Thoughts from a remote village in Kenya.
I remember more than 15 years ago before I started medical school, I attended a small global surgery seminar where several residents and invited speakers introduced the community to global surgery and the needs of health care in third world countries. The night started with a surgical resident saying the following statement “hospitals in third world countries are places where people go to die, not get better”. I still remember my reaction and how infuriated I was with such statement. I was born and raised in Colombia, South America and thought about all the times I had been sick, taken to the hospital, and here I was, alive! I had been inspired in the same hospitals to become a doctor, help people and save lives.
Three weeks ago I started a rotation in Kenya, now six weeks from starting my fourth year of general surgery residence in a prestigious academic institution in the USA. I found myself in a male ward with 76 patients in a room the size of about three private rooms back in my home residency institution in the US. There was a very strong smell that made it hard to concentrate on my medical tasks. The rainy and cold season had brought millions of insects eager to enter the ward to look for a warm dry place, and hundreds had been successful in getting in. Some patients look bright, alive and blessed to start another day. Others looked quite sick, malnourished and tired. The memory of that global surgery seminar more than 15 years ago resonated in my mind. Was that resident right? I wanted to prove him wrong even now. My mind started filling with more questions than answers. Perhaps he did not mean all hospitals in third world countries, perhaps he meant remote, poor, third world hospitals. But even in remote, poor places, do people come to hospitals to die? Is there anything we can do in 2018 with such technological advances to bring patients to remote hospitals to help them get better? What should a mortality rate be in a hospital, any hospital in the world? What should be medical acceptable? What should be morally acceptable? As the questions became so complicated and almost impossible to address, I concentrated only on what I have been trained to do, general surgery, and I started reading about global surgery and their current efforts. The statements that repeatedly show up on the web as one searches the term global surgery is the following definition: "a field that aims to improve health and health equity for all who are affected by surgical conditions or have a need for surgical care, with a particular focus on underserved populations in countries of all income levels, as well as populations in crisis, such as those experiencing conflict, displacement, and disaster.” According to the Lancet commission on global surgery approximately 5 billion people around the world do not have adequate access to basic surgical care. Moreover, the disparity in surgical care is incredible, with the poorest 30% of the world receiving only 3-6% of operations, whereas the richest 30% receiving almost 75%. The work up I do for one patient with pancreatic cancer in the US costs more than everything I had ordered in 3 whole clinic days where I had seen approximately 70 patients total and scheduled 30% of them for operations.
It makes me very happy to see all the international efforts that are currently taking place to help underserved regions in the world have access to surgical care. However, I can’t help to be puzzled about how do we provide health “equity” specially surgical services to poor regions? Do we provide standard of care? The same standard of care I have practiced and studied in the last 5 years that costs thousands of dollars or do we somehow sit together and come to a consensus to what is the absolute necessary preoperative and post-operative work up for a patient. Would it even be possible to come to a consensus? Or do we decide on an individual bases centered on how much they can afford? Most of the patients I have taken care of here, struggled to pay the costs of the consultation (ranges between 10-15 US dollars) and deposit of the proposed operation, with many sharing stories of having to sell their land and cattle to afford hospitalization. Most of them are faithful optimistic individuals full of hope who believe in us surgeons. However, complications are common in surgery, and even more in this environment were sanitation is a struggle, surgical instruments are scarce, old and not fully functional. Surgical patients are complex and can decompensate easily requiring fast and intricate care for survival, care that is not easily available in these regions. You don’t have to train long in a surgical specialty to hear a seasoned surgeon say “A good surgeon is not the one who performs an operation, anybody can do that, a good surgeon is the one that performs the operation and knows how to take care of the complications”. But what happens when the surgeon knows exactly what needs to be done and he or she does not have the tools to carry on the plan, does not have intensive care units to admit the patient, does not have blood to transfuse a patient who is hemorrhaging, does not have a ventilator for a patient on respiratory distress?
I have seen a lot of efforts in training surgeons, opening residency programs around the world, and bringing anesthesia training to perform a safe operation. For example, the world health organization had a crew of four people this week, filming exploratory laparotomies to teach health care providers to perform them by watching the videos. However, I have not seen the same efforts in place to provide access to adequate preoperative and postoperative care. Surgeons are excellent team leaders, but we need a team. One of the most successful innovations of current medical care is the multidisciplinary conferences and teams where surgeons, internal medicine subspecialties, pathologists and radiologists come together to discuss cases. The value of every single one of the members of the discussion is impossible to estimate. I truly believe that to be able to provide safe equal surgical services to underserved communities we cannot focus only on training surgeons. We need to train entire teams including radiologist, pathologists, gastroenterologists, pulmonologist, intensivists, nurses, nutritionists and so forth. The surgeons I have met and gotten to known here in Kenya are incredible humans, more like superhumans, that had learn to increase their scope of practice so they can fulfill the empty places of their imaginary team. However the need is growing exponentially as populations continue to grow and resources become scarce. Internet access however is very accessible in remote areas. I would like to see academic institutions collaborating closely with these hospitals that are putting an extraordinary effort on teaching and providing care to remote communities. Could we open international multidisciplinary meetings regularly where we can discuss hard cases on regular bases? Could we have a radiologist on call thousands of miles away willing to read difficult scans and teach important points, perhaps to continue to train new radiologist on site? In our institution in the US, we are working on remote intensive care units where you can see every data point from heart rate, blood pressure, urine output in your computer at home real time. This technology would be so incredibly helpful in these areas where intensivists are not so prevalent. Finally, one of the things that impressed me the most in the US health system, is the ability to self-regulate. Every statistical data point about what the morbidity and mortality of an specific procedure has been studied and stablished, and if a specific provider or institution is not meeting them, huge efforts are undertaken to study why and how to intervene with solutions. Enormous amount of energy and resources from providers, hospitals, religious and private institutions are undertaken in rural poor regions in third world countries. Results should also be tracked in similar ways so that we are clear on successful endeavors that can be mimicked in other regions, as well as in failures that should be prevented and avoided.
These four weeks have been an indescribable learning experience with many happy and many sad frustrating moments. The bottom line is there are too many people that have no access to surgical care everywhere in the world, and we as world citizens and educated health professionals have a responsibility to help improve the situation. There is definitely not one single right answer that would fix the problem. We need frequent reminders of this problem to engage in open discussions as to what little or big contributions each and every one of us can do to help. Please help me prove to this anonymous resident (he is probably an accomplished attending now) his statement cannot continue to be true in 2018. We cannot allow people in third world countries to come to the hospitals just to die.