Abstract
There are over 200 million operations performed worldwide annually, yet the poorest one-third of the world undergo only 3.5% of them (1). Historically, it has been believed that surgery can only address a small piece of the global burden of disease. This is not the truth. The burden of surgical diseases causes more disability and deaths than HIV, tuberculosis, and malaria combined. These deaths could have been avoided if there had been opportunity for surgical care (2).
Limited surgical capacity is the main reason for the neglect of surgical diseases in low- and middle-income (LMIC) countries. Across LMICs, general surgeon density ranges from 0.13 to 1.57 per 100,000 population (3). Also, the lack of other resources in surgical care in the LMICs is profound; there is lack of qualified nurses and other staff, surgical equipment and supplies, endoscopic and other diagnostic tools, and so on. (4). In addition to limitations of surgical capacity, poverty is a very important factor stopping surgical care. In many developing countries, patients must pay for the care prior to surgery, and extreme poverty prevents this (4). Another patient-related factor which affects the use of surgical services is that in many developing countries, a large part of the first-line medical care is still provided by traditional healers. Their treatment might be even harmful, but patients still rely on them (4).
Because of the lack of surgical care in LMICs, the international surgical community has taken a more active role in global health care. Increasing numbers of surgeons and surgical residents from the developed world are willing to take part in providing surgical services for the people living in LMICs (5). The most common model for surgical interventions in LMICs is that of the short-term surgical mission. In this kind of intervention, a small group of providers from a developed country travel to a developing country to provide as many surgical interventions as they are able (4).
With more than 10 years’ experience of organizing surgical missions to Sub-Saharan Africa, I would like to point out a few important issues in this respect. There have to be qualified surgeon(s) in the group with wide experience in general surgery and preferably in obstetrics; anesthesia; ear, nose, and throat (ENT) surgery; and medicine. The surgical conditions are often very severe, and there is no chance for modern imaging (computed tomography (CT), magnetic resonance imaging (MRI)) or other diagnostic tools. The decision to operate or not to operate is based mainly on clinical judgment. Even the language might cause extra difficulties in the diagnostics and treatment if no trained interpreters are available. Furthermore, when you are performing the operation, you have to cope with anything that transpires. Nobody is going to come and advise you in the case of severe bleeding or other complications. In addition, some of the surgical interventions you are conducting are no longer seen in the developed world, for example, chronic hematogenous osteomyelitis, club foot, and other congenital untreated deformities and sequelae of untreated traumas. It can be concluded that in these kinds of surgical missions, you are operating on very demanding cases with much poorer personnel and equipment than to what you are accustomed. It is good to have surgical residents in the group, but they have to be supervised by an experienced surgeon.
Postoperative follow-up has to be arranged for operated patients including changing of dressings and casts and even reoperations for surgical-site infections or other complications. Without follow-up, the consequences of complications for operated patients could be disastrous. The individual who will take care of follow-up could be a surgeon from a mission group or a local surgeon. The follow-up has to be long enough to detect late postoperative complications.
Voluntary organizations providing surgical missions often pay the cost of interventions for the patients. It has to be kept in mind that this might be a reason for the hospital not to change their health policy on a sustainable basis. Instead, they might expect mission providers to pay more and more of the costs. This is not acceptable. One should require the hospital to change their policy to a more sustainable financial basis, instead of bargaining more money from the mission providers.
Despite the challenges of the surgeons’ work in third world countries, I would like to encourage colleagues to participate in surgical missions to developing countries. It will give a new perspective to work, and when you come home from these kinds of missions, the challenges you are facing at your work seem to be somehow smaller.