Allison F. Linden

Challenges of Surgery in Developing Countries: A Survey of Surgical and Anesthesia Capacity in Uganda’s Public Hospitals

BackgroundThere are large disparities in access to surgical services due to a multitude of factors, including insufficient health human resources, infrastructure, medicines, equipment, financing, logistics, and information reporting. This study aimed to assess these important factors in Uganda’s government hospitals as part of a larger study examining surgical and anesthesia capacity in low-income countries in Africa.MethodsA standardized survey tool was administered via interviews with Ministry of Health officials and key health practitioners at 14 public government hospitals throughout the country. Descriptive statistics were used to analyze the data.ResultsThere were a total of 107 general surgeons, 97 specialty surgeons, 124 obstetricians/gynecologists (OB/GYNs), and 17 anesthesiologists in Uganda, for a rate of one surgeon per 100,000 people. There was 0.2 major operating theater per 100,000 people. Altogether, 53% of all operations were general surgery cases, and 44% were OB/GYN cases. In all, 73% of all operations were performed on an emergency basis. All hospitals reported unreliable supplies of water and electricity. Essential equipment was missing across all hospitals, with no pulse oximeters found at any facilities. A uniform reporting mechanism for outcomes did not exist.ConclusionsThere is a lack of vital human resources and infrastructure to provide adequate, safe surgery at many of the government hospitals in Uganda. A large number of surgical procedures are undertaken despite these austere conditions. Many areas that need policy development and international collaboration are evident. Surgical services need to become a greater priority in health care provision in Uganda as they could promise a significant reduction in morbidity and mortality.

Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries.

BACKGROUND Surgery has been neglected in low- and middle-income countries for decades. It is vital that the Post-2015 Development Agenda reflect that surgery is an important part of a comprehensive global health care delivery model. We compare the operative capacities of multiple low- and middle-income countries and identify critical gaps in surgical infrastructure. METHODS The Harvard Humanitarian Initiative survey tool was used to assess the operative capacities of 78 government district hospitals in Bangladesh (n = 7), Bolivia (n = 11), Ethiopia (n = 6), Liberia (n = 11), Nicaragua (n = 10), Rwanda (n = 21), and Uganda (n = 12) from 2011 to 2012. Key outcome measures included infrastructure, equipment availability, physician and nonphysician surgical providers, operative volume, and pharmaceutical capacity. RESULTS Seventy of 78 district hospitals performed operations. There was fewer than one surgeon or anesthesiologist per 100,000 catchment population in all countries except Bolivia. There were no physician anesthesiologists in any surveyed hospitals in Rwanda, Liberia, Uganda, or in the majority of hospitals in Ethiopia. Mean annual operations per hospital ranged from 374 in Nicaragua to 3,215 in Bangladesh. Emergency operations and obstetric operations constituted 57.5% and 40% of all operations performed, respectively. Availability of pulse oximetry, essential medicines, and key infrastructure (water, electricity, oxygen) varied widely between and within countries. CONCLUSION The need for operative procedures is not being met by the limited operative capacity in numerous low- and middle-income countries. It is of paramount importance that this gap be addressed by prioritizing essential surgery and safe anesthesia in the Post-2015 Development Agenda.

Consensus Statements Regarding the Multidisciplinary Care of Limb Amputation Patients in Disasters or Humanitarian Emergencies: Report of the 2011 Humanitarian Action Summit Surgical Working Group on Amputations Following Disasters or Conflict

Limb amputations are frequently performed as a result of trauma inflicted during conflict or disasters. As demonstrated during the 2010 earthquake in Haiti, coordinating care of these patients in austere settings is complex. During the 2011 Humanitarian Action Summit, consensus statements were developed for international organizations providing care to limb amputation patients during disasters or humanitarian emergencies. Expanded planning is needed for a multidisciplinary surgical care team, inclusive of surgeons, anesthesiologists, rehabilitation specialists and mental health professionals. Surgical providers should approach amputation using an operative technique that optimizes limb length and prosthetic fitting. Appropriate anesthesia care involves both peri-operative and long-term pain control. Rehabilitation specialists must be involved early in treatment, ideally before amputation, and should educate the surgical team in prosthetic considerations. Mental health specialists must be included to help the patient with community reintegration. A key step in developing local health systems the establishment of surgical outcomes monitoring. Such monitoring can optimizepatient follow-up and foster professional accountability for the treatment of amputation patients in disaster settings and humanitarian emergencies.

Best Practice Guidelines on Surgical Response in Disasters and Humanitarian Emergencies: Report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space

The provision of surgery within humanitarian crises is complex, requiring coordination and cooperation among all stakeholders. During the 2011 Humanitarian Action Summit best practice guidelines were proposed to provide greater accountability and standardization in surgical humanitarian relief efforts. Surgical humanitarian relief planning should occur early and include team selection and preparation, appropriate disaster-specific anticipatory planning, needs assessment, and an awareness of local resources and limitations of cross-cultural project management. Accurate medical record keeping and timely follow-up is important for a transient surgical population. Integration with local health systems is essential and will help facilitate longer term surgical health system strengthening.

Distance to hospital and utilization of surgical services in Haiti: do children, delivering mothers, and patients with emergent surgical conditions experience greater geographical barriers to surgical care?

BACKGROUND An inverse relationship between healthcare utilization and distance to care has been previously described. The purpose of this study was to evaluate this effect related to emergency and essential surgical care in central Haiti. METHODS We conducted a retrospective review of operative logbooks from the Clinique Bon Sauveur in Cange, Haiti, from 2008 to 2010. We used Geographic Information Systems to map the home locations of all patients. Spearmans correlation was used to determine the relationship between surgical utilization and distance, and a multivariate linear regression model identified characteristics associated with differences in distances traveled to care. RESULTS The highest annual surgical utilization rate was 184 operations/100,000 inhabitants. We found a significant inverse correlation between surgical utilization rate and distance from residence to hospital (rs = -0.68, p = 0.02). The median distance from residence to hospital was 55.9 km. Pediatric patients lived 10.1% closer to the hospital than adults (p < 0.01), and distance from residence to hospital was not significantly different between men and women (p = 0.25). Patients who received obstetric or gynecologic surgery originated 7.8% closer to the hospital than patients seeking other operations (p < 0.01), and patients who received emergent surgical care originated 24.8% closer to the hospital than patients who received elective surgery (p < 0.01). CONCLUSIONS Utilization of surgical services was low and inversely related to distance from residence to hospital in rural areas of central Haiti. Children and patients receiving obstetric, gynecologic or emergent surgery lived significantly closer to the hospital, and these groups may need special attention to ensure adequate access to surgical care.

A pilot comparison of standardized online surgical curricula for use in low- and middle-income countries.

IMPORTANCE Surgical conditions are an important component of global disease burden, due in part to critical shortages of adequately trained surgical providers in low- and middle-income countries. OBJECTIVES To assess the use of Internet-based educational platforms as a feasible approach to augmenting the education and training of surgical providers in these settings. DESIGN, SETTING, AND PARTICIPANTS Access to two online curricula was offered to 75 surgical faculty and trainees from 12 low- and middle-income countries for 60 days. The Surgical Council on Resident Education web portal was designed for general surgery trainees in the United States, and the School for Surgeons website was built by the Royal College of Surgeons in Ireland specifically for the College of Surgeons of East, Central and Southern Africa. Participants completed an anonymous online survey detailing their experiences with both platforms. Voluntary respondents were daily Internet users and endorsed frequent use of both print and online textbooks as references. MAIN OUTCOMES AND MEASURES Likert scale survey questionnaire responses indicating overall and content-specific experiences with the Surgical Council on Resident Education and School for Surgeons curricula. RESULTS Survey responses were received from 27 participants. Both online curricula were rated favorably, with no statistically significant differences in stated willingness to use and recommend either platform to colleagues. Despite regional variations in practice context, there were few perceived hurdles to future curriculum adoption. CONCLUSIONS AND RELEVANCE Both the Surgical Council on Resident Education and School for Surgeons educational curricula were well received by respondents in low- and middle-income countries. Although one was designed for US surgical postgraduates and the other for sub-Saharan African surgical providers, there were no significant differences detected in participant responses between the two platforms. Online educational resources have promise as an effective means to enhance the education of surgical providers in low- and middle-income countries.

Validation of a community-based survey assessing nonobstetric surgical conditions in Burera District, Rwanda

BACKGROUND Validated, community-based surveillance methods to monitor epidemiologic progress in surgery have not yet been employed for surgical capacity building. The goal of this study was to create and assess the validity of a community-based questionnaire collecting data on untreated surgically correctable disease throughout Burera District, Rwanda, to accurately plan for surgical services at a district hospital. METHODS A structured interview to assess for 10 index surgically treatable conditions was created and underwent local focus group and pilot testing. Using a 2-stage cluster sampling design, Rwandan data collectors conducted the structured interview in 30 villages throughout the Burera District. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. RESULTS A total of 2,990 individuals were surveyed and 2,094 (70%) were available for physical examination. The calculated sensitivity and specificity of the survey tool were 44.5% (95% CI, 38.9-50.2%) and 97.7% (95% CI, 96.9-98.3%), respectively. The conditions with the highest sensitivity and specificity were hydrocephalus, clubfoot, and injuries/infections. Injuries/infections and hernias/hydroceles were the conditions most frequently found on examination that were not reported during the interview. CONCLUSION This study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity was likely related to limited access to care and poor health literacy. Accurate community-based surveys are critical to planning integrated health systems that include surgical care as a core component.

Epidemiology of untreated non-obstetric surgical disease in Burera District, Rwanda: a cross-sectional survey

BACKGROUND In low-income and middle-income countries, surgical epidemiology is largely undefined at the population level, with operative logs and hospital records serving as a proxy. This study assesses the distribution of surgical conditions that contribute the largest burden of surgical disease in Burera District, in northern Rwanda. We hypothesise that our results would yield higher rates of surgical disease than current estimates (from 2006) for similar low-income countries, which are 295 per 100 000 people. METHODS In March and May, 2012, we performed a cross-sectional study in Burera District, randomly sampling 30 villages with probability proportionate to size and randomly sampling 23 households within the selected villages. Six Rwandan surgical postgraduates and physicians conducted physical examinations on all eligible participants in sampled households. Participants were assessed for injuries or wounds, hernias, hydroceles, breast mass, neck mass, obstetric fistula, undescended testes, hypospadias, hydrocephalus, cleft lip or palate, and club foot. Ethical approval was obtained from Boston Childrens Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all participants. FINDINGS Of the 2165 examined individuals, the overall prevalence of any surgical condition was 12% (95% CI 9·2-14·9) or 12 009 per 100 000 people. Injuries or wounds accounted for 55% of the prevalence and hernias or hydroceles accounted for 40%, followed by neck mass (4·2%), undescended testes (1·9%), breast mass (1·2%), club foot (1%), hypospadias (0·6%), hydrocephalus (0·6%), cleft lip or palate (0%), and obstetric fistula (0%). When comparing study participant characteristics, no statistical difference in overall prevalence was noted when examining sex, wealth, education, and travel time to the nearest hospital. Total rates of surgically treatable disease yielded a statistically significant difference compared with current estimates (p<0·001). INTERPRETATION Rates of surgically treatable disease are significantly higher than previous estimates in comparable low-income countries. The prevalence of surgically treatable disease is evenly distributed across demographic parameters. From these results, we conclude that strengthening the Rwandan health systems surgical capacity, particularly in rural areas, could have meaningful affect on the entire population. Further community-based surgical epidemiological studies are needed in low-income and middle-income countries to provide the best data available for health system planning. FUNDING The Harvard Sheldon Traveling Fellowship.

Prevalence of Untreated Surgical Conditions in Rural Rwanda: A Population-Based Cross-sectional Study in Burera District

Importance In low- and middle-income countries, community-level surgical epidemiology is largely undefined. Accurate community-level surgical epidemiology is necessary for surgical health systems planning. Objective To determine the prevalence of surgical conditions in Burera District, Northern Province, Rwanda. Design, Setting, and Participants A cross-sectional study with a 2-stage cluster sample design (at village and household level) was carried out in Burera District in March and May 2012. A team of surgeons randomly sampled 30 villages with probability proportionate to village population size, then sampled 23 households within each village. All available household members were examined. Main Outcomes and Measures The presence of 10 index surgical conditions (injuries/wounds, hernias/hydroceles, breast masses, neck masses, obstetric fistulas, undescended testes, hypospadias, hydrocephalus, cleft lip/palate, and clubfoot) was determined by physical examination. Prevalence was estimated overall and for each condition. Multivariable logistic regression was performed to identify factors associated with surgical conditions, accounting for the complex survey design. Results Of the 2165 examined individuals, 1215 (56.2%) were female. The prevalence of any surgical condition among all examined individuals was 12% (95% CI, 9.2-14.9%). Half of conditions were hernias/hydroceles (49.6%), and 44% were injuries/wounds. In multivariable analysis, children 5 years or younger had twice the odds of having a surgical condition compared with married individuals 21 to 35 years of age (reference group) (odds ratio [OR], 2.2; 95% CI, 1.26-4.04; P = .01). The oldest group, people older than 50 years, also had twice the odds of having a surgical condition compared with the reference group (married, aged >50 years: OR, 2.3; 95% CI, 1.28-4.23; P = .01; unmarried, aged >50 years: OR, 2.38; 95% CI, 1.02-5.52; P = .06). Unmarried individuals 21 to 35 years of age and unmarried individuals aged 36 to 50 years had higher odds of a surgical condition compared with the reference group (aged 21-35 years: OR, 1.68; 95% CI, 0.74-3.82; P = .22; aged 36-50 years: OR, 3.35; 95% CI, 1.29-9.11; P = .02). There was no statistical difference in odds by sex, wealth, education, or travel time to the nearest hospital. Conclusions and Relevance The prevalence of surgically treatable conditions in northern Rwanda was considerably higher than previously estimated modeling and surveys in comparable low- and middle-income countries. This surgical backlog must be addressed in health system plans to increase surgical infrastructure and workforce in rural Africa.

Validation of a community-based survey assessing non-obstetric surgical conditions in Burera District, Rwanda

BACKGROUND Community-based surveillance methods to monitor epidemiological progress in surgery have not yet been employed for surgical capacity building. The aim of this study was to create and assess the validity of a questionnaire that collected data for untreated surgically correctable diseases throughout Burera District, northern Rwanda, to accurately plan for surgical services. METHODS A structured interview to assess for the presence or absence of ten index surgically treatable conditions (breast mass, cleft lip/palate, club foot, hernia or hydrocele [adult and paediatric]), hydrocephalus, hypospadias, injuries or wounds, neck mass, undescended testes, and vaginal fistula) was created. The interview was built based on previously validated questionnaires, forward and back translated into the local language and underwent focus group augmentation and pilot testing. In March and May, 2012, data collectors conducted the structured interviews with a household representative in 30 villages throughout Burera District, selected using a two-stage cluster sampling design. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. Ethical approval was obtained from Boston Childrens Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all households. FINDINGS 2990 individuals were surveyed, a 97% response rate. 2094 (70%) individuals were available for physical examination. The calculated overall sensitivity of the structured interview tool was 44·5% (95% CI 38·9-50·2) and the specificity was 97·7% (96·9-98·3%; appendix). The positive predictive value was 70% (95% CI 60·5-73·5), whereas the negative predictive value was 91·3% (90·0-92·5). The conditions with the highest sensitivity and specificity, respectively, were hydrocephalus (100% and 100%), clubfoot (100% and 99·8%), injuries or wounds (54·7% and 98·9%), and hypospadias (50% and 100%). Injuries or wounds and hernias or hydroceles were the conditions most frequently identified on examination that were not reported during the interview (appendix). INTERPRETATION To the best of our knowledge, this study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity limits the use of the tool, which will require further revision, and calls into question previously published unvalidated community surgical survey data. To improve validation of community-based surveys, community education efforts on common surgically treatable conditions are needed in conjunction with increased access to surgical care. Accurate community-based surveys are crucial to integrated health system planning that includes surgical care as a core component. FUNDING The Harvard Sheldon Traveling Fellowship.