Why I do Global Health

“We are all here on earth to help others; what on earth the others are here for I don't know.”  H. Auden

 With the start of the new semester come many questions from our “Public Health & Surgery” students. One of the most common is why we have been working in global surgery for so many years. There are, of course, many statistics regarding the tragic situation of surgery and anesthesia in low and middle income countries (LMICs):

  • An estimated 288 million people in LMICs are living with a surgically treatable condition1
  • 9 out of 10 people in LMICs cannot access even basic surgical care2
  • There is less than 1 anesthesia provider per 100,000 population in LMICs3 (compared with 24 per 100,000 in the United States)4
  • Mortality from emergency abdominal surgery is three times higher in low- compared with high-income countries5.

These are certainly emotive numbers, and I am sure they have motivated many practitioners to devote careers to help improve the conditions for patients in the under-resourced world. For me, however, appreciation of these numbers came after my commitment to ‘the cause.’

 My indoctrination to global health started as many do, with a service-provision trip to West Africa. My colleague and I had been invited to accompany a surgical team to provide anesthesia for children having ophthalmic surgery. Once on-site we met the physician anesthesiologist who was single-handedly running one of the two nurse anesthesia schools in the country. This gentleman was working 80 hour weeks providing anesthesia care, supervising qualified nurse anesthetists, and teaching classes of 40 student nurse anesthetists. The institution in which he was based tried to support his endeavor, but was limited by its inadequate and desperately oversubscribed budget. 6 Still, our friend persisted – for over 20 years slowly nurturing the practice of anesthesia in his little corner of the low resource world. Now, thanks to his efforts, the institution in question has many physician anesthesiologists, an anesthesiology residency, and a robust nurse anesthetist program that trains providers for their own, and adjacent under-staffed countries.

 When I first met our friend, I felt a moral and professional obligation to help. Not by intermittently providing service on surgical missions, but by assisting in his work. He was the one who knew the needs, cultural and practical hurdles and mechanisms for improvement. 7 We had educational resources and expertise – he knew how to apply them.

 Since those early days this has been my abiding belief; we are here to help, not to do. The fellow professionals we assist are often choosing to stay in a poorly-paid, over-worked and perhaps dangerous 89 position, rather than emigrate to a better situation. 10 They do this with an optimistic vision, and a sense of loyalty and commitment to their fellow citizens and homeland. Not infrequently this necessitates long-term separation from their families.

Collaborating with (rather than directing) these dedicated providers serves as our resignation from the ‘white savior industrial complex’. This abnegation alone is worthwhile, but in addition it places us in the enviable position of helping real heroes.

 References

  1. Gupta S, Groen RS, Kyamanywa P, Ameh EA, Labib M, Clarke DL, Donkor P, Derbew M, Sani R, Kamara TB, Shrestha S, Nwomeh BC, Wren SM, Price RR, Kushner AL: Surgical care needs of low-resource populations: an estimate of the prevalence of surgically treatable conditions and avoidable deaths in 48 countries. Lancet 2015; 385 Suppl 2:S1
  2. Meara JG, Leather A, Hagander L, Alkire BC: Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet 2015 doi:10.1016/S0140-6736(15)60160-X
  3. Dubowitz G, Detlefs S, McQueen KA: Global anesthesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices. World J Surg 2010; 34:438–44
  4. Egger Halbeis CB, Schubert A: Staffing the operating room suite: perspectives from Europe and North America on the role of different anesthesia personnel. Anesthesiology clinics 2008; 26:637–63–vi
  5. Collaborative GS: Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries. BMJ Global Health 2016 doi:10.1136/bmjgh-2016-000091
  6. Citron I, Chokotho L, Lavy C: Prioritisation of Surgery in the National Health Strategic Plans of Africa: A Systematic Review. World J Surg 2015:1–5 doi:10.1007/s00268-015-3333-9
  7. Ginwalla R, Rickard J: Surgical Missions: The View From the Other Side. JAMA Surg 2015 doi:10.1001/jamasurg.2014.2262
  8. Leow JJ, Groen RS, Bae JY, Adisa CA, Kingham TP, Kushner AL: Scarcity of healthcare worker protection in eight low- and middle-income countries: surgery and the risk of HIV and other bloodborne pathogens. Trop Med Int Health 2012; 17:397–401
  9. Bundu I, Patel A, Mansaray A, Kamara TB, Hunt LM: Surgery in the time of Ebola: how events impacted on a single surgical institution in Sierra Leone. J R Army Med Corps 2016 doi:10.1136/jramc-2015-000582
  10. Hagander LE, Hughes CD, Nash K, Ganjawalla K, Linden A, Martins Y, Casey KM, Meara JG: Surgeon migration between developing countries and the United States: train, retain, and gain from brain drain. World J Surg 2013; 37:14–23