Probe and Suture
Global health professionals come together to determine a path to better surgical care
It doesn’t take long to break a leg. It can happen in an instant and in many different ways: a traffic accident, a workplace misstep, or a slip on the way home from school. But what happens afterward differs greatly depending on where you are.
In most parts of the United States, the injured leg would be repaired surgically using well-established orthopedic procedures that have been developed to help restore the limb’s normal functioning, and medications would be administered to stave off the risk of infection from either the injury or the surgery.
For any of the five billion people globally who don’t have access to safe, affordable surgical care, the story could have a different ending: disability, impoverishment, or even death from infection.
Although surgery is an integral part of health care in industrialized countries, research from a report by the Lancet Commission on Global Surgery, an international group that seeks to improve the quality of and access to surgical care around the world, reveals that nine out of ten people living in many low- and lower-middle-income countries simply do not have access to surgical care. In addition, the report estimates that the worldwide human and economic costs of poor to no access to surgical care could reach slightly more than U.S. $12 trillion in the next five years.
This situation, say many in the global health community, may result from the fact that for too long surgical care has been considered too costly to be on the list of must-do improvements to the delivery of health care.
HMS students win innovation challenge with their safe, collapsible, aseptic surgery device
There is, however, a growing chorus calling for change. New collaborative working models are finding unexpected ways to deliver care, while the work of entities such as the Lancet Commission are providing data to help propel that change. And many of the individuals leading the drive for study and change are surgeons and researchers from HMS.
Tundra to Tropics
The Gundrum family from Wisconsin anticipated difficulties even before their son Dominic was born. Ultrasounds revealed a rare, severe facial cleft and, from his forehead, an encephalocele, a protrusion of the brain and its membrane. Searching for ways to help their son, they came across the story of a Haitian boy named Dumanel born with a similar condition. Dumanel, they learned, had received help from HMS surgeon, and co-chair of the Lancet Commission, John Meara.
Dominic also became a patient of Meara’s, and, like Dumanel’s, his facial cleft and encephalocele were repaired. Meara, the Steven C. and Carmella R. Kletjian Professor of Global Health and Social Medicine in the field of Global Surgery at HMS and plastic surgeon-in-chief at Boston Children’s Hospital, has spent years treating patients wherever he finds them, working on the cleft palates and craniofacial anomalies of patients in southeast Asia, Australia, the Caribbean, and the United States. He says he doesn’t think of his work at Boston Children’s and his global surgery work as separate practices.
“Human beings have the same problems and diseases regardless of whether they’re in Boston or Bangkok,” Meara says. “They should have the same care, wherever they are.”
Ron Alterman would more than agree with Meara on the need to improve surgical care and access to such care throughout the world. His work in Chile sets inequities in surgical care and facilities in sharp relief.
In 2014, Alterman, an HMS professor of neurosurgery and the head of neurosurgery at Beth Israel Deaconess Medical Center, traveled to Santiago to perform the first deep-brain stimulation procedure undertaken in Chile’s public hospital system. He was invited by David Aguirre-Padilla, a Chilean neurosurgeon who had spent time in Boston working with Alterman on various neurosurgical techniques, particularly those involving deep-brain stimulation. Aguirre-Padilla hoped to use deep-brain stimulation to treat a young patient who suffered from generalized dystonia, a neurological disorder in which out-of-sync firing of neurons in the brain cause the muscles of the body to contract involuntarily.
Deep-brain stimulation works like a pacemaker for the brain, sending synchronized electrical signals into specific regions of the brain where electrodes have been implanted. The electrical pulses help regulate the firing of neurons and thus calm the involuntary contractions. To make sure the electrodes are properly placed, a surgeon takes a reading of the patient’s brain activity while the wires are being implanted. Conditions must be controlled within the operating room to ensure clean readings: if, for example, there are electrical wires that aren’t properly shielded, background noise can perturb the readings from the implanted electrodes.
Alterman has performed this surgery more than a thousand times in operating rooms in New York City and Boston, so the complexity of the procedure did not trouble him. What did present a challenge that day, he says, was the fact that the hospital’s CT scanner broke, stymieing efforts to visually check the placement of the electrodes. To get a visual read on their placement, he and his patient had to take an ambulance across town to a hospital with a functioning MRI.
Although the patient came through the surgery well, Alterman points out that the lack of suitable support equipment made a complex procedure more challenging than necessary—and could have the same effect on routine procedures. Reliable equipment, a consistent supply of electricity, and clean water can be hard to maintain in some countries, Alterman says, adding that it is a problem that will need to be addressed as Chile and other nations develop their surgical capacity.
Those who question whether surgery should be considered part of global health development often cite this need for across-the-board modernization and standardization as reasons for keeping surgery out of these development discussions. The costs are said to be too steep with the feeling being that focus should instead be placed on efforts such as eradicating a single communicable disease or providing anti-malarial bed nets, which offer quicker and more obvious returns on investment. By contrast, those who want to keep surgery on the table during global health development discussions point out that the basic infrastructure improvements being advocated for surgical care are also needed for effective nonsurgical care.
The need for better surgical equipment and training in her native Vietnam prompted Thanh-Nga Tran ’05 to establish and maintain a center that offers continuing medical education and modern tools to Vietnamese dermatologists.
When Tran returned to Vietnam during her residency with the Harvard Dermatology Program, she saw many children with disfiguring birthmarks. She was also startled to see some who had been burned and scarred by radioactive phosphorus, an outdated technique for treating vascular anomalies. Tran realized that the scars she saw on her young patients weren’t from a disease or accident, but from a misguided treatment.
“The cure shouldn’t be worse than the disease itself,” says Tran, an HMS instructor in dermatology at Massachusetts General Hospital and cofounder of the Vietnam Vascular Anomalies Center, now part of the Ho Chi Minh City University of Medicine and Pharmacy.
During her training at HMS and MIT, Tran had learned about using lasers to treat hemangiomas, the rubbery nodules of extra blood vessels in the skin sometimes known as strawberry birthmarks. With the help of her mentor, Richard Anderson ’84, an HMS professor of dermatology at Mass General, she obtained a donated laser and set out to find a way to get better treatment to the people who needed it.
Tran knew that one laser and a team of volunteer doctors in a rented room would not reach enough patients or make the systemic changes needed, so she developed partnerships with local doctors and institutions. The center now offers continuing medical education training to Vietnamese dermatologists and has launched a public education campaign on the dangers of using radioactive phosphorus as a dermatologic treatment. Center personnel also have convinced the main cancer hospitals and practitioners in Ho Chi Minh City to end their use of radioactive phosphorus.
Throughout the HMS community, the individual humanitarian efforts of professionals like Alterman, Meara, and Tran are being augmented by large-scale projects aimed at addressing the lack of surgical infrastructure around the world. In 2012, the Dana Farber–Brigham and Women’s Cancer Center, for example, collaborated with Partners In Health and the Rwanda Ministry of Health to open the first comprehensive cancer referral facility in rural East Africa, while surgeons from Mass General have been developing surgical education programs in Liberia and Bangladesh since 2002. Yet the question of how to fit all these pieces together to solve the puzzle of improving surgery worldwide remains.
Weights and Measures
From the beginning, Meara says, the goal of the Lancet Commission wasn’t just to quantify the lack of global surgical capacity; it was to create a base of knowledge and measurable indicators that could be used to build that capacity in a coherent, focused way.
When the commission was established in 2013, Meara adds, no one knew what was going on with surgery around the world. There were no comprehensive assessments of how many surgeons worked in different countries, few records of how many or what kinds of surgical procedures were being done in a given country each year, and no reliable estimate of what percentage of a population lived within two hours of a hospital that offered essential surgical procedures.
Even the most basic safety index—how many people survived surgery—has often gone unknown, almost completely absent from international development databases and national health care planning reports.
According to Meara, the commission has been able to derive rough estimates of various measures in many countries, but detailed measures remain elusive. Since the commission published its report in April 2015, Meara has had the growing corps of surgeons working in the Paul Farmer Global Surgery Fellowship in the HMS Department of Global Surgery and Social Change focus on collecting key indicators of surgical capacity from more than one hundred countries and on developing better, more detailed analyses of the data that are available.
The important thing, according to those involved in assessing surgery worldwide, is to know that surgery is not a separate entity that competes with all the other changes needed in health care systems. It’s not just about broken legs—it’s about obstructed labor, cancer, infectious disease, and every other condition you can name.
Jake Miller is a science writer in the HMS Office of Communications and External Relations.
Images: iStock (top); John Soares (portraits)