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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 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 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

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

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 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

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

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

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 →

2014/02/05

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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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 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 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

“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

“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

“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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Kathleen O’Neill

“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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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

“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 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

“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.

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

“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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Dr 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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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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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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Dr 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.