Global Surgery: Experiences from the frontline of developing world healthcare in Uganda

Access to safe surgery is all but guaranteed for us in the Western world, in stark contrast to those in low income countries like Uganda, where there is only one trained surgeon per 200,000 people (compared to 70 in the UK). Travelling hundreds of miles to the nearest hospital with a surgical condition, only to be told that theatres are out of sterile linen, or that the trained anaesthetist is out of town, is the unfortunate reality for many Ugandans. Even those that do receive life saving surgery will seldom receive the close post-operative monitoring and treatment that are required.

As little as a decade ago, provision of surgical services remained all but off the agenda of international healthcare bodies and public health financiers – leading it to be described as the ‘neglected step-child of global health’ 1.

Since then, academics and policy makers have begun to recognise to the burden of surgical disease worldwide. Published in 2015, the Lancet Global Surgery Commission 2 saw a team of international commissioners and researchers, across 110 different countries research the availability of national surgical services. The results were startling:

• Five billion people currently do not have access to safe and affordable surgery
• 18 million preventable deaths occur each year from surgically treatable conditions (four times the mortality of HIV, TB and malaria combined)
• There is a shortfall of 143 million operations a year worldwide

While the statistics seem to illustrate an insurmountable need, the cost-effectiveness of treating surgical conditions provides room for optimism. Surprisingly, surgical services more than pay for themselves in saved disability adjusted life years and subsequent economic growth. We know now that operations like repair of hernia or cleft lip + palate are far more cost effective than public health initiatives such as seatbelt awareness campaigns or even direct treatment of communicable diseases like HIV 3.

So now we’ve established how important and cost-effective surgical services in low and middle-income countries (LMICs) are, how do we best go about providing them? The answer is through a research-driven, simultaneous top-down and bottom-up approach.

Through these measures we can ensure evidenced based solutions to providing safe and affordable surgery through a national and local means, country-by-country and hospital-by-hospital. Being sure to engage and work alongside existing excellent practitioners and policy makers and avoiding the mistakes of the past 5.

My personal involvement in global surgery began in June this year when I took a break from surgical training and travelled to Uganda to undertake a volunteer placement with the general surgery team in Mbale Regional Referral Hospital (Mbale RRH), a government hospital 120 miles east of Kampala.

I wanted to experience surgery in the developing world first hand, and find out where the real needs and gaps in care were. Working alongside Ugandan doctors and nurses, sharing experiences and learning from each other.

At the time of writing I am 6 months into a 9-month placement. My time is split between the wards, outpatient clinic, endoscopy and the operating theatre. There are two local senior general surgeons who are both very capable and experienced but with more a 50-bed ward and more than 1000 major operations taking place a year, they are quite simply overwhelmed. This means they often have to leave junior doctors to undertake emergency cases and part of my role has been supporting the juniors where needed. The work is tiring but unquestionably rewarding.

Working here has given me a candid view of the frontline of healthcare in the developing world. Supplies of drugs and sundries are limited and while healthcare provision is theoretically free, patients will often have to purchase their own antibiotics, sutures or surgical gloves. The hospital is the busiest of its kind in Uganda and serves a population of 4.7 million spread over a wide catchment area, meaning many patients present very sick indeed – sometimes several days into a life-threatening illness. This means patients are often in a bad way prior to their emergency surgery and while the capacity to perform the surgery is there, attentive post-operative care is not. There is no intensive care unit (ICU) here in Mbale so the sickest post-operative patients are cared for alongside everybody else on a 50-bed ward staffed with 1 nurse.

Comparing surgical outcomes data in Mbale with developed countries helps illustrate the importance of good post-op care. Below is data representing outcomes in emergency laparotomy (operation for people with abdominal complaints, finding the cause and treating it) from a recent yearlong audit in Mbale 6, with those from the most recent UK-wide National Emergency Laparotomy Audit 7:

Twice the numbers of patients are dying after emergency surgery in Mbale than the UK despite being half the age of patients in the UK. These statistics are upsetting, but with the theme of quality bottom-up surgical services improvement, a team of us at Mbale have set up a project that we hope will vastly improve things – a new high dependency unit to give patients the post-op care that they deserve.

Providing safe and affordable surgery for the 5 billion will be no easy task, but we can all do our bit to support those in desperate need and provide the high quality healthcare that we in the Western world take so easily for granted. You can help do your part by making a donation to the RCS Christmas Appeal and help us build a much-needed surgical high-dependency unit here in Mbale. You can read more and donate using the link below. Donations will be accepted well into 2019. Thank you.

https://www.rcseng.ac.uk/about-the-rcs/support-our-work/donate/christmas-appeal-2018/

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

1. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008; 32: 533–36
2. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015; 386: 569–624.
3. Grimes CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Cost-effectiveness of surgery in low- and middle-income countries: a systematic review. World J Surg. 2014; 38(1):252-63
4. www.globalsurg.org
5. epuis CC. Humanitarian missions in the third world: a polite dissent. Plast Reconstr Surg 2004; 113:433–35.
6. Hewitt-Smith A, Bulamba F, et al. Surgical outcomes in eastern Uganda: a one-year cohort study. South African Journal of Anaesthesia and Analgesia. 24(5): 122-127
7. https://www.nela.org.uk/reports