Global Surgery: Assuring an Adequate Surgical Workforce Florida Chapter, American College of Surgeons April 7,2018 Patricia J Numann MD, FACS Lloyd S Rodgers Professor of Surgery Emerita Syracuse NY Disclosures No financial disclosures Why Care? • I travel a lot • Broken wrist in Dogon Country, Mali • Cairo -Alexandria highway crash • Woman lying dead on road for hours in Vietnam • Leaking aortic aneurysm Larantuka, Flores • Child with broken leg Laos 1
I could be involved • Association of Women Surgeons • International Society of Surgery • ACS Operation Giving Back • ACS International Relations Committee • ACS International Chapters • ACS International ATLS • International Presidents Access to care and workforce are a major issue • 5 billion without access up from 2 billion in 2000 • 11% of total loss of life per year is due to surgical problems –WHO 2002 • 6% of surgical procedures in 1/3 of world population • Africa only 7% surgeons are women • Trauma kills more people than HIV, Malaria, and TB • 2 million children awaiting surgery for congenital heart disease • 38 million people are blind 48% from cataracts • And then there is war and natural disasters Economic Data Supporting Benefit of Surgery • The Copenhagen Conference in 2008 [3] stated that provision of surgical care was one of the 25 most cost effective investments for low income countries. • Dr Jim Yong Kim, President of the World Bank, [4] has stated his goal is to eliminate extreme poverty by 2030 and eliminate poverty worldwide by 2050, support smart business models, reduce inequality and focus on the lowest 40%. • Providing surgical care will increase the work force and improve the economic status of low income countries. 2
WHO 2011 • Surgical care not part of its public health mission • 4% budget for surgical issues • More people in LMIC die of trauma than HIV,TB, and Malaria combined • US delegate to WHA did not vote in favor of including surgery in the public health mission of WHO WHO Endorsement Matters! • Increasing funding: World Bank support • Development of national policies, training and facilities • The young and women disproportionately affected: Childbirth, accidents, burns, congenital anomalies • Funding and expansion of WHO Global Initiative for Essential and Emergency Surgical Care GIEESC We can make a Difference • Unified to get WHO Resolution passed in 2015 • World Health Assembly Resolution (WHA68.15): “Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage.” • Lancet Commission on Global Surgery • World Bank’s Disease Control Priorities Project 3
The Lancet Global Health Surgeons / 100,000 population •Low Income: 0.7 •Lower Middle Income: 5.5 •Upper Middle income: 22.6 •High income: 56.9 • Homer et al: Global distribution of surgeons, anesthesiologists, and Obstetricians The Lancet Global Health April 2015 Statistics for LIC MD/20,000 Mat Mort Births Poverty Somalia 4 1/14 6 not avail Congo 2 1/24 6 59% Uganda 1 1/35 6.69 35% Senegal 1 1/46 5 34% Chad 1 1/15 6 62% 1100/100,00 0 Tanzania 1 1/23 5 89% US 40 21/100,000 WHO Birth Data 2010 Birth Attended by C Section Rate as percent of births Professional Low Income 46.9% 5.8 Country-$1035/yr Low Middle Income 60% 8.8 countries High Middle Income 97% 30.6 countries High Income 99% 29.6 Countries 4
Complications of Pregnancy • Ethiopia-18,000 women have obstructed labor each year. • 1/2 die the other half lose a baby and gain a fistula • C section available to small percent of low income world then 25% have no anesthesia available • A fistula means the woman will be ostracized and die Millennium Development Goals United Nations by 2030 • 17 Goals • Ensure Healthy Lives and promote well-being for all • Achieve gender equity and empower all women • Develop a global Partnership for development How do we achieve Global Access? What is our role? 5
Complex Issue • Lack of Basic education • Poverty • Social customs • Gender bias • Population density • Corruption Global Commitment • Achieve the Millennial Goals • Establish guidelines for engagement • Promote meaningful cultural change to prevent discrimination and violence • Empower women • Commit personally to help create the change World Health Organization November 2001 Core Domains of Good Stewardship Generation of intelligence Formalizing strategic policy direction Ensuring tools for implementation Coalition building Ensuring a fit between policy objectives and organizational structure and culture Ensuring accountability 6
Standards for Programs • Equitable exchange- give as much as you get • Do not diminish experience of in country trainee • Build Capacity • Be Sustainable • Build on existing facilities • Guidelines for Surgeons on Establishing Projects in Low-Income Countries. Grimes C. World J Surg 2013; 37:1203-1207 Understanding who does surgery • Very variable from country to country • Individual preceptor • Religious figure • 1 year training • Board Certified/Fellowship trained • Determined by the Government/ Surgical College/ Board/Licensure or maybe by the individual Circumcision cave -Mali 7
“Surgeon”-preparing knife Role of Women “Women hold up half the sky” Nicholas Kristof and Sheryl WuDong • Girls less likely to be educated • Must follow traditional cultural roles • Prevalent violence : Rape Honor crimes Female circumcision • In Subsaharan Africa only 7% surgeons women Ghana • Percent women in medical school 35% • Surgeons and related disciplines include ob-gyn, anesthesia, radiology [2007] Total 281 Women 20 [7.1%] Prof. E.D. Yeboah, Past President West African College of Surgeons 8
Lest We Forget The basic infrastructure of hospitals and the country affect the ability to provide surgical care: • Impassable roads with no alternative transportation • Unsafe or unavailable water • Unreliable electrical power ACS Survey • 92% residents • 50%Fellows more are older male general surgeons but 18% under 40 • ACS is committed to be part of solution “Mission” work • Approximately 40% of all surgery in Kenya in performed at such faith-based hospitals • 22% of all surgery in Ghana, but 35% of all surgery done at rural hospitals, is done at faith-based hospitals • ACS Operation Giving Back • Pan African Academy of Christian Surgeons[PAACS] 9
Give what is desired • Laparoscopic Cholecystectomy Surgery Program in Mongolia • Organized by Dr Ray Price-Utah • Now in All Mongolian Hospitals • Instituted Check list usage in all Mongolian Hospitals Laparoscopic Surgery Program in Mongolia • Established by Ray Price MD FACS from Utah • His Mormon Mission • Brought Laparoscopic surgery to Mongolia • More valuable to a laborer in Mongolia than an American • Educated and disseminated the technique to all Mongolian Hospitals ACS Global Initiatives International Relations Committee Develop an International Strategy ACS International Chapters ACS Board of Governors and Regents International Presidents Meeting Address Issues of Mutual concern ACS International Fellowships International ATLS Participate in International Cancer programs 10
Founded in 2004 • Humanitarian Aide • Disaster Relief Simulation Center in Ghana and East Africa Scholarships Exchange opportunities Recruits examiners for exams in COSECSA Global Health Competency for Surgeons Course ACS OGB CONSORTIUM OF ACADEMIC GLOBAL SURGERY • VISION STATEMENT • We envision unifying academic programs to discover solutions for safe, effective and affordable surgical care worldwide. • MISSION STATEMENT • To reduce the burden of untreated surgical disease in resource-limited areas, we collaborate to cultivate the next generation of compassionate, capable global surgery leaders, experienced in education, research, policy, and advocacy. Global commitment to Cancer Prevention and treatment • Smoking is increasing in the world • Reverse smoking causes Chutta cancer in India • Lack of awareness results in average presenting size of Breast cancer in LIC of 6.5cm • Need for liver transplant high in LMIC due to Hepatitis C • Slow to understand the increased risk of Gastric cancer in Japan and Esophageal in China 11
Global Plan • Increasing number of global initiative • Institutional Twining • Academic exchanges • Collaborative research • Building Sustainable Systems • Local solutions for local problems • Cost effective strategy for incremental improvement Funding Needs • Women Surgical Scholars Program in Sub-Saharan Africa Funding Goal: $25,000 annually • ACS Training Hub in Sub-Saharan Africa Funding Goal: TBD • Tumor Board Education Series Funding Goal: $81,000 Opportunities for Involvement • Alliance for Surgery and Anesthesia Presence • World Health Congress • International Studies programs: Duke, UNC, UCSF, U of Utah • Surgical Residencies with International rotations; 39 • MPH programs • Fellowships and Scholarships ACS Sponsors many • ACS committees-RAS, YSA, Trauma Committee • Doctors without Borders, Partners in Health, Local Missions • Keep informed-World Journal of Surgery • Personal volunteerism and philanthropy 12
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