district could be prevented by making basic group of surgeons from Ireland under hospitals. For example, in Malawi, surgical procedures accessible. the European Union-funded Clinical Of- Mozambique and the United Repub- Despite considerable progress in lic of Tanzania, 85–90% of caesarean global health, the development of essen- sections, obstetric hysterectomies and tial surgical services in low- and middle- laparotomies for ectopic pregnancy are income countries “has stagnated or even performed by non-physician surgeons,” regressed” over the last 25 years, mem- Ogendo says. bers of the Lancet Commission write. “It costs less and takes less time to “Case-fatality rates are high for train clinical officers as surgeons, but common, easily treatable conditions still there is still a high unmet need for including appendicitis, hernia, fractures, surgery in these countries,” he says. obstructed labour, congenital anomalies, This unmet need has long been and breast and cervical cancer,” they recognized. continue. In 1980, two years after the Alma-Ata In May 2015, the World Health As- “Health for All” Declaration, former Direc- sembly passed a unanimous resolution tor-General of the World Health Organiza- calling for “strengthening of emergency tion (WHO), Dr Halfdan Mahler, spoke of and essential surgical care including the the central role of surgery in primary care. provision of anaesthesia as a component “The distribution of surgical re- of universal health coverage”. sources throughout the world must “These three developments – the come under scrutiny in the same way Disease Control Priorities report, the Courtesy of Clinical Officer Surgical Training in Africa/JakubTraining in Gajewski Courtesy Officer of Clinical Surgical as any other intellectual, scientific, tech- Lancet Commission and the resolution nical, social or economic commodity. – have really produced a groundswell Clinical Officer Calistus Chiumia examines a patient The era of only the best for the few and of support and enthusiasm for global at Mangochi District Hospital in southern Malawi. nothing for the many is drawing to a surgery,” says Dr Walter Johnson, who Bull World Health Organ 2016;94:163–164 | doi: http://dx.doi.org/10.2471/BLT.16.020316 163 News coordinates WHO’s Emergency and Es- designing minimum standard curricula to talk about the best ways to do this,” sential Surgical Care Programme. for training for mid-level health work- Johnson says. The College of Surgeons of East, ers, and then how to credential them The challenges go beyond the need Central and Southern Africa has been and denote competency,” Johnson says, for training and credentialing. building surgical capacity in 10 coun- Through the efforts of COSECSA District hospitals often lack reliable tries (Burundi, Ethiopia, Kenya, Ma- and other groups, such as the COST supplies of water, oxygen, electricity and lawi, Mozambique, Rwanda, the United initiative that trains clinical officers in anaesthetics or even surgical gloves, Republic of Tanzania, Uganda, Zambia Malawi and Zambia, progress has been making even the most basic surgery and Zimbabwe) for many years. made in standardizing training for sur- challenging if not impossible. A study in the East and Central Af- geons in these countries. “It is very difficult to work with very rican Journal of Surgery highlighted the WHO has developed guidelines and few resources and, sometimes, it lowers barriers to providing adequate surgical checklists for surgical care related to in- the morale because you cannot to do the care in sub-Saharan African countries, juries, congenital abnormalities, cancer, things that you would have otherwise citing limited government health-care infectious disease and childbirth and done,” says Chiumia. budgets and that donors tended to focus these are available on the WHO website, The lack of basic supplies extends on infectious diseases. including Surgical care at the district to medicines routinely available in But the shift in the burden of dis- hospital and the Integrated management developed countries: “About 80% of ease to noncommunicable diseases, the of emergency and essential surgical care all the narcotics used in the world are authors argue, presents an opportunity toolkit, which includes resources to im- consumed in six countries – all of them to raise more funds for surgical capacity, prove surgical care programmes. high-income countries,” Johnson says. since “cancer, trauma and aspects of pa- In 2005, WHO launched the Global “For a big abdominal procedure in tient safety … are increasingly becoming Initiative for Emergency and Essential sub-Saharan Africa – a colectomy or of public health concern and do involve Surgical Care to support low- and middle- hysterectomy, for example – you get an significant amounts of surgical input”. income countries in their efforts to meet the over-the-counter painkiller. So access to Good training is essential, consider- need for emergency, anaesthesia, and surgi- anaesthesia and post-anaesthesia care is ing that many clinical officers, midwives cal care in primary health-care facilities. also part of the problem,” he says. and other mid-level health workers in Three years later, Safe Surgery Saves Those, like Johnson, who are en- developing countries are already per- Lives was established to define core gaged in trying to change the situation forming essential surgery but are not al- safety standards for adoption by WHO’s must battle preconceptions that surgery ways fully trained or qualified in surgery. Member States. is too costly or complex for low-income “We’re reaching out to the people “My task now is to start developing countries. who know the most about training, a roadmap towards implementing the like COSECSA, the American College World Health Assembly resolution. I’m of Surgeons, many of the royal colleges trying to bring surgeons, anaesthetists We need to of surgeons, all partnering to help with and public health experts all to the table see“ surgery as an investment, not a cost. It’s an important distinction. Walter Johnson ” “Most people assume that surgery is very expensive. But it’s been shown for a number of years that it’s actually quite cost effective,” Johnson says. “To bring the 88 lowest-income countries up to the standard-of-care of middle-income countries would cost about US$ 420 billion over 15 years, which seems like a lot,” Johnson says. “But if you don’t do that, the total cost in disability and lost productivity would be more than US$ 12 trillion over the same time period – so it’s a very good Walter Johnson Walter investment,” he says. “We need to see surgery as an in- Two operations being done simultaneously in an operating theatre in a rural hospital in Cameroon.