Adam L. Kushner

Addressing the Millennium Development Goals From a Surgical Perspective Essential Surgery and Anesthesia in 8 Low- and Middle-Income Countries

HYPOTHESISnSurgical and anesthetic care is increasingly recognized as a neglected but cost-effective component of primary health care in low- and middle-income countries (LMICs). Strengthening delivery can help achieve Millennium Development Goals 4, 5, and 6. Large gaps in access to essential surgical care in LMICs result in considerable morbidity and mortality. The goal of this study was to provide a baseline overview of essential surgical and anesthetic capacity at district-level health facilities in multiple LMICs.nnnDESIGNnSurvey.nnnSETTINGnDistrict-level health facilities in multiple LMICsnnnMAIN OUTCOME MEASURESnA standardized World Health Organization tool was used at selected district-level hospitals to assess infrastructure, supplies, and procedures relating to essential surgical and anesthetic capacity. The analysis included facilities from countries that assessed more than 5 health facilities. All data were aggregated and blinded to avoid intercountry comparisons.nnnRESULTSnData from 132 facilities were analyzed from 8 countries: Democratic Socialist Republic of Sri Lanka (n = 32), Mongolia (n = 31), United Republic of Tanzania (n = 25), Islamic State of Afghanistan (n = 13), Republic of Sierra Leone (n = 11), Republic of Liberia (n = 9), Republic of The Gambia (n = 6), and Democratic Republic of São Tomé and Príncipe (n = 5). Universally, facilities demonstrated shortfalls in basic infrastructure (water, electricity, oxygen) and functioning anesthesia machines. Although 73% of facilities reported performing incision and drainage of abscesses, only 48% were capable of undertaking an appendectomy. In line with Millennium Development Goals 4, 5, and 6, only 32% of facilities performed congenital hernia repairs, 44% of facilities performed cesarean sections, and few facilities always had goggles and aprons to protect surgical health care workers from human immunodeficiency virus.nnnCONCLUSIONnEnormous shortfalls in infrastructure, supplies, and procedures undertaken are common at district-level health facilities in LMICs.

Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care.

HYPOTHESISnLack of access to surgical care is a public health crisis in developing countries. There are few data that describe a nations ability to provide surgical care. This study combines information quantifying the infrastructure, human resources, interventions (ie, procedures), emergency equipment and supplies for resuscitation, and surgical procedures offered at many government hospitals in Sierra Leone.nnnSETTINGnSite visits were performed in 2008 at 10 of the 17 government civilian hospitals in Sierra Leone.nnnMAIN OUTCOME MEASURESnThe World Health Organizations Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used to assess surgical capacity.nnnRESULTSnThere was a paucity of electricity, running water, oxygen, and fuel at the government hospitals in Sierra Leone. There were only 10 Sierra Leonean surgeons practicing in the surveyed government hospitals. Many procedures performed at most of the hospitals were cesarean sections, hernia repairs, and appendectomies. There were few supplies at any of the hospitals, forcing patients to provide their own. There was a disparity between conditions at the government hospitals and those at the private and mission hospitals.nnnCONCLUSIONnThere are severe shortages in all aspects of infrastructure, personnel, and supplies required for delivering surgical care in Sierra Leone. While it will be difficult to improve the infrastructure of government hospitals, training additional personnel to deliver safe surgical care is possible. The situational analysis tool is a valuable mechanism to quantify a nations surgical capacity. It provides the background data that have been lacking in the discussion of surgery as a public health problem and will assist in gauging the effectiveness of interventions to improve surgical infrastructure and care.

Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda.

BACKGROUNDnOperative disease is estimated to contribute to 11% of the global burden of disease, but no studies have correlated this figure to operative burden at the community level. We describe a survey tool that evaluates population-based prevalence of operative conditions and its first full-country implementation in Rwanda.nnnMETHODSnThe Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool is a cross-sectional, cluster-based population survey designed to measure conditions that may necessitate an operative consultation or intervention. Household surveys in Rwanda were conducted in October 2011 in 52 clusters nationwide. Data were population-weighted and analyzed with the use of descriptive statistics.nnnRESULTSnA total of 1626 households (3175 individuals) were sampled with a 99% response rate. 41.2% (95% confidence interval [95 CI%] 38.8-43.6%) of the population has had at least one operative condition during their lifetime, 14.8% (95% CI 13.3-16.5%) had an operative condition during the previous 12 months, and 6.4% (95% CI 5.6-7.3%) of the population were determined to have a current operative condition. A total of 55.3% of the current operative need was found in female respondents and 40.3% in children younger than 15 years of age. A total of 32.9% of household deaths in the previous year may have been related to operative conditions, and 55.0% of responding households lacked funds for transport to the nearest hospital providing general practitioner operative services.nnnCONCLUSIONnThe SOSAS survey tool provides important insight into the burden of operative disease in the community. Our results show a high need for operative care, which has important implications for the global operative community as well as for local health system strengthening in Rwanda.

Implementing Liberia's poverty reduction strategy: An assessment of emergency and essential surgical care.

OBJECTIVEnTo document infrastructure, personnel, procedures performed, and supplies and equipment available at all county hospitals in Liberia using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care.nnnDESIGNnSurvey of county hospitals using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care.nnnSETTINGnSixteen county hospitals in Liberia.nnnMAIN OUTCOME MEASURESnInfrastructure, personnel, procedures performed, and supplies and equipment available.nnnRESULTSnUniformly, gross deficiencies in infrastructure, personnel, and supplies and equipment were identified.nnnCONCLUSIONSnThe World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care was useful in identifying baseline emergency and surgical conditions for evidenced-based planning. To achieve the Poverty Reduction Strategy and delivery of the Basic Package of Health and Social Welfare Services, additional resources and manpower are needed to improve surgical and anesthetic care.

Surgical care in the Solomon Islands: a road map for universal surgical care delivery.

BackgroundAccess to surgical care and emergency obstetrical care is limited in low-income countries. The Solomon Islands is one of the poorest countries in the Pacific region. Access to surgical care in Solomon Islands is limited and severely affected by a country made up of islands. Surgical care is centralized to the National Referral Hospital (NRH) on Guadalcanal, leaving a void of care in the provinces where more than 80% of the people live.MethodsTo assess the ability to provide surgical care to the people living on outer islands in the Solomon Islands, the provincial hospitals were evaluated using the World Health Organization’s Global Initiative for Emergency and Essential Surgical Care Needs Assessment Tool questionnaire. Data on infrastructure, workforce, and equipment available for treating surgical disease was collected at each provincial hospital visited.ResultsSurgical services are centralized to the NRH on Guadalcanal in Solomon Islands. Two provincial hospitals provide surgical care when a surgeon is available. Six of the hospitals evaluated provide only very basic surgical procedures. Infrastructure problems exist at every hospital including lack of running water, electricity, adequate diagnostic equipment, and surgical supplies. The number of surgeons and obstetricians employed by the Ministry of Health is currently inadequate for delivering care at the outer island hospitals.ConclusionsShortages in the surgical workforce can be resolved in Solomon Islands with focused training of new graduates. Training surgeons locally, in the Pacific region, can minimize the “brain drain.” Redistribution of surgeons and obstetricians to the provincial hospitals can be accomplished by creating supportive connections between these hospitals, the NRH, and international medical institutions.

Traumatic Injuries in Developing Countries: Report From a Nationwide Cross-Sectional Survey of Sierra Leone

OBJECTIVEnTo use a nationwide household survey tool to provide an estimate of injury prevalence, mechanisms of traumatic injuries, and number of injury-related deaths in a low-income country.nnnDESIGNnA randomized, cross-sectional nationwide survey using the Surgeons OverSeas Assessment of Surgical Need tool was conducted in 2012.nnnSETTINGnSierra Leone, Africa.nnnPARTICIPANTSnThree thousand seven hundred fifty randomly selected participants throughout Sierra Leone.nnnMAIN OUTCOME MEASURESnMechanisms of injury based on age, sex, anatomic location, cause, and sociodemographic factors as well as mechanisms of injury-related deaths in the previous year were the primary outcome measures.nnnRESULTSnData were collected and analyzed from 1843 households and 3645 respondents (98% response rate). Four hundred fifty-two respondents (12%) reported at least 1 traumatic injury in the preceding year. Falls were the most common cause of nonfatal injuries (40%). The extremities were the most common injury site regardless of age or sex. Traffic injuries were the leading cause of injury-related deaths (32% of fatal injuries).nnnCONCLUSIONSnThis study provides baseline data on the mechanisms of traumatic injuries as well as the sociodemographic factors affecting injury prevalence in one of the worlds poorest nations. It is anticipated that these data will provide an impetus for further studies to determine injury severity, associated disability, and barriers to accessing care in these resource-poor areas.

Surgical needs of Nepal: pilot study of population based survey in Pokhara, Nepal.

AbstractBackgroundThe Surgeons OverSeas assessment of surgical need (SOSAS) tool, a population-based survey on surgical conditions in low- and middle-income countries (LMICs), was performed in Sierra Leone and Rwanda. This pilot study in Nepal is the initial implementation of the SOSAS survey in South Asia.MethodsA pilot study of SOSAS, modified for Nepal’s needs and reprogrammed using mobile data collection software, was undertaken in Pokhara in January 2014. Cluster randomized sampling was utilized to interview 100 individuals in 50 households within two wards of Pokhara, one rural and one urban. The first portion of the survey retrieved demographic data, including household members and time to nearest health facilities. The second portion interviewed two randomly selected individuals from each household, inquiring about surgical conditions covering six anatomical regions.ResultsThe pilot SOSAS in Nepal was easily completed over 3xa0days, including training of 18 Nepali interns over 2xa0days. The response rate was 100xa0%. A total of 13 respondents had a current surgical need (face 4, chest 1, back 1, abdomen 1, groin 3, extremity 3), although eight reported there was no need for surgical care. Five respondents (5xa0%) had a current unmet surgical need.ConclusionnThe SOSAS pilot study in Nepal was successfully conducted, demonstrating the feasibility of performing SOSAS in South Asia. The estimated 5xa0% current unmet surgical need will be used for sample size calculation for the full country survey. Utilizing and improving on the SOSAS tool to measure the prevalence of surgical conditions in Nepal will help enumerate the global surgical burden of disease.

Conditions, preventable deaths, procedures and validation of a countrywide survey of surgical care in Nepal

To determine a true denominator of worldwide surgical need, it is imperative to include estimations at a population‐based level, to capture those individuals unable to access surgical care. This study was designed to validate the Surgeons OverSeas Assessment of Surgical need (SOSAS) tool with the addition of a visual physical examination, and describe the prevalence of surgical conditions, deaths possibly averted with access to surgical care, and the number of surgical procedures performed annually, in Nepal.

Topics in Global Public Health

Deficiencies in the delivery of musculoskeletal trauma care in low- and middle-income countries can be attributed to a variety of causes, all of which can be linked to failure of the health system to deliver the necessary services to prevent death and disability. As such, a “systems” approach will be required to improve the delivery of services. The goal of this review is to familiarize the orthopaedic surgeon with selected topics in public health, including health systems, burden of disease, disability adjusted life year (DALY), cost-effective analysis, and related concepts (eg, met versus unmet need, access, utilization, effective coverage).

Cancer surgery in low-income countries: an unmet need.

OBJECTIVESnTo describe the surgical oncology experience at a major regional hospital in Malawi and to identify barriers to improved outcomes.nnnDESIGNnRetrospective review of operating logbooks from a single tertiary referral center.nnnSETTINGnMajor tertiary referral center (Kamuzu Central Hospital) in Lilongwe, Malawi, in sub-Saharan Africa.nnnPATIENTSnPatients were identified with a suspected diagnosis of cancer from January 1, 2004, through March 7, 2007.nnnMAIN OUTCOME MEASURESnCancer cases were classified according to patient demographic characteristics, disease location, and therapeutic intent. The Malawi data were compared with US data from the Surveillance Epidemiology and End Results database.nnnRESULTSnA malignant diagnosis was suspected in 255 of the 1440 patients undergoing a major resection (17.8%) (mean patient age, 53 years). The most common cancers in males were prostate, esophageal, and gastric. In females, the most common cancers were breast, colon, and esophageal. Many of the procedures were performed with palliative intent.nnnCONCLUSIONSnCancer surgery comprises a significant proportion of the surgical caseload in low-income countries. Patients often present with late-stage, inoperable cancer. The participation of the surgical community is critical for addressing barriers to effective cancer care.