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Unsafe surgery is a global crisis, silencing millions of women around the world. Let’s talk about it.
Read the stories. Choose the one that speaks to you. Tell someone about it – and share your experiences.

Margaret Bugyei-Kyei

“You’ve got to wear white for three months.” Margaret is a senior ODP at Great Ormond Street Hospital in London.Read more →

2014/03/06

World Health Organization, Department of Human Res …

World Health Organization, Department of Human Resources for Health – Spotlight on Statistics

2014/03/06

Sandra de Castro Buffington

“Storytelling can help women to know what best practice looks like – and empower them to demand it. It’s probablyRead more →

2014/03/06

Cat Kemeny

“It is hard enough for the men to afford or access treatment, and generally it just will not happen forRead more →

2014/03/06

Alisa Swidler

“Too many people don’t even know what fistula is, because they don’t experience it as an issue.” Alisa is aRead more →

2014/03/06

Dr Ophira Ginsburg

“Women often aren’t the primary decision maker for their own healthcare.” Ophira is a medical oncologist at the Women’s CollegeRead more →

2014/03/06

PLOS One

Obstructed labor and Caesarean Delivery: The Cost and Benefit of Surgical Intervention – PLOS One

2014/03/06

Aisslta Bissang-Kondet

“I’ll tell you the story of a 9 year old girl I can’t manage to forget.” Aisslta – known toRead more →

2014/03/05

Dr Rola Hallam

“About a year ago in Syria I met an obstetrician who was delivering women on her kitchen floor.” Rola isRead more →

2014/03/05

Dr Zipporah Gathuya

“The surgeons were screaming they needed to get the baby out.” Zipporah is a Consultant Anaesthetist working in Kenya. Her areaRead more →

2014/03/05

Dr Sophia Webster

“The assumption is always that flying a light aircraft, especially a single engine, is a risk.” Sophia is a UK-basedRead more →

2014/03/05

Dr Sherry Wren

“They think of surgery as transplants and plastics and don’t realize that there’s a huge population that has no accessRead more →

2014/03/05

Royal College of Obstetricians and Gynaecologists; …

England. Child and Maternal Health Intelligence Network – RCOG Snapshot of surgical activity in rural Ethiopia: is enough being done?Read more →

2014/03/05

Dr Rebecca Jacob

“Patient on the ground, instruments boiled over a kerosene stove by the light of a hurricane lamp.” Rebecca recently retiredRead more →

2014/03/05

Morgan Mandigo

“It reminds me of a quote I heard – that in many African countries people will say “I’d rather haveRead more →

2014/03/05

Dr Lesong Conteh

“If you are looking at the economic impact of surgery on women and their households, then the costs associated withRead more →

2014/03/05

Dr Marianne Stephen

“There might be a more acceptable level of risk, but the grief – that kind of grief is never normalized.”Read more →

2014/03/05

Laura Kilduff

“When the baby’s heart rate was dropping I wasn’t worried about me, it was purely about the baby and howRead more →

2014/03/05

Dr Sandra Leal

“Latin America shares many things, among them a strong regard for family – which constitutes the center for society” SandraRead more →

2014/03/05

Kathleen O’Neill

“In terms of treating breast cancer – even when it’s not curable – the impact of surgery is still immeasurableRead more →

2014/03/05

The Lancet

Global operating theatre distribution and pulse oximeter supply: an estimation from reported data – The Lancet

2014/03/05

Dr Jaymie Ang Henry

“The fast food industry solved problems of global planning, global logistics – if they can, why can’t we? Why don’tRead more →

2014/03/05

Janet Dewan CRNA, MS

“I cared for a woman who had been suffering as an outcast for 25 years, since her first baby. ItRead more →

2014/03/05

Dr Jane Fitch

“The comparison between resources can make anaesthesia a very different experience. It makes you realize how wasteful we are, howRead more →

2014/03/05

Dr Isabeau Walker

“Safe surgery should be a basic right that is available to all women who require it during childbirth.” Isabeau isRead more →

2014/03/05

Dr Eva Hanciles

“Often the first time a pregnant women come to hospital is when she’s been trying to deliver at home withoutRead more →

2014/03/05

Camila Maglaya

“I always say – we’re not always rich back home – but we do whatever we can, we speak out.”Read more →

2014/03/05

Barbara Margolies

“Have you ever met a woman with fistula? It is absolutely devastating. The smell is so overwhelming some people can’tRead more →

2014/03/05

Archives of Surgery

Operative mortality in resource-limited settings: the experience of Medecins Sans Frontieres in 13 countries – Archives of Surgery

2014/03/05

Dr Angela Enright

“Women are the glue that hold the family together. If the mother dies in childbirth, it is a catastrophe forRead more →

2014/03/05

Dr Angela Davis

“There’s a strong cultural message that somehow having an elective C-section is an ‘easier’ way to give birth.” Dr AngelaRead more →

2014/03/05

Dr Ronke Desalu

“Safe surgery is tied up with the socio-economic status, political participation and education of women.” Ronke is an Associate ProfessorRead more →

2014/03/05

Dr Queeneth Kalu

“They say ‘Abasi Akan uman ikwa,’ meaning ‘God forbid delivery by knife!’” Queeneth is a Senior Lecturer and Chairman,Medical AdvisoryRead more →

2014/03/05

Dr Nneka Anaegbu

“In the coming decade we’ll be on the frontier and at the helm.” Nneka is a Consultant Anaesthetist at LagosRead more →

2014/03/05

Evelyn Felicia Somah

“Back home they have this thing – if you’re going to surgery, you’re going to die.” Evelyn is a seniorRead more →

2014/03/05

Comfort Osagie-Ogbeide

“You have to buy your life.” Comfort works in hospital administration in London. She is originally from Nigeria. What isRead more →

2014/03/05

Priscilla

2014/03/05

Dr Kelly McQueen

“Women with cancer in the early stages with the hope of treatment and cure often have no access to anRead more →

2014/03/05

Erica Frenkel

“Retweeting and liking aren’t enough. Change happens when large groups of passionate, committed people make it happen.” Erica Frenkel isRead more →

2014/03/05

Judy Mewburn

“The pelvic outlet on a girl of 11 or 12 – you could no more get a baby through thereRead more →

2014/03/05

Dr Kathleen Casey

“The ability to provide quality surgical care is a proxy for a well functioning medical system.  And that’s part ofRead more →

2014/03/05

Dr Michelle White

“It’s powerful to see how generous they are in their love and affection for each other.” Michelle is Head ofRead more →

2014/03/05

Tropical Doctor

Deaths associated with anaesthesia in Togo, West Africa – Tropical Doctor

2014/03/05

Dr Jannicke Mellin-Olsen

“Anaesthesia and surgery go hand in hand – it is difficult to do surgery if the patient is in pain.”Read more →

2014/02/27

Emma Patrick

Dr Emma Patrick Emma Patrick is a consultant anaesthetist working in New Zealand having trained in the UK. She has a specialistRead more →

2014/02/21

Katy Kuhrt

“I know the majority of my friends at medical school are interested in global surgery” Katy is a 4th yearRead more →

2014/02/05

Dr Amy Keightley

“In the UK we have swabs with a radio band so that if you lose one in the body duringRead more →

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Margaret Bugyei-Kyei

Margaret Bugyei-Kyei

“You’ve got to wear white for three months.”

Margaret is a senior ODP at Great Ormond Street Hospital in London. She trained as a nurse and then in anaesthesia in Ghana.

How do you celebrate a safe C-section in Ghana?

It’s a big celebration! You’ve got to wear white for three months. There has been so much fear that you won’t make it through alive, so everyone is celebrating, rejoicing. “Thank God you’ve come out of surgery successfully,” everyone tells you.

Here you don’t have that tradition – it’s just an everyday fact of life.

Is surgery so unsafe?

There’s a lot of fear, anxiety. People believe that you go into surgery and you don’t come back – because really that happens a lot.

They think it’s the operation that killed you, but surgery is essential when you need to do it. It’s education, transportation, poverty – all these things that delay treatment. By the time you’re ready it’s too late.

What are the barriers to safe surgery for women in Ghana?

Resources, equipment – poverty. Most patients come and they have nothing – but they still need to provide everything. Relatives are sent to the cash and carry to buy the medications, they have to donate the blood before any treatment takes place.

In the U.K. you get emergency care without hesitation. If you need something in the theatre your hands reach out to it, there it is. We have monitors; we have drugs; we have a cupboard of machines to help with difficult intubation, or locating a vein. What do I do back home? How do I get help?

Is equipment a big issue?

Most of the equipment sent to Africa is second-hand – some isn’t even working but it’s dumped on us. There’s a lack of everything. We reuse everything.

Patients die for lack of basic monitoring equipment. Women go into labour and they don’t even have a place to rest their head – a bed is like equipment to put their heads on.

What is it like to deliver care in this setting?

It’s tragic. Tragic for the patient and tragic for the nurse. You are going to let a patient lose their life for no reason – you could have saved them easily with the right equipment, access. So you withdraw; your spirit is demoralized.

And telling the families is so hard. It’s difficult enough to get a surgery. They get there and think – please, now it’s going to be ok.

Why did you train in anaesthesia?

First I trained in nursing. I’m the type who really loves caring for people. But at the time I was working in theatres we didn’t have enough anaesthetists – so I decided I could be a role model for my colleagues. At the time I was the only female who trained as a nurse anaesthetist on the course.

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Sandra de Castro Buffington

Sandra de Castro Buffington

“Storytelling can help women to know what best practice looks like – and empower them to demand it. It’s probably the most effective tool we have to reach people with new ideas and information.”

Sandra is the Founding Director of the Global Medical Center for Social Impact at UCLA’s Fielding School of Public Health, leading social change through storytelling and entertainment.

You worked in family planning and reproductive health in low-resource countries for more than 20 years. Was surgery an important aspect?

I remember that over 80% of admissions were obstetric and gynaecology. Women are absolutely the majority coming in through the emergency rooms for emergency surgery, and it’s a multiple crisis when a woman in a low-resource country loses her health and her wellbeing.

Oftentimes the father doesn’t have the will or the wherewithal to raise a family. Her life is on the line, but so is theirs.

When I was 19 I moved to northeast Brazil, to a very small fishing village. There was a family across the road with nine children, the mother pregnant with her tenth. She died in childbirth. And those children – they became orphans.

The Global Media Center for Social Impact raises awareness and action for health issues through storytelling. How can narrative help women in need of safe surgery?

Storytelling can help women to know what best practice looks like – and empower them to demand it. It’s probably the most effective tool we have to reach people with new ideas and information.

People have to care – you have to entertain, engage and empower, in that order.

But everything from intention to action can change when we’re transported by a story.

And it’s not about story v statistics in my experience. Once writers are inspired on a topic they often incorporate statistics into storylines, so that people never actually realize they’re learning something.

Surgical safety sounds like a dry concept. How could storytelling bring it alive?

It already has! A few years ago when the WHO Surgical Safety Checklist was being launched, I took Atul Gawande as an expert on surgical safety to speak with a couple of TV show executives here in Hollywood. And I asked him, on the way over, to start with a story.

He took a case study from medical literature – a complex case about all the really important and timely steps that were taken to save a child’s life, and won our full attention. We cared deeply about this little 3-year old girl who had drowned, and her parents – we lost our bearings and arrived in a new world. And once we were there, we were so open to learning.

Did it translate to television?

When Atul bought the Surgical Safety Checklist into the story it was so interesting to us. The creator of the TV show ER ended up writing a storyline about how it saves the life of a beloved character, and the audience really cared.

It aired on a Thursday night and Friday morning at 6 a.m., surgeons were being gathered together to watch the episode. Many were so moved they ended up adopting the Checklist for their own practice; patients were coming in and asking if they used the Checklist before surgery; it actually bought global attention to the issue.

What is the long-term impact?

It’s so interesting – you have art imitating life and life imitating art, bringing it into popular culture where it becomes more widely accepted. The stories can strike how you create the future.

There are so many challenges to safe surgery, particularly in low-resource settings where you don’t have equipment to sterilize instruments, or disposal for surgical waste. We can help to create demand for safe surgical practice if we show what a healthy cycle looks like, and inspire women and me around the world to demand it.

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Cat Kemeny

Cat photo

“It is hard enough for the men to afford or access treatment, and generally it just will not happen for the women.”

Cat is a medical student who previously served with the army as a Medical Support Officer in the Joint Forces Medical Group in Bastion, Afghanistan.

Her interview reflects that experience; they are personal opinions and do not necessarily reflect MoD policy.

Why is access to safe surgery an important issue for women’s health?  

Afghanistan, after Chad, has the highest infant mortality rates in the world and giving birth there is an enormous risk to each woman.  Many in the poorer areas, e.g. Helmand, have no access to hospitals.  Medical care must generally be paid for (unless there is a charitable hospital), and when living in a hand to mouth existence (on the absolute limit of survival), paying for hospital treatment is simply not going to happen.

Does gender play a role in accessing treatment?

It is hard enough for the men to afford or access treatment, and generally it just will not happen for the women.  As a result they are seen by other women in the village, who may or may not have any medical training.  More likely they are the older women in the village and just have more experience with birth.

For a woman to receive care she would need to be escorted by a male relative (sometimes these were young boys – perhaps aged 8 years old), and that means he’s not able to contribute to the earning/survival of his family while he is chaperoning the woman.

What is the reality of the situation faced by a woman in need of surgery when she lives in a conflict zone?  

It was pretty much all trauma – we were in Helmand in 2009.  Our remit was to treat coalition forces, including Afghan National Army and Afghan National Police.

While we, the Coalition, would make every effort to help those (men, women, children) who were injured in any cross fire that they were involved in, the reality is that most women would not get surgical care and certainly not long term follow up care.

Life is pretty brutal, and often short.

What role do women play in delivering surgical care in the low-resource setting countries you’ve worked?

The women are key.   If you can teach women some basic obstetric care you can make a huge difference to mother and baby survivability.  Teaching them about hygiene: hand washing, toilet siting etc, and basic care for burns (very common in open fire cooking), minor wounds and sickness will do a great deal to improve the health of the whole village.  However, you need approval from the village elders first and then need a suitable team to deliver the teaching, which can also be very difficult to achieve.

And in the long-term?

You can also achieve wider aims – which are of relevance in a conflict setting, such as improved relations and cooperation – in turn this can improve the lot of the village and help install relative peace.

Successful surgical care must be delivered at multiple levels, tactical and strategic.  From  the women in the villages, improving the local hospital standards and ensuring useable equipment is available through to decisions on how to ‘grow your own’ medics, keep them in country and develop national policy on health care.

It needs to move beyond focusing on helping a few mothers in a few villages, without a longer-term view on how to stabilise and build a health care service.  Survival will never improve if you focus on one level only.

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Alisa Swidler

Alisa Swidler

“Too many people don’t even know what fistula is, because they don’t experience it as an issue.”

Alisa is a leading philanthropist and campaigner for human justice and health issues.

How has motherhood changed your perspective on maternal health?
Comparing levels of care during childbirth – it can get pretty dire. In the U.S. they really hold your hand, they walk you through the tests, the vitamins, the questions. Then you go to a hospital in a low-resource setting and there are no bed sheets in the hospitals, just old torn mattresses. Women deliver, if they make it to hospital, on a cold metal frame.

We talk about health all the time with our children – we’re so lucky when it comes to that.

What’s your greatest frustration when it comes to women accessing healthcare worldwide?

It’s not always a priority for everyone.

I think there could be more focus on it – we should come up with better ways of addressing certain issues, and even exposing them.  Too many people don’t even know what fistula is, because they don’t experience it as an issue.

When did you first learn about obstetric fistula?

About eight years ago, through Richard Branson and Virgin Unite.

That was after I had all my children.  So I actually didn’t know it was a risk; it was not even a concern while I was pregnant.  That’s how it should be, because no one needs to suffer that trauma.

If it does happen – because transport is an issue, because a woman in labour can travel days to get to a hospital – we need to see that it’s not a taboo, that they get the surgery they need.

What can people do about it?

Ask questions.  I’ve been on so many boards in the last 20 years and I’m always the one who won’t stop asking questions.  About accountability, about the specifics, about how money is being spent.

There’s a lot of duplicating efforts in global health and it really bothers me – because there are so many areas, like access to safe surgery for women, that still need attention.

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Dr Ophira Ginsburg

Ophira Ginsberg

“Women often aren’t the primary decision maker for their own healthcare.”

Ophira is a medical oncologist at the Women’s College Research Institute in Canada. Her work focuses on women’s health equality and global cancer control. As the winner of a Grand Challenges Canada award, she and her team are using mobile phone technology to improve breast cancer diagnosis and care in Bangladesh.

Is global surgery for women just about obstetrics?

No, it’s about women’s health – which is about much more than just reproductive health.

Of course access to safe surgery is critically important for complicated births – we lose thousands of women unnecessarily in so many countries for lack of obstetric care. But what a colossal shame for their child to watch them die of breast or cervical cancer ten years later because basic surgical care was unavailable.

What is the reality for a woman with cancer in a low-resource country?

It cuts down women in the prime of their lives. Most of the world’s deaths from cervical cancer are in these countries, and breast cancer strikes at a much lower age – in Canada on average at 61, in India and Bangladesh it’s about 42, 44.

These operations aren’t difficult to teach. But despite all the attention we pay cancer in high-income countries, there is silence on the topic of high-quality – or even basic – surgical intervention for women in low-resource settings.

Is there a gender imbalance?

Gender inequality really plays a role, especially in rural Bangladesh where I work. Women often aren’t the primary decision maker for their own healthcare. Most of the cases we see at our clinic are very advanced (and of course there’s a lack of palliative care) primarily because women aren’t coming when surgery would have made a difference.

They see that their aunty, their mother doesn’t come back – instead they need to see that effective surgery can save their life.

So do women with cancer get no surgical treatment at all?

Sometimes it’s worse than that. A third of the women we interviewed for a study published in the International Journal of Breast Cancer had already had ‘surgery.’ That is to say they’d had a suspicious lump partly cut out, highly unsafe surgery with no pathology, no follow up.

So here they are again a year later with a fungating [necrotic] tumour. It’s a profoundly morbid situation that absolutely could have been prevented with proper surgical management.

What is the wider impact of lack of access to safe surgical care?

Beyond the obvious of women dying unnecessarily? Effectively, orphan children. Children younger than ten may not immediately die from malnutrition, but they’re ostracized, impoverished, less likely to complete school – imagine what happens to them later in life?

Limited access to surgery, inadequate or unsafe surgery, directly contributes to the cycle of poverty.

 

Links:

http://www.womensresearch.ca/researchers/core-faculty/ophira-ginsburg-msc-md-frcp

http://www.hindawi.com/journals/ijbc/2012/423562/

http://biostat3.net/download/articles/paper3_effectofparentsdeathonchildsurvivalinruralbangladesh.pdf

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PLOS One

statistics2

Obstructed labor and Caesarean Delivery: The Cost and Benefit of Surgical Intervention – PLOS One

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Aisslta Bissang-Kondet

Aicha Bissang-Kondet

“I’ll tell you the story of a 9 year old girl I can’t manage to forget.”

Aisslta – known to everyone as Aicha – has been a senior anaesthetic and resuscitation technician in Lome, Togo since 1993. She’s a member of many organisations and has held the position of president and secreatary general. She is married with 3 children, and loves to exchange ideas and experiences.

Selon vous, pourquoi l’accès à la chirurgie est-il essentiel pour la santé des femmes? / Why is access to safe surgery essential for women’s health?

Les femmes ont recours à la chirurgie pour 2 grandes raisons. Une: parce qu’elles sont malades et le traitement est obligatoirement chirurgicale, et deux: elles sont en bonne santé mais elle cherche à devenir mère ou au moment d’un accouchement par césarienne ou alors à la suite d’un traumatisme suite à un viol.

Women need surgery for two main reasons. One: because they’re sick and like anyone else they need surgical treatment, and two: they’re in good health but require obstetric care, like a C-section for pregnancy or following a rape trauma.

Quels sont les obstacles qui empêchent les femmes à obtenir les soins dont elles ont besoin? / What are the obstacles that stop women from getting the care they need?

Brièvement: l’ignorance; les moyens financiers dans les familles; l’absence de structure de santé à proximité.

In brief: lack of awareness; financial resources of the family; lack of any reachable health facility

Que souhaitent faire les jeunes filles dans votre entourage lorsqu’elles seront adultes ? / What do young women in Togo want to be when they grow up?

Si je fais le tour des jeunes filles dans ma propre famille ”africaine” sur 11 filles qui sont au lycée 3 veulent la santé et 2 veulent être médecin mais pas de chirurgie. Les autres c’est finance, gestion ou droit. Oui il y’a un obstacle : l’importance des études (les matières sont exclusivement scientifique) et la durée de la formation très longue

If I look at the young women in my own ‘African’ family, of 11 girls who are at school, three want to go into health and two want to be a doctor – but not surgery. The others – finance, management, law. But obviously there is an obstacle: the importance of education and the long period of training.

Pourriez-vous nous raconter l’histoire d’un patient qui vous a marqué? / Can you share the story of a patient that has stuck in your mind?

Je vais raconter l’histoire d’une fillette de 9 ans que je n’arrive pas à oublier. La fillette pendant les vacances et les jours où il n’y a pas l’école aide sa mère à vendre des oranges. Les oranges sont dans un plateau et elle se promène avec. Tous les passants peuvent l’interpeler et acheter. Alors un monsieur lui dit qu’il veut acheter tout le plateau et lui demande de le suivre chez lui car il n’a plus d’argent sur lui. Arrivé chez lui il dit à la petite de venir prendre son argent à l’intérieur de sa chambre. De la, il viola sérieusement la petite qui a perdu connaissance. Comment a-t-il fait, personne ne sais mais la petite a été retrouvée non loin du petit marché de son quartier et transportée à l’hôpital en état de choc. Les gynécologues ont réussi à faire l’hémostase et avec la réanimation bien conduite l’enfant a la vie sauve mais avec d’important dégât FRV +FVV (vagin vessie et rectum sont confondu). Il a fallu une intervention chirurgicale pour que cette petite soit sauvée.

I’ll tell you the story of a 9 year-old girl that I can’t manage to forget. When the girl didn’t have school or during the school holidays, she would help her mother sell oranges. She’d take a tray of fruit and walk about with it, so that passers by could see. One day a man told her he wanted to buy the whole tray – but she’d have to follow him home, because he didn’t have any money. He called for her to take the money from his bedroom where he raped her. She was found unconscious near the market and taken to hospital in a state of shock. Doctors managed to revive her and stop the bleeding, but they had to repair her bladder and rectum as she’d received a traumatic fistula. It’s only because of surgery that this little girl was saved.

Quel est votre objectif de feminisation de la profession médicale dans les prochaines décennies? / What is your goal for women in the medical profession in the coming decades?

Faire aimer les matières scientifiques aux jeunes filles en proposant des prix d’encouragement ; en soutenant financièrement leurs études afin qu’elles n’arrêtent pas parce que les parents n’ont plus les moyens Pour les femmes qui travaillent déjà organiser des rencontres internationales d’échanges, encourager les promotions professionnelles ou organiser des voyages de perfectionnement pour améliorer leurs prestations.

I want incentives for girls to love science subjects; financial support for their studies so that they don’t have to stop when their parents can’t afford it. For women already working in the field I want to organise international meetings, encourage them to learn and push themselves and develop their skills.

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Dr Rola Hallam

Dr Rola Hallam

“About a year ago in Syria I met an obstetrician who was delivering women on her kitchen floor.”

Rola is a British-Syrian doctor in anaesthesia and intensive care. Since the beginning of the Syrian crisis, Rola has been working on health advocacy and the delivery of humanitarian and medical aid.

Is access to surgery really such an issue worldwide?

It’s a huge, huge problem. But we don’t talk about it very much. I think people underestimate how many incidences in our life we do need surgery, partly because it’s something we take for granted in this country. But for millions and millions of people around the world that’s simply not the case. They don’t have it at all, or it’s unsafe. Which means people are dying unnecessarily.

Is this the case for people in Syria right now?

Very few conflicts resemble each other, especially from a health perspective. Some don’t affect the system that much – and some unfortunately, as in the case of Syria, involve systematic targeting of healthcare and health professionals.

Just two weeks ago a hospital in Aleppo was destroyed with what’s called ‘intelligent’ missiles – a three-bedded intensive care unit, three ORs, 20 beds, newly-furbished by an NGO. It killed five patients, relatives, and injured 14 people.

70% of the hospitals and clinics have been destroyed or are non-functional; it’s near total destruction of the system.

What does this mean for the healthcare workers?

Healthcare providers are either killed, imprisoned or have left the country.

And so Aleppo – the largest populated city in Syria, which had just over 5000 doctors before the conflict – now has about 30.

You’re talking about a staggering reduction and therefore a massive burden of care on the remaining doctors.

A recent assessment of need in Syria found that the health sector is the biggest emergency and biggest priority in Syria, just ahead of food security. It shows just what a massive problem this is.

What does this mean for women?

We have a very high proportion of children and women in Syria – approximately 70% of the population, and we used to have relatively good antenatal and maternal care. Now public health becomes a massive issue, primary health becomes a massive issue – and of course, maternal health is significantly compromised.

And we haven’t even talked about the violence itself. If you were a civilian under constant bombardment you’d think twice before traveling to see a doctor – especially when you can’t afford to pay for medication because there’s huge unemployment.

You can’t collect data easily under the conflict, but there’s a huge amount of anecdotal evidence of harm to women and children.

So where are women giving birth?

About a year ago in Syria I met an obstetrician who was delivering women on her kitchen floor. There was no health service nearby but people knew she lived there. They’d literally go knock on her door and she had no choice – she closed the kitchen and turned it into a little birthing centre.

We’ve been hearing about women who set off over long distances in the last month of their pregnancy, under the shelling, to get to areas of slightly better healthcare.

It’s devastating. In any nice world you’d be sitting down and getting excited about your new arrival. Instead you’re crossing really scary military barricades, questioned for hours perhaps – and then you’re essentially homeless. You have to find somewhere to live, guns and bombs going off around you.

Are their babies surviving?

We’re seeing a huge rise in premature birth, which may well be due to poor nutrition and health of mothers. Some are in the siege area, where food and medicine aren’t allowed in. There’s a lack of clean water.

Some people think it might also be to do with their mental state. If you’re heavily pregnant and suddenly bombs are falling around you, and your neighbours are being killed and your house destroyed – a lot of them are delivering early from the stress.

And because the healthcare system is so inadequate, a lot of babies are dying. If not from lack of facilities, from the lack of baby milk. We’re finding – again, anecdotally – that women under these stressful and malnourished circumstances don’t have adequate breast milk.

I must have heard tens of these cases – it only leads me to believe there must be hundreds, if not thousands.

What can people be doing?

Under humanitarian law it’s absolutely illegal to be targeting and destroying healthcare structures. We’ve heard it condemned but there hasn’t really been anything concrete on that, so we need serious pressure on a policy level.

Everyone needs to do their bit. Governments, NGOs, individuals – whether you adopt a health center to rebuild it, provide security and salary support for doctors so they stay, antibiotics for arriving patients.

You have to be specific about what you need. Hand in Hand for Syria went back to the obstetrician’s kitchen and we built a small children’s and women’s facility in the excavated basement, generously funded by the public. It’s amazing what can happen with willpower and staff and incredibly dedicated colleagues on the ground. It can be done, it is being done, and people can engage with that. I hope so, anyway.

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Dr Zipporah Gathuya

Dr Zipporah Gathuya

“The surgeons were screaming they needed to get the baby out.”

Zipporah is a Consultant Anaesthetist working in Kenya. Her area of interest is Paediatric Anaesthesia and anaesthesia education.

Why is access to safe obstetric surgery essential for women?

Women are the carers for the family, especially in low-income countries. There are always other people who they are taking care of, despite having just had a baby. And there is certainly not much income to spare for complications.

Most women go for delivery being healthy. For them to continue in that health is paramount.

And if they don’t get it? What is the impact on the baby?

When the mother has a difficult labour the child risks hypoxia [oxygen starvation] or another complication like cerebral palsy, which has such a high infant mortality rate. These children can become a big burden on the whole family, and usually have miserable lives.

I have also seen many children whose mothers died at delivery and whose relatives never came to pick them from the hospital. It is very sad for that child, who will never quite appreciate maternal love.

Is there a particular case that sticks in your mind?

When I was training a mother was brought to the labour ward with severe pre-eclampsia [a life-threatening complication of pregnancy]. She was 33 years old, on her third pregnancy but had no living baby.

Just as she was wheeled into the operating room for an emergency C-section she had a seizure and began vomiting. The surgeons were screaming they needed to get the baby out.

We delivered a live male infant, but the mother went into renal shutdown. It took her three weeks to recover, and she went home with her son after a month.

Access to safe anaesthesia was essential to her survival. Though it has been more than 10 years, the scenario is still very vivid in my mind.

What is the role of education here?

The impact and importance of education to the mothers on access to antenatal care cannot be overemphasized. Caesarean sections are now more acceptable, whereas initially women would have the notion that a Caesarean section was a sign of weakness.

Education and skill advancement of both the anaesthesia and surgery providers will go along way towards minimizing the risk of many mothers dying or suffering complications.

Let’s talk again about the positive aspects of safe obstetric care. What is the long-term legacy?

If the mothers are sure that they will have safe pregnancy, delivery and child survival; even the issue of family planning will be more widely acceptable.

A healthy mother is a healthy community.

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Dr Sophia Webster

Dr Sophia Webster

“The assumption is always that flying a light aircraft, especially a single engine, is a risk.”

Sophia is a UK-based obstetrician who recently flew a small airplane from the U.K. to South Africa, landing in 26 African countries along the way to promote safe pregnancy.

Which is more dangerous, having a baby in a low-resource setting or single-handedly flying a plane over an ocean?

Definitely the baby. Unsafe pregnancy is impacting directly on the safety of the life of mothers and children on a daily basis.

The assumption is always that flying a light aircraft, especially a single engine, is a risk. The fact that it’s comparatively much safer demonstrates the level of risk that women around the world are putting themselves through – not just once, but multiple times through their reproductive life.

I don’t think people realize the extent to which women’s lives are at risk just for the fact that they want a family.

What was the idea behind the journey?

It’s difficult to measure women’s health, there are a lot of different angles. Whereas a fairly simple way of thinking about how healthy a pregnant population is: how many women survive that journey?

Women who are going through pregnancy and childbirth in high-resource countries don’t really understand what their counterparts in sub Saharan Africa have to face. There’s under-recognition even within the professional community.

It’s always difficult to marry what you read and what you see. Generally statistics read true on the ground. But a statistic versus seeing the reality is something different. I compared what I saw and it fired me up. It’s not fair on so many levels.

What is the likelihood of childbirth by C-section?

Most women in their lives will get pregnant. We’re all at risk of the same clinical problems, but only in some countries will they advance unmanaged; only in some countries will you die from them.

For a first pregnancy in the U.K. there’s a 20% risk of having a C-section. The exact percentage varies around the world, but one thing remains the same: it needs to be conducted in a theatre with an anaesthetist and a surgeon. In some of the countries I visited women will be laboring in the village without even a skilled midwife.

What does this mean for the healthcare community?

The local professionals work really hard. They’re swamped, under-resourced, overworked, and at times are limited by what they can do as individuals.

The reasons women are dying in pregnancy are usually associated with haemhorrage. They need blood but there’s no transfusion; they have high blood pressure but there’s no doctor to give medication – or no medication at all. Monitoring is a problem – there’s a functioning blood pressure machine but then you find it doesn’t work.

That becomes exhausting after a fairly short period of time. There’s this idea of wanting a healthy mother and baby, and it’s just not always achievable.

Did you bump into a lot of internationals NGOs along the way?

What really struck me was that some places would have lots of outside donations, and NGOs working in the same places. Other countries were really lacking in that funding and collaboration.

In Darfur I landed on a gravel strip, UN helicopters all around – it was quite a difficult area to get to. But when I arrived, all of the student midwives were lined up with a banner, singing. They’re relatively ignored by the global midwifery community and they wanted to show a great welcome to someone coming to talk to them about maternal health.

What did you notice, switching so often between the sky and the land?

As you travel further south the weather changes – there’s cloud and rain and suddenly over Chad, Sudan, you start to see very good views.

You appreciate the beauty, how small we are in comparison to the earth, the moon the stars. But you also realize quite how remote some of the communities on the ground are. Sometimes I couldn’t believe I was looking down into the Sahara desert and there are villages there. You’re looking for roads, and there are no roads. Of course there will be women, and women having babies – and at some point they will need medical help.

You start to marry that up with the maternal death rate.

The first clinic she gets to might not have a theatre or surgical staff; by the time she gets to a place where she can have a C-section, she’s often moribund and the baby’s often dead. If women can’t access a safe place to give birth, what is their chance of a successful delivery?

What’s the change you’re hoping to see?

There was a poster on the wall of a hospital in Zambia that said “no woman should die because she gives life.” You want to see a change in attitude – a fight. I hope the communities I visited will be inspired to make a stand – that it’s not good enough that our women are dying. What can we do at local and national level.

We need to think more about the problems that are happening. Even when it’s not hugely local to us we need to think about it on a wider scale – because effectively it’s a war against woman that so many are not surviving.

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Dr Sherry Wren

Dr Sherry Wren

“They think of surgery as transplants and plastics and don’t realize that there’s a huge population that has no access to the most basic, lifesaving procedures.”

Sherry is an Associate Dean of Academic Affairs and Professor of Surgery at Stanford University School of Medicine. She runs clinical and research programs in global surgery, gastrointestinal oncology, and surgical robotics. She is the co-developer of the International Humanitarian Aid Surgery course which has now trained more than 200 surgeons to prepare for work in low resource settings.

Why is safe surgery essential for women’s health?

When you look at the number one killer of women across the world it really is childbirth. And there’s just no way you can impact maternal mortality without having access to safe surgery.

And that’s just from an obstetric standpoint – women also get injured in car accidents, women get appendicitis – all multiple other conditions that need surgical care.

11% of the global burden of disease can be classified as surgically-treatable. I can think of no more important issue, in many ways, than safe surgery.

What, you mean that ‘neglected stepchild’ of public health?

You know I’ve actually only ever read that once, in the Paul Farmer and Jim Kim Kim article - I think it just gets quoted by everyone who keeps waiting for the situation to change.

I’m amazed when I speak to people in the public health domain who talk about the MDGs for maternal mortality or the ‘Decade of Road Safety’ but have an absolute disconnect and don’t recognize that safe surgery must be part of these programs. There will be excess maternal mortality as long as there is no access to safe C-sections, and consider the best road safety programs in western nations where people still get in accidents and need surgeons to take care of them.

Do you have any theories on why that is?

A couple! Surgery in the western world has become so commonplace it’s seen as standard care, assumed safe. To the point that people say “I’m just getting a minor op,” and they forget that before the advent of laparoscopic surgery having your gallbladder out was a 5-7 day hospital stay.

They think of surgery as transplants and plastics and don’t realize that there’s a huge population that has no access to the most basic, lifesaving procedures. It’s a profound disconnect in reality.

I also think that surgeons need to learn how to speak public health language. We need better research data. We need to go to their meetings – but it can be tough to break into a club, and it’s not like there’s a huge amount of funding for these topics.

Do I think the ‘neglected stepchild’ will be part of the family in my lifetime? I hope so. But I’m not going to hold my breath.

You run a training course for high-income setting surgeons going to work in a low-resource setting. What’s the most important thing for them to realize?

The most common area of concern is obstetric emergencies. Surgery in low-resource settings is split roughly in thirds – obstetric, orthopaedics, and everything else, so you have to be prepared – but in the U.S. you can’t just say “I’m going to learn to do some ortho today.” To participate, or even scrub in on a case you have to have malpractice insurance that would cover that kind of surgery. Anyone who’s not an obstetrician is terrified to take care of a pregnant woman because of the litigation risk.

It’s also about preparation. Some surgeons go overseas as as part of a comprehensive group bringing everything – physicians, machines, resources – you’re bringing a piece of your own world with you and parking it somewhere. It’s very different if you actually go work in the context the way it is with the resources on hand.

Does surgery around the world keep pace with advances in education and technology?

If your hospital doesn’t have power, running water 100% of the time it’s very difficult to keep up with where technology has moved.

Technology is a double-edged sword. I look at global surgery and I think the goal is someplace in the middle – a happy medium between over-care and over-testing (as I think we do in the U.S.) and availability of resources populations fundamentally need.

Interestingly educational knowledge is easier to disseminate. I participate in a collaborative programme in Zimbabwe on medical education where trainees have not had the opportunity to use advanced technology but they are knowledgeable about the recent advances and often will say “if we had the ability to perform x, this is what I think it would show.”

Is surgery a growing field for women around the world?

In the U.S., absolutely. About 40% of new surgical trainees are women, 50% of medical school graduates. There are still some barriers, areas that are still more commonly within the male domain but it’s rapidly going away – as opposed to when I started training and it was me and 17 guys!

In some places I would say that the issue of women in the profession is still many years behind. I believe there are cultural and biases, both conscious and unconscious– on rounds when I’m working in Africa I’ll ask a doctor if he’s going to encourage a bright young female student on a surgical track and he’ll say “oh no, you know women don’t want to be surgeons.”

But I’ve got a group of female students in Zimbabwe who are so excited to be surgeons. Why? Because they see that it’s possible.

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Royal College of Obstetricians and Gynaecologists; World Journal of Surgery

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England. Child and Maternal Health Intelligence Network – RCOG

Snapshot of surgical activity in rural Ethiopia: is enough being done? World Journal of Surgery

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Dr Rebecca Jacob

Dr Rebecca Jacob

“Patient on the ground, instruments boiled over a kerosene stove by the light of a hurricane lamp.”

Rebecca recently retired as a Professor of Anaesthesia at the Christian Medical College in Vellore, India. She now works as a consultant anaesthetist in Bangalore. Her focus is on paediatric anaesthesia and, in particular, working with children with clefts with the Smile Train charity.

Why is access to safe obstetric surgery essential for women?

No brainer! Everyone wants to be safe, even when the surgery is minor – let alone when there are two lives at stake.

You’ve helped to develop a training programme for students going out to work in a rural setting. What are their biggest concerns?

They feel very much alone. They’ve trained in a protected environment, with the safeguard of senior mentors. That doesn’t exist in the rural areas.

Suddenly, as well as gaps in their knowledge and poor support services, they have to worry about things we take for granted in the city such as uninterrupted water, electricity, suction – its an immense responsibility.

An operation can become very dangerous, very quickly – but really you don’t have a choice.

Can you give an example?

A student and her husband went to take up their new post in rural North East India. That same night a woman with prolonged obstructed labour was bought to them. Her only chance was an emergency Caesarean section.

With no electricity they performed the operation – patient on the ground, instruments boiled over a kerosene stove by the light of a hurricane lamp.

What changes would you like to see?

Those students came back to Vellore, obtained post grad degrees and went back to the same area. They set up a good hospital with three operating theatres, a sterilizing machine for instruments, generators for electricity. The only problem is that their oxygen and supplies have to come by boat – or four hours by road from the nearest airport!

So we need better training opportunities for our doctors and nurses. Improved facilities – hospitals, drugs, electricity, water, equipment in rural areas. Better salaries, housing and schools for the families and children of health care workers so that they will want to continue to work in rural areas.

This is the greatest loss we in developing countries suffer – we spend a lot on the education of our doctors most of whom leave to work in ‘greener pastures.’

What do you tell your students?

Don’t ever stop caring. No matter how little each of us can achieve, that little bit could still make a difference in one life.

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Morgan Mandigo

Morgan Mandigo

“It reminds me of a quote I heard – that in many African countries people will say “I’d rather have HIV than cancer” because it’s much easier to get plugged in to treatment.”

Morgan is a fourth year medical student in the Department of Global Health and Social Medicine at Harvard. She’s currently based in Haiti.

Why is safe surgery essential for women’s health?

The obvious answer is obstetrics – but what I didn’t fully appreciate until I came to Haiti was the magnitude of the cancer problem. We see case after case after case after case of devastating breast cancer, and a huge portion of the general surgeries we do are mastectomies.

Who is affected?

It strikes women at such a young age in low-resource countries, and we really don’t have a good understanding of why this is. But it seems to be that more and more women in their late 20s, early 30s are presenting with cancers that progress very quickly.

We always use maternal mortality as the example of trickle-down effect on the children, the community, the economy, but more and more we’re going to see the same argument playing out here.

The cancers that only affect men hit at a much later age – in the U.S. more men die with prostate cancer than from it – so women’s cancers can have a bigger impact on the children and families.

Why are the cases so devastating?

The presentation is so late. Some academic articles estimate 80-90% of breast cancer in low-resource countries is diagnosed at stage 3 and 4 – that is lymph node involvement, metastases.

Cancer treatment requires so many things – surgery, chemo, radiation, pathology. When you don’t have access to all of those tools, often surgery is the only option. But there is a very real threat of doing unsafe surgery when you haven’t been trained in oncology.

Why is there such late diagnosis?

Because there are such high barriers to actually receiving care. The geography, the logistics, the money – the day’s work you’re losing traveling to the hospital, sleeping outside on the ground so you have a good place in line the next morning, all the while not knowing if the doctor will even be able to help you.

That’s an awfully big set of challenges to overcome for a little lump in your breast that may not cause you any pain.

How does surgery become unsafe?

Oncology surgeries can be dangerous because tumors are so vascular. You could run into significant bleeding problems if you’re not properly trained.

There’s also the risk of not getting all the cancer, or even worse, of spreading the cancer. Cancer ultimately starts at the cellular level, and if you’re not using proper surgical techniques you can miss the margins; or you can risk seeding that cancer into other cavities in the body.

Even when you have the ability to do safe surgery, you don’t always have what you need to fully treat the cancer.

Can you give an example?

A few months ago a woman arrived with a mass growing out of her face – it was roughly a quarter of the size of her own head. It was a very rare tumour that had obliterated her vision on one side. The only thing available to help her was surgery.

The team did the best job they could to remove the tumour, but we don’t have pathology, the biomedical resources we’d have in the U.S. Your natural inclination is to try to take out a tumour like that – it’s so public, and you could see the suffering on her face from the stigma of carrying it around. But it was a very tricky surgery to do.

The team was able to resect the tumour successfully but they couldn’t be sure they had removed it entirely, and last Friday she came back. The tumour was bigger than before. This time it was also more vascular and had invaded more of the bone in her face, and though we wanted to be able to help her, we knew this time it would be unsafe.

It highlights the importance of safe surgery and knowing when you can operate and when you shouldn’t, but also what else we need to be able to do to provide better cancer care – to have a more positive impact.

Why do you think that cancer treatment has been so slow to develop in low-resource settings?

If you ask a dozen people on the street ‘what is global health’ they’ll say HIV, tuberculosis, malaria, malnutrition. By focusing our efforts so much on particular diseases, rather than seeing health itself as a human right, we risk creating this dichotomy where we see other diseases running rampant, untreated.

It reminds me of a quote I heard – that in many African countries people will say “I’d rather have HIV than cancer” because it’s much easier to get plugged in to treatment. For cancer there’s often nothing.

But we know what to do about it?

We know what needs to be done, but it’s the how that is difficult. We need to prioritize the development of surgical infrastructure around the world and ensure that there is equitable access to safe surgery. The trend towards a high burden of non-communicable diseases will continue, and many of them are treatable with surgery. But in the meantime, women bear a huge burden.

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Dr Lesong Conteh

Lesong Conteh

“If you are looking at the economic impact of surgery on women and their households, then the costs associated with surgery are not straightforward.”

Lesong is a senior lecturer in health economics at Imperial College London. Her research focuses on low- and middle-income country (LMIC) health economics and health system research, primarily in sub-Saharan Africa. She’s a Commissioner on the Lancet Commission on Global Surgery.

Your background is in health economics and infectious diseases. Did anything surprise you when you first started looking at global surgery?

Lack of economic evidence. I assumed there would be more data on the costs, cost effectiveness and financing of surgery, but what we have is so disparate.

The clinical evidence for surgery is of course strong, but we’re also forced to acknowledge there’s a fixed budget. A minister of finance – who is often equally important as a minister of health in decisions about health provision – needs a strong case for why they should invest in surgery and not some other health or non-health activity.

It’s hard to make your case for investment when you don’t have the data to support you.

Global surgery isn’t a new concept. Why do you think it has taken time for momentum to develop?

Surgery doesn’t have its own Millennium Development Goal [MDG] – it’s subsumed in with the other issues. When we say ‘surgery’ it means so many different things to people that it gets diluted and does not have a clear ‘identity’ or ‘brand’ that people can quickly understand.

When you start talking about an essential package of surgical care even surgeons themselves find it hard to reach a consensus. And if those inside the tent can’t agree, it’s hard for those outside to appreciate what surgery does.

Part of the problem is a limited number of surgeons who have time set aside to advocate for global surgery. They’re so busy that it’s hard for them to protect time to reach out and build a global movement.

Why do you think surgery is an essential component of women’s health, of global health?

It touches everyone, at every age. It relates to the focused MDG on maternal health and also shapes the broader MDG that promotes gender equality and empowerment of women.

It is often life changing, you can go in for your operation, you’re incredibly unwell – then you have surgery and within a matter of minutes, hours, days, you can be back to full capacity.

You could almost couch this in a human rights narrative. It’s a human right for women to access essential, safe, good quality surgical interventions.

What’s the economic perspective?

The first question to ask here is who’s economic perspective?

If you are talking about the Ministry of Health, then when you look at providing surgery it can be very expensive. However, it’s a perfect example of what economists refer to as economies of scope. Build the theatres and suddenly you can provide a range of services and operations. Your costs aren’t necessarily going to escalate linearly and you can do a lot, you can help a lot of people.

If you are looking at the economic impact of surgery on women and their household’s, then the costs associated with surgery are not straightforward. Costs of not accessing care can be catastrophic, however the financial cost of having an operation can also be very high, certainly when there is out of pocket expenditure for the operation itself and add to that costs of transport and food etc. Therefore it is important to compare the cost of surgery to the cost of living with certain conditions for a lifetime, then not only is there a clear health benefit, but there is likely to be a clear economic case for surgery.

And of course from a macroeconomic perspective it makes sense to have these women who need surgery healthy again, contributing to the economy and helping bring up the next generation.

How else do you rationalize the need for global surgery?

What I’m aware of now, as we start this work with the Lancet Commission, is that there is – in a way that works against surgery – emphasis on primary and preventative healthcare. Surgery seems almost a luxury until you have those other things covered.

But as we move to universal healthcare we have to realize that you can’t have either or. Surgery isn’t a substitute, it’s integral to reaching some of these goals.

It touches all of us, in our everyday lives. So the question is, how do you relate the importance of surgery, how do you get peoples’ attention? We all know someone who has had an operation, and that’s a central narrative coming out of our first Lancet meeting. The human element.

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Dr Marianne Stephen

Dr Marianne Stephen

“There might be a more acceptable level of risk, but the grief – that kind of grief is never normalized.”

Marianne is an obstetrics and gynaecology registrar who has worked with Médecins Sans Frontières in Pakistan and on the border of Myanmar and India.

Why is access to safe surgery an important issue for women’s health?

Women of childbearing age are a unique group of patients in that they’re usually well when the come to you. Childbirth is one of the unique circumstances where an operation is performed on someone who is not sick, making the decision to do so very important.

For a woman in this country it’s important to think: if this was your daughter, your mother, your sister, going in healthy to hospital to have a baby, how much of a tragedy it would be if they died. The tragedy is the same wherever you go in the world. There might be a more acceptable level of risk, but the grief – that kind of grief is never normalized.

How does surgery in a low-resource setting become unsafe?

The problems are so complex, on many different levels, from bureaucracy at the top end to the grassroots clinical level where local healthcare staff can be extremely overburdened, often working in an environment lacking support and training. It can be very disheartening, on call 24 hours a day, seven days a week; going home and waiting for the phone to ring them back to an ill-equipped theatre with lack of staff and little recovery care.

These people may be the only healthcare professionals for miles around and as a result their work takes over their lives.

The working environment itself presents a challenge. An unreliable electricity supply can mean performing a caesarean by torchlight with very poor visibility or in the blistering heat with lack of fans or air conditioning. This results in a very difficult operating environment for the surgeon. Poor lighting makes it difficult to see what you are doing and a hot operating theatre is an infection risk, not to mention the surgeon can barely stand by the end of the operation.

And when that reality is also conflict zone?

One of the first things to collapse is the structure of healthcare, although despite this women will continue to have babies.

A distressed population will present with many different medical problems, some like trauma are linked directly to conflict but what persists in any affected population are the problems in maternal and child health. Aid workers going into an emergency zone will find themselves performing many caesarean sections and the decision to operate on someone in such circumstances can be a difficult one.

Can you describe a case that stayed with you?

Probably the first post-partum hysterectomy I did for a woman with uncontrollable bleeding following delivery. The staff were able to recognize very quickly that she was unwell, which was the first life saving step. We used our small but well equipped field theatre which had just enough of the right surgical instruments to perform the operation. She had been bleeding for a week before she got to hospital and without the surgery would have died very quickly.

Looking back I can see that it was really good teamwork but at the time it felt a little like a miracle. I came in the next morning and she was sitting up in bed, nursing the baby and eating biscuits.

What’s the role of the visiting healthcare worker?

It’s extremely important not to go in, do operations and then leave again, without leaving any legacy. That’s even more disruptive.

An obstetrician performs about 5 key procedures regularly, all of which are potentially life saving, in a safe surgical setting. By teaching someone to perform a safe caesarean you allow them to go on and teach 5 more, which is important in building a lasting healthcare structure in resource poor settings.

Healthcare workers in ‘developed’ countries have so much to learn from working in low resource settings. The current trend in our training is moving away from the question ‘did you ever do any work abroad’ and towards asking ‘why didn’t you?’. This can only help to broaden our horizons.

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Laura Kilduff

Laura Kilduff

“When the baby’s heart rate was dropping I wasn’t worried about me, it was purely about the baby and how we were going to get him out safely.”

Laura Kilduff is 33 years old and lives in Oxfordshire, U.K. She is a Chartered Occupational Psychologist and runs her own business from home. Her first child, Charlie, was born by emergency caesarean section last year.

What were your concerns going in to your pregnancy?

The main thing – which must be similar to every woman around the world having their first child – was fear of the unknown. You can ask what a contraction feels like, but no one can properly describe it. Everyone seems to have a different experience. So at night, when you can’t sleep, you’re on your iPhone Googling questions – and the answers are always the worst.

You wind yourself into this ball of tension and worry about what is going to happen.

How did you prepare? Was the possibility of C-section discussed?

I took an antenatal course. That environment of women together, sharing fears and experiences, it was so important. But the option of caesarean section was mostly glossed over – we focused on that ‘ideal’ natural birth.

It’s something cultural we seem to be going through in the U.K. at the moment – births have to be natural and if it’s not natural the sense is that it’s unnatural.

So I went into it not really thinking a C-section would happen. Everyone talks about the candles, the birthing room, the pool! All this lovely stuff. Although in the end – with nine in the group – only one had that ‘ideal’, everyone else had a lot of intervention.

What happened at the hospital?

I went into labour the night before I was scheduled to be induced, two weeks past my due date. They put me in a room at the hospital and I said, “I don’t think I need an induction, I think labour is on its way!” They put a monitor on my tummy to check the baby’s heart rate – it kept dropping suddenly, and he was obviously in a bit of distress.

I was there three hours, four hours, contractions getting painful and stronger. But whenever I had a contraction the baby’s heart rate dropped, and they didn’t know why. At this point the consultant looked at all the print outs and said there’s a possibility you may need a C-section.

We’re lucky in this country in that we have some fantastic anaesthetists, great surgeons and nurses, and you have to trust that they know when it’s needed, necessary. I’m not medical, but I could see and hear the beeps of when the baby’s heart rated dropped – I knew something was wrong.

And then…

I was on a gurney and on the way to theatre in less than five minutes. It turns out the baby’s head was pressing on the cord, so during contractions he wasn’t getting enough oxygen.

You have to be strong. You’re in tears because of the pain, so you look to the people around you, to reassure you.

Although what you’re not really prepared for is the number of them. At least two anesthetists, two surgeons, the midwife, a couple of nurses, my husband. You’re in pain and surrounded by all these people, most of whom you’ve never met before – you just have to trust them. Half an hour max and he’ll be with you.

What was it like after the operation?

You don’t realize how debilitating it is; the first night you can’t really move at all. I couldn’t pick up the baby, and I was only just about ready to walk by the time we left the hospital. The recovery is much longer than you think as well. You stumble down the road and turn back after five minutes, exhausted. You can’t push the pram because it puts pressure on the stitches. And you need a lot of time for your muscles to recover.

Then there’s that question of a second baby – because of the incision there’s more of a risk, so do you have to have another C-section?

Has this experience changed the way you think about the issue of women’s health worldwide?

You hear stories in the media of women who haven’t survived, or had stillbirths. You can’t imagine it. And thank god I didn’t have to. When the baby’s heart rate was dropping I wasn’t worried about me, it was purely about the baby and how we were going to get him out safely. And whether he would be ok when he came out.

After the birth a lot of people said ‘oh, you had an emergency C-section – it must have been awful’ – but childbirth is pretty horrific generally, for the child and the mum! You need that awareness that it isn’t an easy thing to do – there’s going to be pain and upheaval whether or not you have an operation.

It was the right thing for me. The baby came out in 10 minutes. He was fine, cried quickly. They stiched me up and then we went back to the delivery room to bond with him.

Actually, nine months later it’s almost hard recalling it – you mentally block out a lot of what happens, that’s nature’s way.

You can’t forget if you don’t have the baby there.

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Dr Sandra Leal

Dr Sandra Leal

“Latin America shares many things, among them a strong regard for family – which constitutes the center for society”

Sandra has been anesthesiologist at the Social Security Maternity Hospital in El Salvador for 20 years. She is past president of the Anesthesiologists Association of El Salvador.

How does safe surgery for one woman have a positive impact on more than one life?

Latin America shares many things, among them a strong regard for family – which constitutes the center for society.  In this context women are acknowledged as the bond that holds this nucleus together, and more often than not, are the sole providers of the family income.

Many an individual, call it parents, spouse or offspring, depend on her either emotionally, economically or even both.  Under this perspective, it can be understood why their safety and well-being becomes so important, why safe healthcare is a vital cornerstone.

Access to safe surgery and anaesthesia is essential, though not always possible.

Latinoamérica comparte muchas cosas, entre ellas resalta un fuerte vínculo con la familia, la cual constituye el centro de la sociedad. En este contexto las mujeres son reconocidas como como el lazo que mantiene este núcleo unido, y con frecuencia son el único sostén económico familiar; a menudo muchos individuos, entre padres, cónyuges e hijos, dependen de ella emocionalmente, económicamente o más aún ambos. Bajo esta perspectiva, puede comprenderse por que su seguridad y su bienestar se vuelven tan importantes, y proveerla con servicios de salud seguros es un pilar para ello.

Why is that?

Resources are relatively scarce and sometimes just not available; distances are in many instances broad, or transportation is an issue, which can mean that access to surgery, even if safe, comes too late or doesn´t come at all.

In El Salvador, anaesthesia still plays a significant role in many adverse events for women; most surely, without safe, solid, anaesthesia equipment and anaesthesia provider, no surgery can come out a success.

El acceso a cirugía y anestesia seguras es esencial, pero no siempre posible. Los recursos son relativamente escasos y a veces simplemente no están disponibles, las distancias en muchos casos son amplias, o el transporte es difícil, lo que puede ocasionar que el acceso a la cirugía, aún si es segura, sea alcanzada con retraso o no pueda accesarse en lo absoluto. En El Salvador,la anestesia todavía juega un papel importante en muchos eventos adversos maternos: indudablemente, sin un equipo y un proveedor de anestesia sólidos y seguros, no puede haber cirugía exitosa.

What are some of the other barriers to safe surgery?

To this scenario, we have to add cultural issues, in many instances so strongly attached that they will work against any conscious and well-intended attempt to deliver good quality healthcare.  This raises the stakes and potentially turns what could have been a routine and relatively safe procedure, into high risk, full blown major surgery and/or anaesthesia for which neither the personnel nor the patient are prepared.

These type of settings are more frequent in rural areas, where education is poor, sanitary facilities are few and hospitals almost always lack even the basics.  It is here where young doctors and paramedics start their practice, which raises their main concern: who or where to go for consultation, and what to do when the resources needed are not available?

A este escenario, debemos agregar aspectos culturales en muchos casos tan fuertemente arraigados que actuarán en contra de cualquier intento consciente y bien intencionado de proveer salud de alta calidad, elevando los riesgos y potencialmente volviendo lo que pudo ser un procedimiento seguro y rutinario en una cirugía y/o anestesia de alto riesgo y grandes proporciones, para la cual ni el personal ni la paciente suelen estar preparados.

Este tipo de situaciones son más frecuentes en las áreas rurales, donde la educación suele ser pobre, las instalaciones sanitarias escasas y casi siempre carecen incluso de lo básico. Es aquí donde los jóvenes médicos y paramédicos inician su práctica, lo que da paso a su principal preocupación: a donde o a quien acudir por apoyo o para consultar, o que hacer cuando los recursos necesarios no están disponibles?

What can we do to change this?

To address these issues we have to understand that it is essential to provide not only the much needed equipment , but also to stimulate a continued medical education program.  Together with a public-oriented education program, this will allow all parties involved to work together and make the most of what they have at hand.

Para poder abordar estos tópicos primero debemos comprender que es esencial proveer no solo el tan necesitado equipo, sino también estimular un programa de educación médica continuada junto con un programa de educación orientado hacia la población que permita a todos los involucrados trabajar juntos y sacar el mejor partido de lo que disponen.

 

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Kathleen O’Neill

Kathleen ONeill

“In terms of treating breast cancer – even when it’s not curable – the impact of surgery is still immeasurable in how much it can affect someone’s life in a positive way.”

Kathleen is a research associate at the Program in Global Surgery and Social Change at Harvard Medical School. She is also a 4th year medical student at the University of Pennsylvania. She recently returned from working at Hôpital Universitaire Mirebalais in their surgery department for six months in Mirebalais, Haiti. She plans to begin a general surgery residency program following graduation next year.

Why is global surgery essential for women’s health?

The average person in the U.S. has eight operations in a lifetime. If you’re living a long and productive life, it’s likely that at some point you’ll need access to surgery. Because of the risks of childbirth, women are more at risk of needing a life-saving surgery than the average man – particularly in low-resource settings where fertility is usually higher and more pregnancies means more risk.

But it’s not just about reproductive health. A lot of the work I was doing in Haiti was around the issue of breast cancer – and surgery is absolutely necessary as part of that treatment.

Is there much access to surgical care for cancer in Haiti?

It’s similar to many low-resource countries in that very few centres treat surgical disease and people generally live far away from them. I interviewed patients getting chemo at the hospital and most had been seeking care for a year or more.

Cost is a huge factor. Just the process of diagnosis is incredibly difficult and the cost of surgery could range from a few hundred dollars to a few thousand. Any money they had saved was gone very quickly.

Is the surgery generally safe?

Safe and effective surgery isn’t just a question of availability, but integration. Surgery in Haiti isn’t really plugged in to a larger system of treating cancer, and there’s limited pathology or chemotherapy. A surgeon might remove a lump and hope it was benign, but it’s difficult to know what they’re cutting out.

You see women going severely in debt for surgery that wasn’t a definitive cure. Four years later they have metastatic disease.

What is the impact of this?

Having this life-threatening illness, searching for so long for treatment – the whole process affects the family. The majority of women getting treatment usually had several children, and they’d be struggling to take care of them. Often kids became the breadwinners of their family, taking care of their moms. An illness like that doesn’t just affect one person, it affects the whole family.

So a lot of what we talked about during our interviews was how grateful they were to find care – to finally have someone taking care of them. The entire oncology team at the hospital is composed of women – nurses, physicians, led by a Haitian physician trained in oncology, Dr Ruth Damuse. It’s a wonderful place, women taking care of women.

What is the chance of survival?

Women would notice the lump in their breast relatively early but, particularly at the lower socio economic level, delay and delay care. They say ‘I don’t have the money to be able to do that, I can’t leave my family.’ It has to be something that affects their lives to a very large extent before they seek care, so often the lump isn’t only noticeable to them, but grossly obvious to everyone.

Unfortunately in Haiti whenever we were diagnosing it was rarely a question of ‘is this breast cancer’ – by the time the woman presented, it was very obviously so. And that is a very difficult thing, because the chance of cure becomes so small.

Does that mean the surgery isn’t worthwhile?

In terms of treating breast cancer – even when it’s not curable – the impact of surgery is still immeasurable in how much it can affect someone’s life in a positive way.

When you can remove a fungating mass on their breast so it’s no longer infected or at risk of bleeding, you remove the stigma. The ability to move about and not have to daily worry about this gaping open wound that won’t heal, which cancer ultimately turns into – it confers a level of dignity to patients that I think is lost in the standards ways we measure outcomes. It’s life-changing.

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The Lancet

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Global operating theatre distribution and pulse oximeter supply: an estimation from reported data – The Lancet

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Dr Jaymie Ang Henry

Dr Jaymie Ang Henry

“The fast food industry solved problems of global planning, global logistics – if they can, why can’t we? Why don’t we?”

Jaymie is co-founder and Executive Board member at the International Collaboration for Essential Surgery (ICES). She is the producer and director of “The Right to Heal,” a global surgery film. She is a lecturer in global health at the UC Berkeley School of Public Health.

Why is safe surgery essential for women’s health?

Childbirth is an all or nothing phenomenon. When you have your baby it’s happening right now, and 15-20% of the time it is likely to involve a complication requiring surgery to save the mother and baby’s life. We know exactly what to do in these situations, we know the step-by-step process. But it’s as if people are saying: “ok – it depends where you live.”

This is life we’re talking about, a process with us since the dawn of humanity. The fact that there are so many women who are marginalized because they don’t have access to safe surgery feels like a failure of our civilization, a failure to bring this technology to half the population of the world.

You’re a surgeon, but you’ve made a documentary, The Right To Heal, about the need for access to safe surgery. Why the change in medium?

I grew up in the Philippines, and have first-hand experience of lack of access to healthcare. But working in ‘global surgery’ felt increasingly like an idealistic, academic experience. We were looking at it through a second-hand lens.

I started traveling, and meeting people, talking about their experience of not having access to something so vital. And I thought the gap was really just about letting people know. We become complacent knowing everything for us is working well. But how can you be a human being and stand by, not do something about it?

We have to let people know, and trust in their humanity and compassion to really want to do something about this.

On an individual level? A societal level?

There’s a fistula surgeon, a woman from Sri Lanka who went to Tanzania eight years ago to train, and couldn’t leave. She saw the need and said, how can I leave when I can do so much? People have been pushing quietly on their own, but it also needs to be done bigger.

Imagine how much more we can do if we worked together on an international level. If we’re able to reach government and policy makers, get people who hold the purse strings to say absolutely, this is something that needs to happen.

This is not something that can be solved by individuals, but by a community.

There have been decades of talk about a push for global surgery. Do you think things are actually changing?

Well I feel like our generation is becoming increasingly global. There’s this huge opportunity with technology – through social media, the internet – to cross those huge divides. We care about women in India, we care about women in the Philippines more than we used to.

A problem like obstetric fistula, which is really one of those horrible, medieval conditions that should have been gone a long time ago – it has been solved a million times over by other industries. The fast food industry solved problems of global planning, global logistics – if they can, why can’t we? Why don’t we?

We really have to be very clear in our message: we cannot compromise on this. It’s something that we can’t shortchange.

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Janet Dewan CRNA, MS

Janet Dewan

“I cared for a woman who had been suffering as an outcast for 25 years, since her first baby. It only took us 30 minutes to repair her fistula.”

Janet is a nurse anesthetist based in Boston, U.S.A. She first worked in Niger in the 1970s and has returned there many times, and now works regularly in Rwanda with the International Organization for Women and Development, an organization that provides fistula repair surgery to women suffering from this condition.

Is there a gender imbalance in access to surgical care?

When there are shortages in healthcare, women and babies are often the ones least advantaged.

It’s not at all unusual to find in the maternity section that the monitoring or anesthesia equipment is inferior to what’s used even for minor surgery in the same hospital. Childbirth is something that is considered just a natural process. But without a skilled birth attendant, and access to resources such as safe surgery if a c-section is required, it carries a high mortality with it. There is a vast global disparity in maternal and infant mortality statistics between well resourced and developing health systems.

What is an obstetric fistula, and how does it happen?

There are two types that we see. The first is obstructed labour – the woman is in labour for days without progress. The baby’s head pressing against her pelvic organs, so that no blood flow can get through, causing ischemic tissue damage.. The baby may die before the women receives help , and by the time it passes she has developed an ischemic hole, either between the vagina and the bladder or the vagina and the rectum.

Fluid freely flows out, of her vagina and she becomes incontinent.

The second type of fistula we see results from damage to pelvic organs after surgical interventions, Ceasarian Section. These injuries tend to be higher, involving the bladder and uterus or in the cervical region and often require open abdominal surgical repairs.

Can access to surgical services reduce the risk of fistula?

Absolutely. Fistula is a direct result of lack of available maternity and obstetric care, and the rate of C-section in some low-resource settings is very low, in others skilled health providers and other resources are not available for surgical and anesthesia care. when C-section is indicated.

Lack of personal and capital resources contribute to surgical care being performed under less than the safest circumstances. Some women do not have access to skilled services. Without an adequately trained birth attendant who recognizes the need for intervention and knows how to get a mother to it, complications are either not treated or treated too late so that complications , such as obstetric fistula result.

My own specialty, anesthesia, is not always available to care for the mother and infant. Anesthesia care goes beyond simply administering a spinal anesthetic. Monitoring the mother, so the earliest signs of serious complications are detected while they are correctable, is probably the most important anesthesia function. Anesthesia personnel also care for fragile infants. Anesthetists need to recognize their role in safe surgery goes beyond the technical. Current anesthetists should have the opportunity to participate in continuous education opportunities so they can be mentored in current principles of safe practice, interpretation of monitoring and appropriate interventions,.

Without the training and the resources it’s impossible to meet global targets for safer surgical care.

Does fistula ever occur in wealthier countries?

It does happen occasionally with urgent or repeat sections or can occur following pelvic radiation therapy.. At our hospital in Boston a woman suffered a fistula following a second urgent C-section – but we were able to repair her, with all that fancy equipment and skilled personnelwe have. She’s fine, the baby’s fine. Of course she wasn’t happy to have the complication, but that’s how treatable fistula is, how little suffering should go with it. Two weeks after her injury she was repaired and home caring for her healthy baby and toddler.

On the other hand I cared for a woman in Niger who had been suffering as an outcast for 25 years, since her first baby. It only took us 30 minutes to repair her fistula under spinal anesthesia

What can women around the world do about this?

I see quite a large number of female medical students these days – in Rwanda I have met many outstanding female medical students and I think this is likely to make a difference. Nurses and midwives also have an important role if they educate women about their bodies and normal birth and empower them to seek the appropriate care they deserve. Safe maternity care is a core component of the right to health.

It’s estimated that up to 500,000 women are suffering with the condition with 50,000 new cases at year. With our current resources we have the capability to treat barely 12,000 of these cases every year. The fact that fistula is a too common obstetric complication that occurs almost exclusively in the poorest countries, speaks to the global disparity in access to health care, including health personnel and other resources. Fistula is almost completely preventable and if it occurs it is treatable. The global capacity to eliminate this scourge exists,

And nobody should be suffering for any length of time.

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Dr Jane Fitch

Dr Jane Fitch

“The comparison between resources can make anaesthesia a very different experience. It makes you realize how wasteful we are, how disposable everything is for us.”

Jane is President of the American Society of Anesthesiologists.

People don’t always recognize the role of anaesthesia in safe surgery. What can you tell me about it?

There are very few medical specialties where you can literally take care of people from birth – and actually, pre-birth – all the way to end of life. Anaesthesia cares for everyone, and everything in between.

What about in lower-resource countries where you’ve worked?

The comparison between resources can make anaesthesia a very different experience. It makes you realize how wasteful we are, how disposable everything is for us.

In the U.S. we have all kinds of fancy warmers for giving blood products and fluid. In Egypt we draped it across some lights to get the ambient heat. Working in China in the late 1980s you’d see rooms chock full of inoperable equipment. Purchased or donated, it was broken and there was no one who could maintain it, no spare parts.

We know that 70,000 operating rooms around the world don’t even have a basic pulse oximeter [a monitoring device essential for safe anaesthesia]. Literally a couple of billion people don’t have access to safe anaesthetic and surgical care.

How important is access to safe surgery for women’s health?

It’s critically important. The medical care of women during their childbearing years – the majority of their lifetime – is primarily obstetric and gynecological. It’s critical that all around the world, women have access to these surgical procedures.

And when safe surgery isn’t available?

There are complications that have a huge personal and social impact on a woman and her family.

If she doesn’t have appropriate care during childbirth she risks damage to the birth canal and development of fistula that can lead to incontinence. A woman in low-resource settings without the ability to have this repaired can be ostracized from her family, her social network, her employment.

And the mom’s status clearly impacts and somewhat determines a lot of what the child’s life will be like.

What can we do to support safer anaesthesia around the world?

Nicholas Greene, one of the ‘founding fathers’ of modern anaesthesia, recognized early on the constraints that low-resource settings have in being able to provide safe surgical and anaesthetic care. His focus was on training and education, and our Global Humanitarian Outreach committee and Charitable Foundation have really taken off from there in the last decade.

What is your hope for the future of women in global anaesthesia?

It’s only in the last 40-odd years that we’ve moved away from a 25-30% female minority in the field of anaesthesia in America. I hope that women will realize the critical role that we do play in the U.S. and beyond – women all over the world are vital for providing the safest anaesthetic care possible.

We all need surgery and anaesthesia at some point – but in particular I’ll go back to the fact that we know that women really need obstetric care at certain times to prevent complications that will negatively impact themselves, their children and their families. It’s just critically important.

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Dr Isabeau Walker

Dr Isabeau Walker

“Safe surgery should be a basic right that is available to all women who require it during childbirth.”

Isabeau is a Consultant Paediatric Anaesthetist in London, Vice President of the Association of Anaesthetists of Great Britain and Ireland and a trustee of Lifebox Foundation.

Who needs a Caesarean section?

We are so used to people talking about caesarean section rates that are too high, and women who are ‘too posh to push’. But for a woman in obstructed labour or with a low-lying placenta, a caesarean section is a life saving procedure, for herself, the baby, or for both…

Safe surgery should be a basic right that is available to all women who require it during childbirth.

Is this not the case?

No, this is definitely not the case. Thousands of mother’s lives could be saved if surgery was prioritised within all health systems. Tens of thousands could be saved from debilitating injuries, and millions of stillbirths, neonatal deaths, or newborn birth injuries could be avoided.

The rates for caesarean section in poor communities in sub-Saharan Africa or southern Asia are consistently less than 2%. It isn’t clear what the ‘minimum’ rate for caesarean section should be, although some academics have suggested that at least 5% of all births should be by c-section; so it is likely that many women die in these communities because they don’t have access to safe surgery.

Thousands of mother’s lives could be saved if surgery was prioritised within all health systems, not just those in high-income countries. Many more women could be saved from debilitating injuries, and millions of stillbirths, neonatal deaths, or newborn birth injuries could be avoided.

What does this mean for a woman in labour in a low-resource country?

Lamula’s story is a true account written by Juliet Tumwebaze, an anaesthetic officer working in Uganda.

Lamula was a mother from a rural village in obstructed labour, carried on the back of her husband’s bicycle ‘amidst her screaming’ for 4 hours to the local health centre. When she got there, they found that the hospital was not equipped to help her.

WHO has estimated that 800 women die every day due to complications of pregnancy or childbirth, and 7300 babies are stillborn, with almost half of stillbirths occurring when the mother is in labour. 99% of these deaths occur in low-resource countries and could be avoided.

Is global surgery keeping pace with technology?

As we develop ever more sophisticated equipment to improve patient safety in high-income countries, patients in low-income countries are denied even the most basic of surgical care. The gap between what we know and what we can deliver in poorer parts of the world seems to be widening.

Does that mean available surgery becomes unsafe?

Yes, definitely. A number of publications in the last few years have surveyed facilities in rural hospitals in sub-Saharan Africa, and found that they are not staffed or equipped to deliver even basic surgery. So there is poor access to surgery, and when surgery is provided, the essential equipment to provide safe surgery is often not there.

What are the repercussions?

When a young woman dies during childbirth, it is a tragedy for the whole family. The health, education and economic prospects for the entire family are affected, and the risk of the surviving children dying is increased. An effective way to make a difference is for patients to stand up and tell their stories, and to demand better services. Sadly, these women’s voices are rarely heard, so it is particularly important on International Woman’s Day that we tell their stories in solidarity.

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Dr Eva Hanciles

Dr Eva Hanciles

“Often the first time a pregnant women come to hospital is when she’s been trying to deliver at home without progress. She’s in urgent need of a Caesarean section.”

Eva is a Fellow of the Faculty of Anaesthetists of the Royal College of Surgeons in Ireland and of the West African College of Surgeons. She at present heads the Intensive Care Unit at the only Tertiary Hospital in Sierra Leone and lectures Nurse Anaesthetists in that country

Let’s talk about anaesthesia. Why is access to safe anaesthesia important for women?

Anaesthesia isn’t considered a lucrative and fashionable option for post-graduate doctors, but without safe anaesthesia – which also includes post-operative care – there’s increased morbidity and sometimes mortality.

It’s of vital importance to women, especially in low-resource countries. Often the first time a pregnant women come to hospital is when she’s been trying to deliver at home without progress. She’s in urgent need of a Caesearean section.

Can you talk us through how you handle a case like that?

I recall a patient who had been in prolonged labour at home and presented at hospital in a collapsed state. We couldn’t get her blood pressure and her pulse was weak and thready. We could only get a line in through the internal jugular vein.

It was obvious we were dealing with a ruptured uterus.

This is something you would never see in a country with wider access to surgical services and we had to do surgical intervention and resuscitation at the same time because her heart was so unstable.

Of course a dead foetus was delivered and the bleeding was stemmed only after a hysterectomy. But the mother’s life was saved.

What changes have you seen over your career that have made anaesthesia safer?

The greatest change to safe surgical care has been the widespread use of spinal anaesthesia. In settings where there is no oxygen supply, little or no monitoring, poor power general anaesthesia is out of the question – it’s very risky and can contribute to high maternal mortality rates.

Let’s talk about anaesthesia.  Why is access to safe anaesthesia important for women?

Anaesthesia isn’t considered a lucrative and fashionable option for post-graduate doctors, but without safe anaesthesia – which also includes post-operative care – there’s increased morbidity and sometimes mortality.

It’s of vital importance to women, especially in low-resource countries.  Often the first time a pregnant women come to hospital is when she’s been trying to deliver at home without progress.  She’s in urgent need of a Caesearean section.

Can you talk us through how you handle a case like that?

I recall a patient who had been in prolonged labour at home and presented at hospital in a collapsed state.  We couldn’t get her blood pressure and her pulse was weak and thready.  We could only get a line in through the internal jugular vein.

It was obvious we were dealing with a ruptured uterus.

This is something you would never see in a country with wider access to surgical services and we had to do surgical intervention and resuscitation at the same time because her heart was so unstable.

Of course a dead foetus was delivered and the bleeding was stemmed only after a hysterectomy.  But the mother’s life was saved.

What changes have you seen over your career that have made anaesthesia safer?

The greatest change to safe surgical care has been the widespread use of spinal anaesthesia.  In settings where there is no oxygen supply, little or no monitoring, poor power general anaesthesia is out of the question – it’s very risky and can contribute to high maternal mortality rates.

Who is it important to educate?

Everyone.

In rural Sierra Leone, anaesthesia services are provided by nurses, who must be constantly updated.  Failure to provide continuing education can make anaesthesia very unsafe.

At the same time, further education of pregnant women to encourage them to visit ante-natal clinics would lead to further reductions in mortality.

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Camila Maglaya

Camila Maglaya

“I always say – we’re not always rich back home – but we do whatever we can, we speak out.”

Camila is a senior staff nurse at Great Ormond Street Hospital. She moved to London from the Philippines a few years ago.

How hard is it to get a caesarean section?

It’s not easy to have surgery unless it’s really urgent. Even when it is urgent. Sometimes there’s nothing to do but surgery – like for a woman in obstructed labour – but if you don’t have the money, you don’t have the C-section.

Or if you can get to a hospital that caters to the really poor people, you have to get through a lot of red tape, pass a process, meet the criteria, how urgent are you really…It’s tedious and it’s dangerous. Before you can be seen you’re at the end point already.

How do people handle this?

Some families will just accept it. This is what I’m receiving because I’m poor. They’re used to it. They have that mentality ‘I’ll always have the second type of services.’

But some of them of course still fight for what they deserve. For their mother, their sister, their child. They will go to the complaint system. But it’s a long process.

And when you lose someone you love, and you know they could have been saved – the grief is still the same, the loss is still the same. Whatever standard of life you live, you go through the same process.

What can you do to change the system?

You can only fight for it – you don’t know if you’re going to change the result, even if you get the surgery.

I always say – we’re not always rich back home – but we do whatever we can, we speak out. Then at least you’ve done what you can, and you pray and hope that the next time it happens there will be a better outcome – if not for your family, for someone else.

Why is access to surgery so important?

It’s the difference between rich and poor. It’s poverty, isn’t it. If you have money, you can do everything.

But health should be the ultimate equal opportunity. Rich or poor, a woman or a man. Whatever standard you are in life, you should have an equal chance at this. If one needs surgery – it should be given.

 

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Barbara Margolies

Barbara Margolies

“Have you ever met a woman with fistula? It is absolutely devastating. The smell is so overwhelming some people can’t go into the same room.”

Barbara, a retired New York City elementary school teacher, is the Founder and Executive Director of IOWD. She’s an educator, author, lecturer and photographer who has worked in development projects for more than 25 years.

50-100,000 women worldwide develop obstetric fistula each year, but you don’t seem to hear a lot about it.

I’ll tell you why. Because it’s not pretty. It’s not sexy enough. Once Oprah did something so that was ok, but generally people don’t want to talk about women leaking urine or feces. Women hysterically crying because you can’t help them. What do you do, put that in the newspaper?

There is so much publicity about HIV, tuberculosis, malaria; children with facial deformities and sweet smiles, but there isn’t a lot of publicity about this. So most people don’t know what fistula is about. I certainly didn’t when I first learned of it years ago.

But when they learn of it, they’re shocked.

What is life like when you’re living with this condition?

Have you ever met a woman with fistula? It is absolutely devastating. The smell is so overwhelming some people can’t go into the same room. They’re constantly washing their clothes. When they get undressed for medical exams you will see they’re wearing so many layers, plus plastic wrapped around them.

Some of these women have been living with a fistula for decades, and they’ll go from hospital to hospital looking for help. Some are so isolated they think they’re the only one with this condition. Often their husbands leave them; their friends; even their own children are repulsed. So there’s no physical touching. No one to hug them. No one to talk to.

You are completely alone. And that’s something that if more women in the world understood, then maybe more would pay attention. My God, they would gather, they would fundraise, they would support organizations that provide education and training and safe surgery.

There’s a nursing assistant you worked with in Niger, Mariama – she came to you with a fistula?

She was going to kill herself. She tried twice, but her mother stopped her.

Mariama had an arranged marriage at 15, got pregnant with a baby boy and went into obstructed labour. He died inside her, and she developed a fistula. She lived in the courtyard of a hospital in Niger, and we met her when she was 30.

In the exam room for the first time I saw that someone had given her a colostomy – I don’t know who, I don’t want to know who – and from a hole in her stomach she had a garbage bag. There was feces all over her, the smell was appalling. She was very much alone, and desperate. She wanted to die. Our doctors repaired Mariama and gave her back her life…and I have to tell you – she is one dynamite woman.

One night when we were at the hospital a catheter came out of one of the patients and there was no nurse, no doctor. So Mariama put the young patient in a wheelchair, pushed her all along the broken cement of the hospital grounds to the emergency room, demanding a doctor to re-insert the catheter. And then she put her back in the wheelchair and brought the girl back to the ward and stayed up all night with her.

You can share that story, because Mariama is remarkable. It shows what women can do for other women. Women who have nothing, still helping each other. Women who understand the pain and humiliation of fistula are happy to help their sisters.

Because unfortunately we know that surgery isn’t always safe.

Some of the women have been operated on before; you see what has been done and it’s horrible, it’s cruel, it’s immoral. Sometimes doing surgery is not the right thing to do, and people don’t understand that. You can’t fix every woman with fistula.

That’s why you need education. Fistula can be prevented – so can maternal mortality, child mortality, all the terrible infections… if you have access to antenatal care and safe obstetric surgery at the right time.

But in the meantime we have to counsel these women, tell them we can’t help them. We give them – which is a sad comment – two cloth diapers and waterproof panties that we make ourselves. When the diapers are ruined they’ll use rags, or whatever cloth they have. At least their clothes won’t be wet; at least the urine won’t leak down their legs.

But when women get access to safe fistula repair surgery - I wish the world could see that too. Last visit to Rwanda we held an outreach session for 70 fistula women, under a big tree at the hospital. About 15 had returned from our previous visit, all dry, and I cannot even begin to describe the explosion of emotion that ran through this group.

The women asked questions, expressed their frustration – and their amazement that there were others with the same problem. When the dry women stood up, they clapped, began to sing and then dance. There was hope. It was electric!

It’s all we need to know that we must keep returning to help and teach the local medical staff so that one day they will do theses surgeries on their own.

Tell us why unsafe surgery is our issue.

We take surgery for granted. But it has got to be available to every woman. It’s 2014! It is every woman’s right to have safe surgery offered to them. Women are the strength of every nation – in low-resource countries they carry the heaviest burdens. They deserve to have safe surgery, it must be provided for them. If women throughout the world stand together, we can help make safe surgery a reality for all.

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Archives of Surgery

statistics5

Operative mortality in resource-limited settings: the experience of Medecins Sans Frontieres in 13 countries – Archives of Surgery

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Dr Angela Enright

Dr Angela Enright

“Women are the glue that hold the family together. If the mother dies in childbirth, it is a catastrophe for her and for the children.”

Angela is Head of Anesthesia for Vancouver Island. She’s a past president of the World Federation of Societies of Anaesthesiologists and the Canadian Anaesthesiologists’ Society, and a trustee of Lifebox Foundation.

Why is access to safe surgery and anaesthesia an important issue for women’s health?

In low-income environments, emergency obstetric surgery such as Cesarean Section and ruptured ectopic pregnancy constitute a large part of the surgical volume. Women also endure other surgical conditions such as trauma, cancers and bowel obstructions that require surgical intervention.

Often they present late to the hospital and are in a high-risk state. The rate of complications such as severe blood loss is high.

But if a woman in a low-resource setting needs a surgery?

The challenges are huge. Poor transportation, long distance from a surgical facility, lack of money to pay for surgical care, distrust of the care available and late presentation all affect the ability of the patient to access timely and appropriate surgical care.

In addition, women may have cultural issues which may prevent them going to a hospital for surgery – such as requiring a husband’s permission, which may not be freely given or delayed if he works away from home.

Has global surgery kept pace with developments in medical knowledge and technologies?

There are improvements in some areas – for instance education of women, which makes them more aware of what they need and how to access it. Provision of local health care workers, such as in Malawi, has improved care and resulted in earlier referral to a surgical or obstetrical centre. Cesarean section is now most frequently performed under spinal anesthesia. That provides a measure of safety over poorly managed general anesthesia.

But you need early access, resources and skilled providers to be able to treat these patients successfully. This is still a problem, as well as practical issues, like a functioning blood bank for life-saving transfusion during a crisis.

Does surgery in these conditions become unsafe?

Yes!

What are the repercussions?

Women are the glue that hold the family together. If the mother dies in childbirth, it is a catastrophe for her and for the children and also for the husband, who now has to figure out how to care for his family whilst trying to work to support them.

Many women have ‘cottage’ jobs – something they can do from home which brings in some money, like weaving baskets sold to tourists. This type of income often pays for the children’s education.

Late management of surgical problems such as breast cancer results in increased morbidity and early mortality for the woman. Often other problems such as an enlarged thyroid may be left until it presents a major airway problem. Bleeding from untreated uterine fibroids can result in severe anemia and a mother bereft of energy and the ability to care for the family.

Do women play a role in delivering care too?

I would say that women provide the backbone of care in anaesthesia and nursing. Most surgical care is still provided by men.

Does this crisis get much recognition?

There is a belief that surgery is expensive and unaffordable but that is not the case. Routine surgical conditions should be treated early to return people quickly to the workforce.

Major agencies such as WHO have invested much time and effort dealing with public health issues and communicable infectious diseases. Obviously these need attention but much has been done to improve their status and it is time to turn some attention to surgery.

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Dr Angela Davis

Dr Angela Davis

“There’s a strong cultural message that somehow having an elective C-section is an ‘easier’ way to give birth.”

Dr Angela Davis is a historian at the University of Warwick, interested in motherhood, parenting and childcare.

Your research has focused primarily on 20th century Britain. Is it possible to talk about universalities of childbirth beyond a particular place or time?

Yes there is universality in the process of birth – but it’s also something which is quite contextually-specific. For women giving birth in the U.K. it’s still a leap into the unknown, the fears are there – but it’s very different to when you’re giving birth in a time or place with a high maternal mortality risk.

Even women giving birth in the U.K. sixty years ago – their mothers’ generation would have had a much more risky experience. They knew those stories, that much more striking association with death which we haven’t really had for he last 40, 50 years.

How have access and attitudes towards Caesarean sections changed since the 1900s?

Small numbers of C-sections were done for hundreds of years but without antibiotics, without blood transfusion, usually resulted in mothers dying. Being able to do a safe C-section was a dramatic improvement and for certain groups of women – for instance those with complicating factors (like rickets, which can deform the pelvis) who were never going to have a good outcome, it was transformative. It allowed them to have a healthy pregnancy and birth.

Rates in the U.K. climbed throughout the second half of the 20th century with a dramatic increase in the last decade, for reasons that aren’t just medical.

When they’re used routinely – perhaps unnecessarily, like as a matter of protocol for a second birth following a C-section delivery – you need to question the evidence-base more closely.

Why do you think this has happened?

Misinformation. Not on a medical level but on a cultural level; the threat of litigation, the influence of the media. There’s a strong cultural message that somehow having an elective C-section is an ‘easier’ way to give birth. When of course the fact is – in this country or any other – it’s major surgery.

If you talk to a woman who has had one the idea that it’s easier – risk of infection, complications with breastfeeding – there’s a gulf between the image and the reality.

Obstetric fistula is a traumatic consequence of obstructed labour – did you come across much discussion of this in your research?

It’s constantly present in women’s stories, but not something that was frequently talked about.

There are many accounts of women living with the legacies of frequent childbirth, but these are the things that really changed after the introduction of the National Health Service (NHS). Suddenly in the 1940s there’s a huge rush of people getting all these conditions they’d been living with for a long time, fixed.

One woman I spoke to had a very difficult experience with fistula. But it was picked up after the birth, she had the surgery and went on to have more children successfully. It was weeks, rather than a lifetime.

Is it helpful to look at the global context?

There are big questions that apply everywhere – the importance placed on reproduction, the resources that are made available, and the relationship between women and the high-level policy decisions that are being made about a women’s issue. Because if it concerned men, the whole thing would be treated very differently everywhere.

And there’s a lot that we can learn from one another – not just taking a ‘western’ approach and applying it on a global scale, but vice versa, seeing what works well in different contexts. Still, you need to be cautious.

Why is that?

There’s an element in the U.K. that goes against women and those who criticize their care. It’s easy to say that if you were in this or that country you’d really have something to be concerned about. When the point is – no one should be in that scenario to begin with.

You need women to be well-informed, empower them to know their bodies, their choices – but you need a system that empowers them as well.

What impact do you think personal storytelling can have in changing opinion and practice?

It’s so important. Most of the effective campaigning groups – AIMS, NCT – started with women sharing their stories. There’s an immediacy that touches people in ways that statistics can’t.

Stories are part of the universal, the global context. We can identify with stories of women giving birth in other places, even if you know the context is different – there’s something about having a child you can identify with. These personal stories are really vital.

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Dr Ronke Desalu

Dr Ronke Desalu

“Safe surgery is tied up with the socio-economic status, political participation and education of women.”

Ronke is an Associate Professor and Consultant in Anaesthesia at the Lagos University Teaching Hospital. Her sub-specialty interests are paediatric anaesthesia and Training in CPR. She is happily married with 2 grown-up children.

Why is access to surgery essential for women’s health?

A third of the 4500 surgeries performed at my hospital in Lagos last year were related to women’s reproductive health. This is a substantial percentage for one ‘special group,’ and emphasizes the importance of ready access to safe surgery for women.

Yet not all women are lucky to get this professional treatment; the maternal mortality rate in Nigeria is approximately 585 per 100,000 live births.

Why did you become an anaesthetist?
I always wanted to be a doctor, even as a young girl growing up in Lagos in the 1960s. With two aunties showing that women were just as capable as men, and could be doctors, my mind was made up.

I’m passionate about helping the vulnerable and the sick, and it gives me great satisfaction to see the outcome and the value one person’s actions can have on another person.

Can you tell us about one of your most memorable cases?
I’m in a profession that has its fair share of risks, but I like to look on the positive side of my work, the good we do and the relief we bring.

Many years ago we treated a 5-year-old child with a large cystic hygroma [a growth that appears on a baby’s neck]. The surgery was difficult, and afterwards she was unable to breathe on her own. We admitted her to our intensive care unit, which didn’t have a functioning ventilator at the time.

The trainees and technicians took turns to manually ventilate her for 100 days.

The case emphasizes the importance of teamwork, perseverance – and above all, commitment to your patient.

What is the government doing to reduce maternal mortality?

In the last six years, the Lagos State Government opened six specialized maternal and child health hospitals, with full surgical facilities. This means more theatres, more surgeries, more training and better health service delivery.

What is the role of women in the surgical ecosystem?

Safe surgery is tied up with the socio-economic status, political participation and education of women. We need to support groups that advocate for women’s health issues – women shouldn’t have to travel such long distances for basic care.

I take as one of my critical roles in life, to uplift and raise the bar for young women. To show them that it is indeed possible to have both a happy home front and a sky that is the limit in their career.

 What is your goal for women in the medical profession?

I want them to realize that they’re part of a unique team. Many organisations assume that women can’t cope with the top positions and we need to change that mindset. We need to be amongst the counted when it comes to doing our job well.

Women need to be fully involved in the implementation and management of healthcare, as well as in the policy and mapping of future health plans for their community – and indeed the world.

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Dr Queeneth Kalu

Dr Queeneth Kalu

“They say ‘Abasi Akan uman ikwa,’ meaning ‘God forbid delivery by knife!’”

Queeneth is a Senior Lecturer and Chairman,Medical Advisory Committee at the University of Calabar Teaching Hospital in Cross River State, Nigeria.

Do women recognize that surgery can play a life-saving role in safe childbirth?

In my locality they say ‘Abasi Akan uman ikwa,’ meaning ‘God forbid delivery by knife!’ When it comes to childbirth, most Nigerian women prefer a vaginal delivery, meaning going to hospital is a last resort.

This translates to late presentation after laboring for hours in the traditional birth attendant’s home. They commonly present with obstructed labour, severe preeclampsia, foetal distress, haemorrhage – conditions requiring surgical intervention to save mother, baby or both.

The importance of safe anaesthesia in these emergency patients, arriving in suboptimal states into our very challenging health service system, cannot be over-emphasized.

What kind of challenges?

As a trainee anaesthetist I once had a patient who needed a Caesarean section at night. As soon as I gave her the spinal anaesthesia, there was a public power outage.

There was no back up power supply in the theatre. W e had no automated patient monitors at the time. We put on the small light of the laryngoscope, checked blood pressure every 5 minutes, palpated the pulse, kept communication with the patient and waited in the theatre till the anaesthesia receded.

We’re familiar with occasional power outages during surgery and will usually carry on with torchlights until power from the generator or public supply is restored. In this case we felt it was too risky, so we returned the patient to the ward and surgery was done the following morning. These are not things we are proud of but the reality in Africa is: we work in a challenging environment.

Does experience of working in other countries change your perspective?

I witnessed a case of placenta acreta [a sever complication of pregnancy that often requires surgery] during my obstetric anaesthesia fellowship at Wolfson Medical Centre in Israel.

The early diagnosis and preparation of equipment, blood availability, personnel – obstetricians, anaesthesiologists, interventional radiologists, perfusionists, nurses…it was amazing. Such a sharp contrast to what’s available in our environment when we see the same condition.

I realised why our maternal mortality rates are so high and theirs so low. I realize that saving a woman’s life in an obstetric emergency situation, especially where there’s bleeding is more or less a warfare and must be treated as such. All hands must be on deck.

What are your goals for women in the healthcare profession?

My joy is that I have found my passion for public health being fulfilled along my career path, and I encourage women to rise to professional excellence.

They should strike a work life balance. Make the most of the opportunities that come their way, engage in community development projects. Share their knowledge through health education programs in churches, market places, media houses.

I pray that in the coming decades, women will not be looked upon in terms of gender but will be seen as too relevant to be ignored.

 

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Dr Nneka Anaegbu

Nneka Anaegbu

“In the coming decade we’ll be on the frontier and at the helm.”

Nneka is a Consultant Anaesthetist at Lagos State University Teaching Hospital, Nigeria.

Why is access to surgery essential for women’s health?
The woman’s role is vital in the maintenance of the family. Since the family is the smallest unit of the society, their function is essential for society at large.

Inability to get access to safe surgery can lead to unnecessary demise of a woman, a tragedy and a great disaster to her children and husband. Children who lose their mothers are negatively affected psychologically, which may affect their behavior in the society.

Does a woman’s role in society affect her ability to get surgical care?
There are various challenges that women face while trying to access health care. They include financial, educational, cultural, gender inequality, poor governance and religion.

In my culture the young girls are usually at a disadvantage due to gender inequality – their parents may not send them to school because they believe it is a waste of resources. Girls are soon married out to end up in a man’s kitchen, seen and not heard.

This leaves women financially dependent on their husbands for every need, including healthcare support. A woman whose husband does not provide money for her to access healthcare when needed is a woman at risk.

Is surgery seen as a safe option?

Education about safe surgery is vital, and sometimes lacking.

In our environment some women run away from Caesarean section for various reasons. Some believe they may die during the surgery, others feel that their family and friends will look down on them for not delivering naturally. Others feel that it means that they are not prayerful enough.

I remember a woman who was pregnant and attended antenatal care at the hospital. The doctors noticed that she had pre eclampsia, therefore she was told that she would require surgery to deliver her baby. Instead she went to a traditional birth attendant to deliver.

She eventually developed eclampsia, and by the time she came to the hospital the baby was dead. She still had to have a Caesarean delivery and died in intensive care after about 10 days.

What can women around the world do to support safer surgery?
Women should strive to educate their girls to enable them have a brighter future and be independent. Many of the young girls I know want to be professionals in various fields, and have a passion for healthcare. But there are many barriers –parents lack the financial capacity, while some girls get pregnant in secondary school and can’t further their education.

Women should be supported by other women to achieve their goals. My aim for women in the medical profession is that in the coming decade we’ll be on the frontier and at the helm of activities in the industry. Taking decisions that will favor women, in order to improve women health and prevent avoidable eventualities that may affect women.

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Evelyn Felicia Somah

Evelyn Felicia Somah

“Back home they have this thing – if you’re going to surgery, you’re going to die.”

Evelyn is a senior staff nurse at Great Ormond Street Hospital. She was born in The Gambia, and trained in the U.K.

Why did you train as a nurse?

My grandma was a midwife, my mum was a nurse – it’s part of me. When I grew up my dad said – and you listed to your parents! – nursing doesn’t pay here, you need to study something else. So I trained as a secretary, I was working with the UN in The Gambia.

But when I moved to the U.K. I saw technology was changing – you don’t really need a secretary, you’ve got a computer. So I’m going to do what I love to do, what I wanted to do when I was a child.

Tell me about access to surgery in The Gambia.

In The Gambia, healthcare is the biggest issue. People are just dying from things that they shouldn’t, and women are suffering the most. They don’t have the right equipment, they don’t get emergency obstetric care. I know of a cousin who just died giving birth back home. They couldn’t stop the bleeding.

So where do you go if you need surgery?

I have an uncle who nearly died – he had fluid on his lungs, but he was rushed to Senegal, because they couldn’t diagnose him in The Gambia. Half an hour flight away – but he would have died if he’d stayed; he would have died if he wasn’t working for a bank which paid for him to go.

When people have money they can rush to Senegal. But when they don’t – you have lost your life.

Do people worry about unsafe surgery?

Back home they have this thing – if you’re going to surgery, you’re going to die. Take medication, go to the doctor – that’s fine. But if they’re putting you to sleep?

It’s because they haven’t seen successful surgery. People aren’t diagnosed soon enough, so the surgery is much more complicated. My dad – we lost him – when you’d talk about an operation he’d say “oh no, no – I don’t want anybody to cut my body.”

My mum, too, was diagnosed wrongly. She’d had the problem ten years, and by the time we were able to get her to America she only had two weeks. They used to give her cough mixture, but her heart was gone. The doctors couldn’t believe she had traveled so far.

How does this change?

People need to be educated. They need to be informed that surgery will help. For me, since I’ve been here, I’ve really changed my perspective. We were never taught that surgery could do that.

Both my parents gone because they couldn’t get diagnosed properly; they couldn’t get treated in time.

So many people visit Gambia, they can see all this. But it’s a tourist place for them. They go for the holiday and everything else is just put aside.

 You have so many difficult stories. I’m sorry to make you go through them all again.

I enjoy caring for people; I enjoy it so much. That’s why I’m in this field. I like helping people and I like education. I do health checks at my local church, and I always encourage women to take care of their health.

It’s ok. If telling stories can help to let people know what’s happening – if it can make a difference – then I want to share them.

 

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Comfort Osagie-Ogbeide

Comfort Osagie-Ogbeide

“You have to buy your life.”

Comfort works in hospital administration in London. She is originally from Nigeria.

What is your experience of surgery?

Well it saved my friend’s life. She needed a caesarean section for her second baby, and she survived. But it was very difficult.

Why is that?

The attention she needed wasn’t really there, due to lack of financial resources and unavailability of the right equipment in Government hospitals. She decided to go private but lacked the initial deposit. If you don’t have the money, you don’t get the treatment.

There’s so much pressure on the family. The price they may charge is huge, and of course if she’s pregnant the lady hasn’t been working. It pains you to see this happening – women dying from illnesses that are not supposed to take them. You have to buy your life.

So is it hard to trust in surgical care?

Recently I heard about a young lady who died from an incomplete operation. Not immediately – she went for a surgery to deliver a stillbirth and they left some products behind. She kept going for follow up, kept complaining that she had pains. She wasn’t wealthy, and her life didn’t get enough attention. She was neglected until she developed sepsis, and she died.

From a stillbirth. A tragedy followed by a tragedy. It is really difficult to trust surgical care.

Surgery is that line between life and death, and it’s the common belief that if you go into surgery you’re not likely to come back.

Has your attitude changed since you moved to the U.K.?

Here at least they’ve got the right equipment to look after the patient. I’ve come to realize that there’s nothing inherently dangerous about surgery when you need it and you do it safely.

It’s when you need it and they don’t have the resources for that. My friend and her baby almost wasted away. It’s just a nightmare. You don’t want to talk about it.

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Priscilla

“It’s very complicated to walk away from people. You have to wait for them to walk away first.”

Priscilla is a student in Kenya. She recently underwent fistula repair surgery to correct the damage done by four days of obstructed labour, nine months after she was raped at age 15. 

Priscilla shared her story in The Right To Heal, a documentary examining the personal cost of lack of safe surgical care worldwide. It’s hard to look away from her animated face, and her devastating, statistically ordinary story.

The Right To Heal director and surgeon Jaymie Henry spoke about getting to know Priscilla, and the impact of her story.

What was Priscilla like when you first met her?

Just like in the video! She was so vigorous and joyful and passionate.

Did it change the way you had been thinking about global surgery?

What she suffered was completely inhumane. She was marginalized, cast aside by family, friends, because she didn’t have access to something as simple as surgery for her baby.

It brought that home to me – how we’ve relegated her to someone who can’t even function in society, who didn’t have opportunities.

What happened after the surgery?

It was life-saving; it just completely turned her around. She thought she was dead. Now she’s a vibrant young woman who wants to help other people. She wants to be a nurse, to give back to society.

What next?

Imagine that simple procedure, and it alters the course of her life. It’s profound. For me, there’s a sense of purpose. There are so many Priscillas in the world who can benefit from something as simple as this.

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Dr Kelly McQueen

Dr Kelly McQueen

“Women with cancer in the early stages with the hope of treatment and cure often have no access to an exam or biopsy”

Kelly is Associate Professor, Department of Anesthesiology and Director of Vanderbilt Anesthesia Global Health & Development Affiliate Faculty at the Vanderbilt Institute for Global Health, and president of the Global Surgical Consortium.

How is surgical need related to gender?

The health of men and women over a lifetime is associated with risks specific to their gender and to their roles in society.  For women, there are several unique periods in her life when the availability of safe anaesthesia, and emergency surgery is vital – the most obvious time frame is during childbirth.

The biggest risk to mothers worldwide is peripartum haemorrhage, often requiring surgery.  In low-income countries the risks are even greater because they relate to a lack of access to an emergency cesarean section for obstructed labor and for seizures related to high blood pressure.

Access to surgery and safe anaesthesia for these conditions – haemorrhage, obstructed labor and eclampsia – will save the lives of mothers and babies, and prevent related complications such a vaginal fistula and stroke.

Is it just about reproductive health?

Cancer affecting women specifically also illustrates the important relationship between certain surgeries and gender.  Cervical and breast cancer often require a biopsy for diagnosis, and frequently surgical intervention for treatment, palliaton and cure.

Cervical cancer when diagnosed early has a very good prognosis.  But when diagnosed late – often when the kidneys are blocked, or the tumour is so large that it protrudes from her body – there is little hope of treatment.

The later is a common outcome in the poorest countries, and the unnecessary death of a women often leaves children in need of care behind.

Why is this a global rather than local concern for women?

Disease for the most part knows no geographical boundaries.  But the prevalence of surgical disease does correlate with increased non-communicable disease such as heart disease, trauma and cancer that we’ve been seeing for many years in higher-resource countries.

Recently in low-income countries, non-communicable disease has been increasing and therefore the need for safe surgery and anaesthesia has as well.  The needs for these same services are commonly required by women all over the world, and so women from every country must engage to create awareness about the role of surgery and safe anaesthesia in our good health.    

What is the reality of the situation faced by a woman in need of surgery when she lives in a low-resource setting? 

In the lowest-income countries, need for surgery has never been greater.  Sadly it’s in these same countries that access to safe anaesthesia and surgery is most often unavailable.

Organizations such as the The Global Surgical Consortium are committed to revealing the unmet need, and advocating for availability: in many hospitals surveyed we note a lack physicians and other providers, the absence of essential medicines including oxygen, and the absence of safety equipment and basic surgical supplies

This means that many women who need an emergency Caesarean section never receive one or are delayed until after the baby has died and the mother has birth trauma – which will affect her the rest of her life.  Women with cancer in the early stages with the hope of treatment and cure often have no access to an exam or biopsy, and therefore are diagnosed very late in the disease when it is too late to provide definitive care.

What role do women play in delivering healthcare worldwide?

Of course women in every society are often engaged in care-giving.  In lower-resource countries this is especially true within the home, and also in the nursing profession.  They’re also physicians, but many fewer of them have the opportunity for the extended education that is required and available to their higher-resource counterparts.

More women should be given the professional opportunity to work in health care for one very important reason we’ve seen. Women are much less likely to leave their families to seek higher pay or new opportunities outside their community – the retention of women in professional roles in the low-income countries is higher than for men.   

For someone who has never worked in a low-resource setting hospital, or thinks safe surgery is a luxury –

Just a few hours in a hospital of a low-income country bears witness to the vital role of safe anaesthesia and surgery in the lives of women.

Women die in childbirth everyday because of a lack and unsafe practice of anaesthesia, and limited or no access to a life-saving surgical intervention when they need it.  Their babies die too because of the mothers excessively high blood pressure or being stuck in the birth canal with no availability of a cesarean section.

Walking in the halls you see women with large tumors protruding from their breasts, or large thyroid goiters taking over their neck.  Visiting the Emergency Department you see women – mothers, sisters, aunts – morning the loss of a husband or son, because there is no access to emergency anesthesia and surgery for trauma.

Safe anaesthesia and basic surgery can be provided in a cost-effective and appropriate manner. There is no doubt that the lives of women around the world are impacted daily by lack of access to it.

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Erica Frenkel

Erica Frenkel

“Retweeting and liking aren’t enough. Change happens when large groups of passionate, committed people make it happen.”

Erica Frenkel is the Vice President, Business Strategy for Gradian Health Systems, a nonprofit social enterprise dedicated to promoting safe surgery and safe anaesthesia worldwide. She holds a MPA in Development Studies from Princeton University’s Woodrow Wilson School and lives in New York City.

What’s the impact of gender when it comes to surgical need?

Safe surgery – and reliable, consistent access to it – is an important issue (a human right!) for everyone, every day. Injury, congenital malformations, cancers and many other issues that require some form of surgical treatment impact men and women, adults and children.

However there are certain surgical conditions uniquely experienced by women and which, when performed unsafely (or when unavailable) uniquely affect their health and very survival: obstructed labor, post-partum hemorrhage, obstetric fistula, cervical and uterine cancers, to name just a few. International Women’s Day is a chance for us to call attention to the need to make those surgical interventions safe and available for all women everywhere.

Your work focuses on bringing an environment-appropriate piece of technology to low-resource settings.   What role can technology play in supporting access to safe surgery?

Certainly in my job, my answer tends to be that medical technologies (when functional and properly used) facilitate those interventions inside the operating theatre.

But today, on International Women’s Day, the technology I’m using technology to support access to safe surgery is this platform, and Twitter, and Facebook, and every platform I can find to call attention to this vitally important topic.

Retweeting and liking aren’t enough. Change happens when large groups of passionate, committed people make it happen. And these platforms can help individuals create a network – like this one – to catalyze action.

What should people know about unsafe and inaccessible surgery around the world?

For starters, some of the statistics. Approximately 1/3 of the world’s population cannot reliable access safe surgical care. Two million women across Africa alone are estimated to be living with (and often ostracized because of) obstetric fistula.  Common estimates about the number of women die in childbirth each year hover around 287,000

But those are just statistics.

One of the greatest challenges I have found in the course of this work, particularly around advocacy on this issue, is making the staggering statistics resonate. 287,000 is an unconscionable number of women needlessly dying. But it’s only a number. It does not illustrate who each of those 287,000 women were, or what dreams they had, or who they left behind.

So where do we take it from here?

Safe surgery does not occur in a vacuum. It relies on a sufficient numbers of trained health care providers (from community health workers to physician specialists); large-scale infrastructure investment beyond the hospital (such as roads and electrical grids and telecommunications capacity); efficient supply-chains with strong oversight (ensuring that disposables, medicines and other items are in regular supply); and much, much more.

The challenge seems daunting – and unfortunately that’s what keeps a lot of people from acting. But today, on International Women’s Day, let’s flip the narrative. With such a big challenge, there are roles for all of us to play.

So let’s do our homework. Let’s use this powerful technology called the Web to connect to all of the great work being done around the world to make sure that every woman – and man and child – has access to reliable, safe surgical care whenever they need it.

 

 

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Judy Mewburn

Judy Mewburn

“The pelvic outlet on a girl of 11 or 12 – you could no more get a baby through there than the moon.”

Judy is a registered nurse who has worked for many years with nursing communities across Africa, delivering training and supporting the vital role of nursing in safe surgery.

Why is a C-section necessary?

Surgery is essential because it’s life-saving. Women die without one. But with this one operation you’re saving two lives.

You always need a C-section for obstructed labour or prolonged labour, and sometimes for breech. And of course for the younger ones, whose pelvises are not big enough. The pelvic outlet on a girl of 11 or 12 – you could no more get a baby through there than the moon.

Why don’t women in low-resource countries get the operations they need?
When you look at a C-section it’s a relatively straightforward procedure – incision, muscle, uterus, get the baby out. But so many hospitals don’t have the right equipment, or the only surgeon isn’t there. Or there’s an even worse case ahead of you.

These hospitals deal with a huge catchment area, and the women are far away. They’ve been laboring for days before they walk in – or wheel in, if they’re lucky enough. The mother arrives exhausted (goodness, you try walking a few miles in labour). And the foetus will be incredibly distressed, if not dead.

On my last visit I saw a woman who had been in second stage labour for two days, lying there, saying “that’s it. I can’t push anymore.”

What happens if you can’t get a C-section in time?
After prolonged obstructed labour the baby dies in utero and starts to decompose. The mother becomes toxic and her body tries to push it out.

Depending on how many children she’s had, her uterus may burst, in which case there’s bleeding – so much bleeding their blood won’t clot any more, and without the right transfusion or a hysterectomy they’ll bleed to death.

I saw a case like that recently in Ethiopia. Holding the mother’s hand, I didn’t speak the language – but there’s a body language that is universal, isn’t there.

What happens next?

For the mother? She’s shattered. Nine months of pregnancy and she looses the baby. She cries. She goes home. Life is pitched against you.

And if she dies but the baby survives? Devastation visited on the family. Who is going to look after the children?

What about when it goes right?

When a baby is delivered safely – in two minutes it’s as though it were born with clothes! They wrap it up – nappy, blanket, second blanket, this big rolled wodge, and the mother carries it around with a little face poking out. It’s the start of everything.

So yes, safe surgery is a women’s issue. But really, it’s a world issue.

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Dr Kathleen Casey

Dr. Casey copy

“The ability to provide quality surgical care is a proxy for a well functioning medical system.  And that’s part of the reason why it should be important to the entire global health community.”

Kathleen is a general surgeon who created the Operation Giving Back program for the American College of Surgeons and served as its director for 10 years.  She co-developed the International Humanitarian Aid Surgery course that has trained over 200 surgeons to prepare for work in low resource settings.  She serves as an officer in the Alliance for Surgery and Anesthesia Presence (ASAP).

Tell us why surgery is an important part of a country’s healthcare system.

In our advocacy efforts, we speak of the need for “access to surgery and anesthesia when needed”.  That currently doesn’t exist for more than 2 billion on this planet.

But having surgical capabilities and infrastructure in place doesn’t only serve surgical patients – those facilities that can deliver quality surgical care are more likely to have lab and radiology capacity, skilled staff, and more of the medical infrastructure that is essential to all medical care.

The ability to provide quality surgical care is a proxy for a well functioning medical system.  And that’s part of the reason why it should be important to the entire global health community. 

Why is it essential for women?

With regard to women, the most distinctly female condition is, of course, pregnancy, which is a life threatening condition in much of our world.  Whether for a difficult delivery that requires Cesarean section, or the complications of delivery that require control of hemorrhage or repair of a fistula, access to safe and timely surgical care is critical for women.

Is surgery for women just about reproductive health?

Women’s surgical needs extend beyond those related to childbirth.  Where access to quality healthcare is lacking, patients with breast or cervical cancer often present with such advanced disease that unfortunately the only appropriate treatment is palliative.

Burns – either from cooking fires or chemical burns as a form of violence against women – are another common condition that needs early treatment to avoid debilitating contractures and disfigurement.

And women are susceptible to most of the same surgical problems as men – trauma, appendicitis, cleft lip, etc.   Appropriate access to surgical care would allow these women to be diagnosed and treated at an early enough stage to potentially save their lives and allow additional medical care as indicated.

The term ‘neglected stepchild’ is heard so frequently in conversations about global surgery.  How do you see it becoming fully part of the global health family?

Neglected stepchild” comes from an opinion piece written by Drs. Jim Kim and Paul Farmer several years back. It was significant to have such prominent figures in global health outside the surgical community make a public statement in support of surgery in global health.

In the years since, I dare say that surgery is not so off the radar anymore.  We’ve made tremendous inroads in terms of collecting and publishing data and participating in multidisciplinary conferences in order to better tell the story of why surgery is a critical part of an effective global health strategy.  But despite the progress, we have quite a way still to go to see that happen.

How are we going to do this?

One important current effort is advocating for a formal resolution on surgery and safe anesthesia at the World Health Organization.  We need all the members of the global health community to lend their voices in support of this resolution because of the synergies that it will bring about in improving health care across the board.

If a medical facility has the ability to safely perform an emergency C-section or effectively treat road traffic injuries, it has the skill sets, equipment, and infrastructure to perform emergency abdominal surgery and handle important more routine cases like hernias too.

Have you noticed any trends in attitudes to global surgery or approaches to addressing the issue in the last 10 years?

Well, I like to think there’s been an increased appreciation for the importance of surgical care in low and middle-income countries and as a part of the global health strategy as a whole.  Trending in the right direction at least, but still not there yet!

One important trend has been recognizing the importance of community building – both within the global surgical community as well as for surgery within the greater global health community.  With greater awareness of what others are doing and how it is all interconnected, we’re able to better collaborate and learn from each other to improve access, quality, outcomes, education, communication and collaboration across countries as well as across disciplines.

This Lifebox initiative in honor of International Women’s Day is a great example of multidisciplinary collaboration – many voices with a common commitment to saving lives, improving patient care, building community and raising awareness of the importance of surgical care for women around the world.  Thanks for doing this!

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Dr Michelle White

Dr Michelle White

“It’s powerful to see how generous they are in their love and affection for each other.”

Michelle is Head of Anaesthesia on the MV Africa Mercy, the largest floating hospital NGO in the world. She is currently docked in Congo.

Are women at a disadvantage when it comes to access to surgery in low-resource countries?

Any money usually goes to the men, to the children; women are the neglected person in the family unit, often the poorest of the poor.

But with a lot of women’s health issues – uterine prolapse, obstetric fistula – there really is no other alternative to surgery. So it’s important that they get access to surgical care, that it’s safe – and that it’s effective. Obstetric fistula has a high rate of cure if you get it right first time, dropping dramatically with each further attempt.

Is it hard not to get emotionally involved in these cases?

It’s certainly a very moving surgery to be part of. These women have been ostracized completely from society – very often they’re barred from home, left in an outhouse and someone brings them food. Corrective surgery restores their dignity and their place in society. They can socialize, take a bus, go to market. They can finally get rid of the stench of stale urine.

How do the women respond to this second dramatic change in circumstances?

We try to have a ceremony on the ship for the ladies who have had successful fistula surgery, as a way of showing that they are valued, appreciated. We give them a new dress, symbolizing a new start. There’s applause and dancing – it’s incredibly moving, after the many years of hardship they’ve suffered.

And it’s powerful to see how generous they are in their love and affection for each other. The women who haven’t had successful surgeries nearly always participate. They know how much it means, and their hope of that is so great that they are still willing to rejoice.

What’s the reality for surgery on the mainland, when you leave the ship’s hospital?

It’s not only about access to surgery – people also have to survive their operation, and there are some very practical problems. Many hospitals don’t have access to clean running water or electricity to sterilize the equipment. They don’t have antibiotics, everything disposable is reused.

Everything compromises the safety of surgical care, even the unreliable lighting – it’s very difficult to do a good repair when you can’t really see what you’re doing.

What does this mean for someone with a surgically-treatable condition?

It means they endure with pain, exhaustion, incontinence. For the woman particularly there are economic and social implications – if her husband takes another wife he may reject the infants from the first wife. If she takes the children she may not have the means to look after them.

There’s a lot of social stigma attached to disability, but if we turn a mirror back on ourselves we can see that we take a similar view in the west – we just hide it better.

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Tropical Doctor

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Deaths associated with anaesthesia in Togo, West Africa – Tropical Doctor

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Dr Jannicke Mellin-Olsen

Jannicke Mellin-Olsen

“Anaesthesia and surgery go hand in hand – it is difficult to do surgery if the patient is in pain.”

Jannicke is a Consultant anaesthesiologist at Baerum Hospital, Norway, and Deputy Secretary of the  World Federation of Societies of Anaesthesiologists. She is secretary of the European Society of Anaesthesiology, Vice Chairman European Patient Safety foundation, Past President European Board of Anaesthesiology, on the board of the European Society of Anaesthesiology.  She has participated in several international missions with the UN and Red Cross.

Why is access to safe surgery an important issue for women’s health? 

Safe surgery is important to both men’s and women’s health, but as females are the ones giving birth – a very high-risk situation – they are overall at greater risk than males.

People don’t always think about anaesthesia in relation to surgery.  Why is it essential?

Anaesthesia and surgery go hand in hand. Some form of anaesthesia is required for almost all surgical procedures, both because it is difficult to do surgery if the patient is in pain, and because pain provokes reactions in the body that are negative for the wound healing process.

What changes have you seen within access to safe surgical care over the course of your career? 

In my context, surgical care has been getting safer across the last almost 30 years. If you are a trained and experienced clinician, then you can do a lot with your eyes, ears and fingers. The major problem worldwide is the lack of trained personnel. In addition, major steps towards improved safety can be achieved by introducing simple monitors. In my setting, these devices are required for all general anaesthetics, and this is far from available globally.

Why is it important to talk about this issue?

For those that live in areas where anaesthesia and surgery is unsafe, it is important that their situation is made known. They should be invited to report their needs if they feel that it has been ignored in their setting.

For those of us who have drawn the golden ticket and live in areas where anaesthesia services are available and safe, we should share our knowledge, competence and resources with others. For some, it is difficult to know how.  Then a donation to Lifebox would be a good way to support a reliable, well documented programme to improve access to safe anaesthesia and surgery in every corner of the world.


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Emma Patrick

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Dr Emma Patrick

Emma Patrick is a consultant anaesthetist working in New Zealand having trained in the UK. She has a specialist interest in obstetric anaesthesia, especially in improving maternal safety. She was a volunteer for a recent Lifebox trip to Vietnam and hopes to continue assisting in this project.

What’s the relationship between gender and healthcare?

In many low-resource countries, inequities of poverty, geography, ethnicity and gender are direct barriers to health care.  They often compound the lack of resources available to women in these settings, resulting in poor outcomes – and women are much more likely than men to need access to healthcare providers.

Why is that?

Maternal mortality and morbidity remains unacceptably high in many countries due to a lack of trained midwives and access to obstetric surgical care.  The sequellae of poorly managed labour and delivery results in gynaecological and bowel damage that may require further surgery and intervention.

At the same time they often lack the financial resources to pay for treatment, or the ability to leave the family and extended family whom they may be caring for. In some cases it is just not deemed important that scarce resources are spent on females.

Does lack of access have an impact on safety of surgery?

As an anaesthetist I am acutely aware that the more unwell a patient is when they present for surgery, the greater the risks from the anaesthetic and the surgery to that patient. Hence any delay in access to healthcare can result in a worse outcome.

In a low resource setting this may prove to be critical.  For example if a woman arrives after being in labour for a prolonged period and requires a caesarian section, she is at much higher risk of bleeding from the surgery and afterwards. This may be in a hospital that has no blood bank or access to the multitude of interventions that can be performed in a tertiary care hospital.

What is the wider fallout?

Long-term morbidity from unsafe, delayed or no access to surgery has a huge impact of families and communities.

In many societies the communities are matriarchal in that it is the female roll to care for the extended family.  The economic consequence to a family with either a disabled, chronically unwell or deceased female member can be disastrous.

And of course there are limited or no rehabilitation services, as we would expect to have access to. In effect she will become a financial burden.

What is the situation in Vietnam, where you’ve worked to deliver anaesthesia equipment and training?

Vietnam has experienced rapid economic growth over the last 2 decades. The Socialist Government has been committed to meeting the MDGs and is on target to do so.  They are striving to provide a universal healthcare system and overall, life expectancy has improved, infant mortality rates have dropped dramatically and maternal mortality continues to drop.

However, communicable diseases remain a problem and there is a rise in non- communicable disease that is commonly seen in growth economies.

And as economic growth occurs, the poverty gap widens – even though a significant proportion of the population have been lifted out of poverty.   That’s particularly noticeable in the ethnic minority communities within Vietnam, such as in the Northern and Central Highlands area where utilization of health resources remains low, maternal mortality high and other health indicators remain poor in comparison with the majority of the population.

The dedicated healthcare professionals that I met were working in small hospitals with limited resources and in some cases were unable to meet the minimum monitoring standard that we would expect for safe anaesthesia.

How does this change your own perspective? 

We should never take for granted the free access to healthcare that is available in many countries – nor the fact that when we go into hospital for surgery we should and do expect that the doctors and health professionals have a high standard of training, equipment and safety measures to reduce error are in place.

 

 

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Katy Kuhrt

Katy pic

“I know the majority of my friends at medical school are interested in global surgery”

Katy is a 4th year medical student at Bart’s and the London School of Medicine and Dentistry.  She completed a BSc in fetal and maternal medicine at King’s College London, and has volunteered in hospitals in Nairobi, Kenya and Aksum, Ethiopia.  She is helping to organise this year’s Medsin Conference for students interested in global health. 

Do medical students care about global surgery, or is the focus on graduating?

I know the majority of my friends at medical school are interested in global surgery – most of them will be doing some form of surgical attachment in a low-resource country during their electives.  I think that with the arrival of increasingly sophisticated technology the world is becoming closer knit and it is easier than ever to exchange skills and share resources.

Why do you think it’s important?

It is important for students to understand that the way we do things here is a way, not the way.  There is so much to learn from other countries and their systems and in turn I think, where we can, and where it is appropriate, we should offer to share our own experiences and skills.

What was the availability of safe surgery at the government maternity hospital in Nairobi?

The department was midwife run. There was one lead midwife and the majority of others were students.  It was frustrating for them because they knew some of the women needed a caesarean section but there were no doctors or anaesthetists available to perform them most of the time.

Was there anything that surprised you?

I was surprised to see that it was often less about a lack of medicines and material resources and more about people.  They need people trained to perform simple but life-saving operations, to deliver pain relief and to talk to and inform patients.

The lead midwife said that one of the biggest problems is a lack of patient education. They identify mothers with a breech presentation and ask them to come at 38 weeks’ gestation for a C-section, but many women don’t return because they worry that an operation will be more dangerous for their baby.

As a result the baby will often die and the mother can also suffer serious problems, even death.  The midwife went on to say that it is hard to convince women otherwise – and they don’t have enough time to spend with each woman to explain things properly.

Do you think you’ll stay invested in global surgery long-term?

I don’t think I was there long enough to learn what my role could be – so I want to go back to Kenya for my elective to find out.

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Dr Amy Keightley

Amy Keightley

“In the UK we have swabs with a radio band so that if you lose one in the body during the operation you can identify it.”

Amy is an Obstetric and Gynaecology Registrar, recently returned from Hoima Hospital in Uganda, currently working at Lincoln County Hospital.

C-sections make up an enormous proportion of all surgeries in low-resource settings.

Yes, but the C-section rate in Uganda, if you look at the place as a whole, is actually very low. There’s not a lot of access to healthcare, and then you arrive at these facilities with a high volume of operations being done in a relatively small space – pockets of high-risk women, clumped together.

Without the training and experience of managing difficult labour, you can end up seeing C-section as a safer way out – without addressing the long-term consequences, and how risky the operation is itself.

So you get this situation where lower-risk women get surgery, and women who needed a C-section three days ago are waiting, waiting, waiting for days, because the theatre is always full.

What are the immediate risks?

Horrible post-natal infection; risk that the surgeon will pick up HIV or hepatitis because they don’t have the right equipment or training.

Resources are a huge problem. In the U.K. there’s someone whose whole job it is to look after the surgical instruments, keep track of equipment. And you can use swabs with a radio band so that if you lose one in the body during the operation you can identify it.

In low-resource settings there’s much smaller theatre teams, and the surgeon may not have someone to assist. The swabs are much smaller and harder to count, and one maternal death we saw was from a swab left in the abdomen – she died of sepsis.

Is the anaesthesia dangerous?

9 times out of 10 the anaesthesia is absolutely fine – but when something goes wrong, it suddenly makes the whole thing very dangerous.

When I arrived, a woman died of a high spinal – an anaesthetic that goes too far up the spine so that the patient can’t breath – because the anaesthesia provider hadn’t been trained to manage the emergency. In the U.K. that would never happen; the patient would be intubated, ventilated, or the anaesthesia would be reversed. Instead, a woman came in for a C-section and died from spinal anaesthesia.

And the long-term consequences?

There’s the impact for the next baby. In the U.K. we can offer mothers a second C-section if they choose, or monitor the second pregnancy closely to make sure that her scar doesn’t rupture.

But in Uganda, what will she do when she goes back to her village, three days walk away, and is laboring with the next one? Who will monitor them when the baby is obstructed? Who will be there to deliver her safely?

What is the impact on hospital staff?

We had two doctors running 4000 deliveries a year, 24 hours a day – no breaks, no weekends. We were losing about 5 women a month, roughly, we were losing babies every day. It’s crisis mode the whole time, and you could never even find half an hour to sit with everyone together because the workload doesn’t ever stop.