technology

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

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

Erica Frenkel

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

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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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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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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.