With the growth of global health awareness, global surgery has emerged as a key focus area. This article examines short-term surgical trips (STSTs) as one of the ways used to address some of the gaps in global surgery. It demonstrates the Kenyan experience in organising and participating in a short-term surgical trip with a 10-year history. Their experience has been that STSTs should be co-organised between the regional hosting surgeons and the visiting surgical team, with an emphasis on education rather that the ‘number of surgeries’ performed during each camp.
Background
With justice, human rights and equity at the core of global health, there has been an increased effort to address some of the challenges affecting the health of the greater population of the world. This has seen the discussion focus on countries with less resources and with higher burdens of disease.
Traditionally there has been a greater focus on communicable diseases such as HIV/AIDS, tuberculosis, and malaria. However, recently there is increased interest in the field of non-communicable diseases and, in particular, the field of global surgery. Indeed, there is need to focus on surgery, as 30% of the global burden of disease is surgical. The Lancet Commission on Global Surgery released a report in 2015 noting that five billion people lack access to safe, timely, affordable surgery, the majority of whom are in low- and middle-income countries (LMICs). An additional 143 million surgical procedures are required yearly in LMICs [1]. Some refer to surgery as the neglected stepchild of global health, showing the gravity of the issue. Slowly, attention has begun to shift to surgery.
The challenges faced by LMICs are many, including lack of resources both in infrastructure and manpower. In sub-Saharan Africa, with a population of one billion people, the ratio of the surgical workforce to population is less than 1-14.99/100,000 as compared to high-income countries (HICs) which range from 40-100/100,000 (Figure 1) [2]. This is despite having a disproportionally higher burden of disease than their HICs counterparts.
Figure 1. Global distribution of surgeons, anaesthesiologist, and obstetricians per 100,000 population.
Image courtesy of the Lancet Global Health [2].
Short-term surgical trips (STSTs)
One of the strategies to address access to surgical care has been through STSTs, also referred to as ‘short-term surgical missions’, ‘surgical blitzes’, ‘surgical outreaches’, or ‘surgical camps’. STSTs involve visiting teams of surgeons congregating at a particular area, usually an underprivileged region, and offering surgical care usually for free to the community for a short duration (generally one-to-two weeks). They have been in existence for some time, and initially involved missionaries providing healing for the body and soul. Over the years, as the field of global surgery grew, non-governmental organisations and academic institutions got involved. Many STSTs focus on otolaryngology and diseases of the head and neck e.g. cleft lip/palate, chronic otitis media, and other head and neck pathology.
Controversies around STSTs
The STST model of global surgery is not without controversy. The sustainability of STSTs has been questioned [3]. There have been questions about outcomes of patients operated on, whether STSTs are a cost-effective health delivery model, and that reported outputs of STSTs have generally simply focused on the number of patients operated on.
Even though concerns raised should not be ignored and should be addressed, judging all STSTs in a negative light may not be warranted. With limited access to surgical healthcare, the deployment of highly-specialised surgical teams can be very valuable for local communities. The experience of some of the camps that have been run successfully for many years may offer solutions to some of the concerns. The views of LMIC surgeons who have benefitted from such STSTs are also essential to consider when tackling the reported shortcomings of STSTs. In a publication by Mulwafu W et al, rules of engagement for surgical outreaches in ENT have been highlighted and valuable pearls on an approach one may take when organising an STST are provided [4].
A successful STST model
The authors have been involved in organising and attending head and neck surgical camps with a 10-year history in Malindi, Kenya. It is a collaborative effort, primarily between the Kenya Ear Nose and Throat Society (KENTS), University of Nairobi and the Vanderbilt University, led by Prof Jim Netterville and the Caris Foundation.
Photo of the 2019 Malindi head and neck surgical camp team.
Prof Jim Netterville giving a didactic lecture before surgery.
Dr Macharia from Kenya performing a thyroidectomy under the guidance of Dr Mike Moore.
The camp has been instrumental in empowering the local ENT surgeons in head and neck surgery. By 2014, 25% percent of the local ENT surgeons had participated in the camp [5]. Post-camp surveys indicate increased confidence in the surgical skills of the attendees. The visiting team also benefits from seeing the spectrum of head and neck disease presentation at Malindi and learning how to manage them in a low-resource setting.
Based on our first-hand experience, training of the local workforce in safe surgery should form the backbone of STSTs. With the primary objective being training, it should be a genuine collaborative effort, with local surgeons determining the training needs together with the visiting surgeons. Once this is determined, it will influence patient selection. A focus on safe surgery while understanding the strengths and limitations of the local environment is key. A structure for preoperative workup and postoperative follow-up should be determined as this may determine whether one proceeds with some surgeries. While running the camp, attention should be focused on ‘quality control’ to ensure the principle of safe surgery. With the high volume of surgeries being performed, there should be general principles that the camp should adhere to from the outset: relevant investigations need to be done; informed consent taken (the local team may help with translation); pre-anaesthetic reviews should be conducted; a World Health Organization surgical checklist should be completed; patients’ charts should be updated regularly; and a clear discharge summary written.
Even though STSTs may not be the ‘magic bullet’ that sorts out global surgery challenges, when integrated with the other efforts such as dissection courses, online resources, and fellowship programmes among others, STSTs can contribute to improve and increase the skillset of the local surgical workforce [5].
Conclusion
As the field of global health, and in particular global surgery evolves, some of the traditional avenues used to address surgical challenges in limited resource areas need to refocus on more sustainable approaches. From our experience, truly collaborative and educational surgical outreaches are highly impactful and sustainable.
References
1. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet 2015;386(9993):569-624.
2. Holmer H, Lantz A, Kunjumen T, et al. Global distribution of surgeons anaesthesiologists and obstetricians. The Lancet Global Health 2015;27(3):s9-11
3. Shrime MG, Sleemi A, Ravilla TD. Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training. World Journal of Surgery 2015;39(1):10-20.
4. Mulwafu W, Fagan JJ, Mukara KB, Ibekwe TS. ENT outreach in Africa: rules of engagement. OTO Open 2018 May;2(2).
5. Fagan JJ, Zafereo M, Aswani J, et al. Head and neck surgical subspeciality training in Africa: sustainable models to improve cancer care in the developing world. Head and Neck 2017;39(3):605-11.
