Africa and the surgical imbalance

Nick Czernkovich on the neglected stepchild of global health, surgery in the developing world
A young woman lies in a hospital bed in Masisi, in the eastern portion of the Democratic Republic of Congo. She had been shot in the knee and back of the neck and had been carried 16 hours to the nearest hospital where surgery could be performed. (Nick Czernkovich/CBC)

I met Adam in the Democratic Republic of Congo. He was born by cesarean section and then, a few months later, he was back at hospital for emergency stomach surgery. At the age of 23, he again found himself under the knife for an appendectomy.

Adam is one of the lucky ones. Born and raised in the U.S., he had access to these relatively basic but life-saving surgeries without which he — and his mother — would probably not have survived.

Now 44, Dr. Adam Kushner is a certified general surgeon, but the small miracles of his early surgical encounters have not been lost on him.

Dr. Adam Kushner in Masisi, DRC, in April 2010. (Nick Czernkovich/CBC)

When I met him he was working for Doctors Without Borders in a rural hospital in the town of Masisi in North Kivu province, one of the most troubled in the eastern Congo.

As we talked, he explained just how grossly imbalanced surgical care is between the developed and developing worlds.

"For Canada, the U.S. and Europe, most estimates indicate that for every 100,000 people there are about 10,000 surgeries performed every year," he said.

"But in sub-Saharan Africa, there are about 300 operations for every 100,000 people."

As world leaders gather in Toronto for their G8 and G20 summits, health care for Africa — maternal health care in particular — is once again on the agenda.

In the run-up to these gatherings there was much talk about Canada's position not to pay for therapeutic abortions in Africa, where unsafe, backroom procedures have been linked to the deaths of at least 25,000 women annually, while injuring as many as 1.7 million others.

But while it is one thing for the leaders of developed countries to differ, as they did, over the appropriateness of such procedures, the debate on the ground is much less rarified: where to find the teams and facilities to perform such procedures safely in the first place.

Surgical imbalance

The CBC's Nick Czernkovich spent three weeks in the Democratic Republic of Congo in April 2010, visiting relief camps and interviewing those involved in trying to stabilize the country. You can read his earlier article The Congo at 50.

The surgical imbalance that Kushner talks about may make it onto the G20 agenda and is the focus of a recent paper co-authored by Surgeons OverSeas, of which he is a co-founder, and the World Health Organization.

In it, researchers examined 132 health-care facilities in eight developing countries only to find that many of the operating room elements vital to safe surgery sometimes couldn't be found.

Four essential items — oxygen, water, electricity and an anesthesia machine — were "always available" in only 21, 50, 36 and 32 per cent of the facilities, respectively.

Indeed, in some places, some or all of these items were "never available," the study reported.

Surgery has been called the neglected stepchild of global health and, while much emphasis has been placed on addressing formidable diseases like HIV, tuberculosis and malaria through drugs, conditions requiring surgery have taken something of a back seat.

Maternal deaths

African women have the highest rates of maternal mortality in the world, at least 100 times those in developed countries.

More than 50 per cent of all maternal deaths worldwide can be attributed to six countries: India, Pakistan, Afghanistan, Ethiopia, Nigeria, and the Democratic Republic of the Congo.

Sources: WHO, Lancet, April 2010

At the same time, it has been found that surgically repairable conditions are among the top 15 causes of disability in much of Africa.

What's more, in places where physical labour is a way of life, the absence of surgical care can be devastating.

One statistic that stands out: The SOS/WHO study found that only 33 per cent of the hospitals surveyed had the unrestricted ability to manage an open fracture.

Maternal health

When it comes to maternal health, the findings were equally dismal.

The study found that only 44 per cent of the 132 hospitals surveyed could perform a C-section all of the time.

In Canada, just over 26 per cent of pregnant women have a C-section every year. It is a high number, too high, some say.

But it is also a reflection of the fact that complications during labour can be life-threatening to both mother and child.

Sadly, when I was in the DRC, I witnessed a case in which a mother was not able to get help in time and the fetus died inside of her.

In the few places, like Masisi, where there is a hospital, pregnant women are invited to stay in a special residence nearby in case any complications arise. (Nick Czernkovich/CBC)

Physicians from Doctors Without Borders were able to save her life, but only because they had the capacity to surgically remove the dead fetus.

In the developing world, more than 500,000 women die each year during childbirth, the UN says (a recent Lancet study put the figure lower, 342,900 in 2008). But there is little debate that access to surgery would save many of them.

Indeed, the World Health Organization has suggested that a C-section rate of about 10 per cent in these low-income countries — which is at least double the current rate — would be a huge step in improving maternal and infant survival.

Gloves and aprons

Improving the surgical capabilities of developing countries has been implicitly promised since UN countries set out the Millennium Development Goals in 2001, pledging to reduce child mortality, improve maternal health and combat HIV/AIDS: Millennium Development Goals four, five and six.

Fixing fistula

Since 2003, the UN has been on a campaign to reduce and eliminate fistula in the developing world, particularly sub-Saharan Africa. One of the concerns that will almost certainly be on the G20 agenda, fistula is a birthing condition that is almost unheard of in advanced countries. 

Access to timely C-sections relieve the pressure on the birth canal and prevent a rupture of the walls separating the vagina and the bladder.

Fixing fistula is a simple surgical procedure that costs about $300. But an estimated two million women remain untreated and at least 50,000 new cases develop each year. The consequences are usually shattering: the baby usually dies and the mother is left with chronic incontinence and is often shunned by her family.

This does not just mean focusing on procedures that require specialized knowledge and expensive equipment however. There are simple things that can be done as well, the SOS/WHO paper argues.

For example, with regard to HIV/AIDS, the use of proper protective equipment during the surgeries that are currently being performed is essential to stopping the spread of these viruses.

Yet the study found that only 52 per cent of the hospitals had access to sterile gloves. Only 33 per cent had surgical aprons and only 18 per cent had eye protection.

In the context of a country such as Malawi, for example, where as many as 30 per cent of patients undergoing surgery can be HIV positive, inadequate protection poses a huge risk to health care professionals and subsequent patients.

Unfortunately, addressing surgical deficiencies in these developing countries is arguably more complex than addressing communicable diseases.

Improvements to a country's surgical capacity requires more than a vaccine or pill. They require a system that can sustain itself.

Kushner argues that even facilities ostensibly offering certain types of surgery, such as C-sections, must be examined and probably upgraded so they can deal with any complications that might arise as well.

There is no one-size-fits-all solution when it comes to addressing surgical deficiencies, he says. It must be done on a case-by-case basis and it won't be done overnight.