India

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

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

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 →

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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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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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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.