USA

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

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

Barbara Margolies

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tell us why unsafe surgery is our issue.

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