One way that UCSF Global Health Sciences (GHS) is working to improve health and reduce the burden of disease in the world’s most vulnerable populations is by addressing the lack of surgical care in Africa.
“Through our efforts to expand the medical infrastructure of countries like Tanzania and Uganda, we educate ourselves about the medical issues patients and professionals face outside the US,” says Haile Debas, MD, professor of surgery and executive director, UCSF Global Health Sciences.
“Surgical conditions, as defined as those conditions that require suture, incision, excision or anesthesia to treat, constitute a substantial global burden of disease,” he says.
Debas and colleagues note that in developing countries where there are few doctors, other health care workers — such as nurses or general practitioners — can be trained to perform surgery.
The need for surgical care is great. Injury accounts for a significant percentage of all disability-adjusted life years (DALYs) lost worldwide. DALYs combine the morbidity and mortality metric into a single number to measure the overall burden of disease. More than 90 percent of the people who suffer from these injuries live in low- and middle-income countries.
As developing nations expand their economies, they face the double burden of infectious disease — historically prevalent in these countries — and injuries that come with growing prosperity, such as trauma from motorcycle, car and truck accidents. Decreasing the number of injuries has a positive impact on the economies of the families and communities burdened with caring for someone living with a survivable injury.
Building Capacity
UCSF GHS is partnering with leaders internationally to address the issue of a trained health care workforce and increase the number of health care workers in developing countries to meet critical needs. Highlighted in the University’s strategic plan, GHS is partnering with institutions in developing countries to contribute to the reduction of health disparities.
“We often only view capacity building from the other end, but we’re building our own capacity here at UCSF through partnering with institutions in developing countries,” says Sarah Macfarlane, associate adjunct professor and director of program development and planning, Global Health Sciences.
To address the issue of building surgical capacity and to support the need to draw attention to surgery as a global health concern, GHS partnered with Makerere University in Uganda to convene a group that included leaders from 11 African countries, Europe and the United States. The effort, funded by a grant from the Bill & Melinda Gates Foundation, culminated in a meeting that met in Kampala, Uganda, in July 2008.
The meeting was a follow-up to a 2007 meeting in Bellagio, Italy, and was inspired by a chapter written by Debas and colleagues in the second edition of Disease Control Priorities in Developing Countries.
Participants formed the Bellagio Essential Surgery Group to call for urgent international action to address the crisis in surgical services in sub-Saharan Africa by working toward universal access to essential surgical care.
Recommendations from the recent Kampala meeting included supporting analyses of countries’ needs, improving the morale of surgeons, expanding surgical competencies to nonsurgical personnel, encouraging educational reforms and strengthening the health care delivery system overall.
One successful method of increasing surgical capacity cited by several African countries was training nonsurgeons at district hospitals, which are located in rural areas. The idea is that increasing surgical capacity can often improve care in general.
“We’re saying that if you strengthen surgery at the district hospital level, you’re actually strengthening the whole hospital and the district health system itself,” says Macfarlane.
Global Health Concern
Developing surgical capacity is one side of the coin; add to that the idea of considering surgery as a global health issue. GHS is actively promoting improvement of the availability of surgical procedures as part of the global health agenda.
At the Kampala meeting, a key theme, as described by Sam Luboga, MBChB, PhD, associate professor in the Faculty of Medicine, Makerere University, was recasting the role of the surgeon. The idea is to encourage surgeons to play a greater role in policy decisions and to form partnerships with those outside the medical profession. Luboga, representing the secretariat of the Bellagio Essential Surgery Group, recently addressed a meeting in Mozambique of surgeons from eastern, central and southern Africa, urging them to expand their roles and responsibilities beyond their operating theaters.
Macfarlane says it is also necessary to draw upon a wide group of specialists — economists, epidemiologists and public health experts, among others — to do the appropriate research and ensure that plans are laid to integrate surgery into the entire health care system.
UCSF can play a leading role in bringing diverse individuals and organizations together around the idea of increasing surgical capacity. Leaders believe that UCSF can leverage its credibility in terms of surgical skills and ability to influence a health systems focus, which can help African leaders build relationships with international organizations and leaders and draw attention to the problem of diseases impacted by surgery — those that need a scalpel or suture to treat.
According to leaders who spoke at the annual American College of Surgeons (ACS) conference in San Francisco, including Diana Farmer, MD, surgeon in chief of UCSF Children’s Hospital, and Doruk Ozgediz, MD, former GHS fellow, global health is most often synonymous with infectious disease. In fact, the United Nations Millennium Development Goals do not include surgery, other than emergency obstetrical care.
Like leaders in Africa, Farmer, Ozgediz and others are hoping to bring attention to the global surgical crisis.
“When I was working in Uganda, we saw a 7-year-old girl who had been struck by an auto several days earlier and had not been treated,” says Ozgediz. “On arrival, she was barely alive, with a chest full of blood. We struggled to find IVs and blood pressure cuffs, all routinely available here. This type of thing occurs every day.”
Surgical Training
Health leaders in Africa and at UCSF believe a mutually beneficial relationship in which both parties have a vested interest is key to ensuring long-term sustainability of capacity-building efforts.
“While the benefits of US trainees working in a host country are apparent, alone they are unlikely to have an impact on disparities,” says Ozgediz. “There is a 90-10 gap in global health research. Africa needs to address 25 percent of the burden of disease with 2 percent of the workforce. There is a need for a greater surgical workforce in developing countries.”
A few years ago, UCSF’s Department of Surgery set up a collaborative program at Makerere University.
“Uganda has many attributes which lend to an ideal relationship,” says Ozgediz. “These include appropriate electives for US medical residents in their medical school, a surgery training program, a politically stable government and an English-speaking environment.”
For the past five years, a group of seven UCSF residents and nine faculty members has been working for periods from several weeks to several months in Uganda. Three of the residents are in the GHS Clinical Scholars Program.
One issue addressed at the ACS meeting by a representative from the national Residency Review Committee (RRC) was how to count international experience as part of the five-year formal surgery training program. Right now, the RRC counts international work as experience, but does not add it toward the five years required for a surgical residency. The RRC says sustainability is a necessary component of building a credible international program at a university.
The idea is to get away from a model in which individual students and faculty work in a hospital in a developing country for a short time and then leave. While trainees can enhance their residency experience by working in developing countries, the idea is to promote a sustainable relationship that builds capacity at both institutions.
A key component is to make sure the needs of the partner institution are being considered in order to ensure a long-term relationship. The needs of partner institutions, such as Makerere University, include the need for research collaboration, more visiting faculty to enhance their training programs, and recruitment and retention of trainees.
In June 2008, Ozgediz wrote in an article published by the National Institutes of Health that surgical conditions need to be brought into the global health conversation.
Ozgediz says the impact on health care systems of vertical, primarily infectious disease-specific support and donor programs needs to be evaluated, and that access to essential surgical care must be recognized as a basic human right by the global health community.
“Much of what trainees learn in a developing country can be applied to working in an inner city hospital,” says Ozgediz. “There are parallels between poverty, access to care and the advanced presentation of disease. Dealing with cultural challenges, especially around communicating with a patient, is often similar to what is experienced in inner city hospitals.”
In addition to capacity building at both institutions, there is an obvious local-global connection. Some parallels can be drawn between the limited resources of hospitals in Africa and those of hospitals serving underserved patients in the United States.
One key benefit for UCSF trainees in working abroad is that they are likely to see a more advanced presentation of disease than they might be exposed to at home. Often, trainees see in one week more than what it might take them a year to see in the United States. Junior researchers are also able to conduct trials in which they can see a large cohort of participants in a short time. That said, there are resource limitations in trying to set up research trials, and clinical hospital supplies are often limited in the host country.
“We have a lot of work ahead of us,” says Debas. “Fortunately, we know which problems need to be alleviated and where we can make progress. What is left for us to do is to implement the solutions and establish lasting relationships from which each partner can benefit. Together, we will learn more and have a greater chance of positively affecting the health of peoples around the globe.”
