Gita N. Mody

Shared learning in an interconnected world: innovations to advance global health equity

The notion of “reverse innovation”--that some insights from low-income countries might offer transferable lessons for wealthier contexts--is increasingly common in the global health and business strategy literature. Yet the perspectives of researchers and policymakers in settings where these innovations are developed have been largely absent from the discussion to date. In this Commentary, we present examples of programmatic, technological, and research-based innovations from Rwanda, and offer reflections on how the global health community might leverage innovative partnerships for shared learning and improved health outcomes in all countries.

Ten-year clinical experience of humanitarian cardiothoracic surgery in Rwanda: Building a platform for ultimate sustainability in a resource-limited setting

Objective: Despite its near complete eradication in resource‐rich countries, rheumatic heart disease remains the most common acquired cardiovascular disease in sub‐Saharan Africa. With a ratio of physicians/population of 1 per 10,500, including only 4 cardiologists for a population of 11.4 million, Rwanda represents a resource‐limited setting lacking the local capacity to detect and treat early cases of strep throat and perform lifesaving operations for advanced rheumatic heart disease. Humanitarian surgical outreach in this region can improve the delivery of cardiovascular care by providing sustainability through mentorship, medical expertise, training, and knowledge transfer, and ultimately the creation of a cardiac center. Methods: We describe the experience of consecutive annual visits to Rwanda since 2008 and report the outcomes of a collaborative approach to enable sustainable cardiac surgery in the region. The Ferrans and Powers Quality of Life Index tools Cardiac Version (http://www.uic.edu/orgs/qli/) was administered to assess the postoperative quality of life. Results: Ten visits have been completed, performing 149 open procedures, including 200 valve implantations, New York Heart Association class III or IV, with 4.7% 30‐day mortality. All procedures were performed with the participation of local Rwandan personnel, expatriate physicians, nurses, residents, and support staff. Early complications included cerebrovascular accident (n = 4), hemorrhage requiring reoperation (n = 6), and death (n = 7). Quality of life was assessed to further understand challenges encountered after cardiac surgery in this resource‐limited setting. Four major domains were considered: health and functioning, social and economic, psychologic/spiritual, and family. The mean total quality of life index was 20.79 ± 4.07 on a scale from 0 to 30, for which higher scores indicated higher quality of life. Women had significantly lower “social and economic” subscores (16.81 ± 4.17) than men (18.64 ± 4.10) (P < .05). Patients who reported receiving their follow‐up care in rural health centers also had significantly lower “social and economic” subscores (15.67 ± 3.81) when compared with those receiving follow‐up care in urban health facilities (18.28 ± 4.16) (P < .005). Value afforded to family and psychologic factors remained high among all groups. Major postsurgical challenges faced included barriers to follow‐up and systemic anticoagulation. Conclusions: This report represents the first account of a long‐term humanitarian effort to develop sustainability in cardiac surgery in a resource‐limited setting, Rwanda. With the use of volunteer teams to deliver care, transfer knowledge, and mentor local personnel, the results demonstrate superior outcomes and favorable indices of quality of life. The credibility gained over a decade of effort has created the opportunity for a partnership with Rwanda to establish a dedicated center of cardiac care to assist in mitigating the burden of cardiovascular disease throughout sub‐Saharan Africa.

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.

Design, testing, and scale-up of medical devices for global health: negative pressure wound therapy and non-surgical male circumcision in Rwanda

Products with high efficacy and low cost are desirable in all market sectors and environments, particularly in settings where resources are limited. The health sectors of developing nations are an example of this basic economic principle as constrained financial and human resources must be budgeted toward large (and often, growing) populations’ health needs. However, the cost and quality characteristics that are absolutely necessary in resource-limited settings (RLS) remain highly desirable in wealthy markets as well. Consequently, technologies and strategies designed in RLS are frequently adopted by high-income nations, a process termed “reverse innovation” [1-4]. In recent years, some medical and surgical devices designed for RLS have been adopted by high-income nations. These reverse innovations have simultaneously overcome historical barriers to medical device deployment in RLS and challenged previously held assumptions regarding the direction of information transfer between high- and low-income nations. The potential for reverse innovation has subsequently been proposed as a reason in and of itself to develop products for RLS [4]. Products that result in reverse innovation offer improved care quality and treatment outcomes at lower costs to health care systems, expand markets for manufacturers, promote bidirectional transfer of information, and strengthen global partnerships for health equity [1-4]. One country that has made investments in myriad health innovations is Rwanda, a landlocked East African nation of approximately 12 million. Within the past two decades, Rwanda’s limited resources and diverse health care needs have combined to produce health care innovations ranging from community-based service delivery pathways to novel vaccine roll-out strategies [5-10]. Rwanda’s innovative approaches to seemingly insurmountable health challenges, and the nation’s resounding successes in these initiatives, have been described in a previous article in this Globalization and Health special series [2]. In the present article, we describe our experience with medical device innovation in Rwanda through two case studies, highlighting approaches taken to accelerate development and facilitate bidirectional flow of information. We also discuss ongoing challenges to progress in the field of health technology innovation for RLS. In sharing our experiences, we add our voices to the call for health technology innovation for low- and middle-income countries (LMICs).

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.

Thoracic Endovascular Aortic Stent Graft to Facilitate Aortic Resection During Pneumonectomy and Vertebrectomy for Locally Invasive Lung Cancer

Endovascular stent graft placement has been used to facilitate resection of tumors invading the thoracic aorta. Here we describe the first use of an aortic endograft for preoperative protection of the thoracic descending aorta before left pneumonectomy for a primary lung cancer invading the thoracic spine and thoracic descending aorta.

Early Surgical Outcomes of En Bloc Resection Requiring Vertebrectomy for Malignancy Invading the Thoracic Spine.

BACKGROUND En bloc vertebral resection of locally invasive T4 lung cancers led to the development of a surgical sequence for resection; posterior stabilization, reposition, thoracotomy, lobectomy, vertebrectomy, and anterior spine stabilization in 1 procedure. This technique expanded indications for vertebrectomy to selected patients with sarcoma and metastatic disease. We review our experience to identify areas for clinical improvement. METHODS Operative case logs were cross-checked with billing data from 2003 to 2014 with Current Procedural Terminology (CPT, American Medical Association) codes for vertebrectomy. Thirty-two cases involving en bloc resection of malignancy invading at least 1 thoracic vertebra were selected. Outcomes data were analyzed using summary statistics. RESULTS Series includes 14 men and 18 women, median age 50 years. Twenty-five patients (78%) received preoperative chemoradiation. Nineteen total and 13 partial vertebrectomy were performed. Average number of vertebrae resected was 1.6 (range, 1 to 4). Median operative length was 8.5 hours (range, 2.8 to 14.5), mean blood loss 923 mL (SD ± 477 mL), and median length of stay 8 days (range, 3 to 56). Major morbidity followed 56% of cases. Thirty-day mortality was 3%. Overall median survival was 43.6 months, 1-year survival was 73.6%, and 5-year survival was 40.3%. CONCLUSIONS En bloc vertebrectomy for malignant disease is feasible. Our 1 stage and 2 team approach allows completion of the operation within a standard day, but is associated with long operative time. Complication rates may improve with decreased operative times. Review of available data warrants future prospective studies.

Biomechanical and safety testing of a simplified negative-pressure wound therapy device.

Background: There is a large, unmet need for acute and chronic wound care worldwide. Application of proven therapies such as negative-pressure wound therapy in resource-constrained settings is limited by cost and lack of electrical supply. To provide an alternative to existing electrically powered negative-pressure wound therapy systems, a bellows-powered negative-pressure wound therapy system was designed and iteratively improved during field-based testing. The authors describe the design process and the results of safety and biomechanical testing of their simplified negative-pressure wound therapy system. Methods: Simplified negative-pressure wound therapy was tested at two hospitals in Rwanda. Patients with wounds ranging from 2 to 150 cm2 and meeting inclusion and exclusion criteria were enrolled. Wounds were categorized by difficulty of dressing application according to location and contour. Outcomes were maintenance of negative pressure and occurrence of adverse events. Results: Thirty-seven patients with 42 wounds were treated with simplified negative-pressure wound therapy. Eighty-five dressings in total were applied. On average, the final simplified negative-pressure wound therapy dressing maintained negative pressure for 31.7 hours on all wounds (n = 37), and 52.7 hours on wounds in easy-to-dress locations. No unexpected adverse events occurred. Conclusions: This is the first systematic report of the performance of a bellows-powered negative-pressure wound therapy device designed specifically for use in resource-constrained settings. The authors found that elimination of air leaks in the simplified negative-pressure wound therapy dressing is essential, and that their system is safe and feasible for use in these environments. Subsequent trials will study the system’s efficacy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Carpal tunnel syndrome in Indian patients: use of modified questionnaires for assessment.

This study was conducted to assess the use of a modified carpal tunnel syndrome questionnaire (the Boston Carpal Tunnel Questionnaire, BCTQ) in an Indian patient population. Seventy-six Indian patients with carpal tunnel syndrome (CTS) were recruited to this prospective study. On a scale of one to five, the average score for the severity of symptoms was 2.09 (0.89). The average score for functional disability was 1.94 (0.74), which was lower than the average function score reported for Western CTS patients (Levine et al., 1993). The symptom severity and function disability scores were higher in patients with positive Tinel’s sign and Phalen’s test. The function disability score was moderately correlated with other clinical tests for CTS. The average modified BCTQ scores for Indian CTS patients was established through this study. This modified questionnaire might assist physicians in developing countries to assess disability from CTS, although socioeconomic and cultural differences will have to be taken into account when comparing assessments across different populations.