One of the world’s most pressing global health stories has long been hiding in plain sight — the devastating shortage of surgeons in many countries around the world.

All told, roughly 5 billion people lack access to safe and affordable surgery and anesthesia; about 17 million people a year die because of it. These are pregnant women having birth complications that a simple caesarean section section could fix. They are fathers who bring their children to hospitals only to find that no doctors have the skills to save their sons and daughters. Or they are families that simply can’t get to a surgeon hours or miles away.

The issue requires the sense of urgency that we have given to communicable diseases. Five million people a year die from traumatic injuries alone, a significant portion of which could have been averted had they been taken to skilled surgeons.


I went to Tanzania after finishing a cerebrovascular fellowship at Harvard Medical School, the end of a long tunnel of training that gave me skills to do the most demanding operations in neurosurgery. I was exhausted and needed a six-month break to take stock of my life and career. I wasn’t on a mission to save others.

But when I arrived, I discovered that Tanzania then had just three neurosurgeons for a nation of about 43 million people. That’s one neurosurgeon for every 12 million people. Compare that with one neurosurgeon for every 85,000 Americans.


The dominant humanitarian model for helping people who need surgery has been the short-term medical mission. More than 6,000 medical missions are organized from the United States every year. Most involve doctors and nurses who treat as many patients as possible, do a little sightseeing, and then leave. I think of this as hit-and-run medicine.

There’s no doubt that these volunteers save lives. And their intentions are noble. But there are unintended consequences of this humanitarian model. The worst one is that it teaches dependence and corrupts the organic growth of local health care systems. In addition, even though 6,000 medical missions sounds like a lot, they will never fill the surgical gap.

When I was in Tanzania, I faced a choice. I could treat as many patients as possible or take a different approach with a more long-lasting effect. So I did something that might horrify many Americans, especially medical school deans: I taught brain surgery to an assistant medical officer named Emmanuel Mayegga, a talented clinician who had yet to get his medical degree. Mayegga learned basic brain surgery, and he has been saving lives ever since. Here’s where things get even more exciting. Mayegga taught a second Tanzanian, who in turn taught a third.

This is what needs to happen, but on a global scale. In pediatrics, internal medicine, family medicine, surgery, and many other branches of medicine, we need to transfer skills. Teach forward to create more clinicians. Lots more. And we need to come to terms about short-term medical missions; they simply aren’t getting the job done.

Instead of focusing solely on treating those in need of medical care, we need to build long-term partnerships in countries that will focus on training new surgeons and skilled health care officials. We can look to the Global Fund, which focuses on infectious diseases, as a model. Corporations and foundations have poured hundreds of millions of dollars into this organization to help end AIDS, tuberculosis, and malaria as epidemics. This has made a real difference. We’re getting close to developing a vaccine for malaria.

We need a Global Fund for Surgery. A coalition of corporations, nongovernmental organizations, and universities could help bridge the surgical gap, just as the Global Fund has done for infectious diseases.

The focus for the Global Fund for Surgery should be first and foremost on teaching local doctors new skills. It needs to emphasize skills, not equipment, because these new surgeons will find ways to get equipment and technology on their own. Transferring stuff is easy. Transferring skills and knowledge, though, are truly lasting gifts.

Dilan Ellegala, MD, is a neurosurgeon and founder of Madaktari Africa, a nonprofit organization aimed at advancing medical expertise and care in sub-Saharan Africa. His work is featured in the new book, “A Surgeon in the Village: An American Doctor Teaches Brain Surgery in Africa,” by Tony Bartelme, a senior projects reporter for the Charleston, S.C., Post & Courier (Beacon Press, 2017).

  • For the vast history of mankind , learning skills in apprentiship like relationships were the norm. Industrialized teaching, and the for profit model displaced that effective teaching model . Apprentiships were better at adjusting the needs of the learner, to the needs of the tasks. The Bell shaped curve replaced that individualized style of learning and teaching. We persist in utilizing the industrial method , in spite of all evidence that cognitive mapping and individualized teaching is effective in teach many more ” students” to a level of competency . The military , to some extent utilizes that approach. NPs, PAs, Midwifes, Nurse Anesthetist , among many, have disproved the misconception that only the MD model of teaching, learning, is necessary to achieve care giver competence . Surgical skills are being taught to non Physicians. A team of a Surgical technicians ( for lack of a more descriptive term) and MD internist, is more than able to care for any surgical issue. The Guild mentality, both in Guild members , and the general public convinced that the guild is the only qualified provider , is a false concept. Demonstrated competence trumps Guild controlled educational institutions . Bottom line, if a person accumulates the necessary skills , verified by a certifying process , why is that any less than the Guild model presumed proof of competency? It is a Brave New World . Many prior enforced mis beliefs are crumbling today. This is just the next battle to ensure Lower cost Medical, Surgical , care is available to the Masses! Maybe it’s time to get rid of the Train Coal shoveler !

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