equality

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 →

2014/03/05

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

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 Ronke Desalu

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

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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.

 

 

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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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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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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.