O

ne 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.

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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).

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  • Missing the point? I thought we were talking about non-physicians filling in for fully trained physicians, which is what you are not advocating, except when you are. Case in point: you said, “I am not advocating nurses becoming full time surgeons, but in situations where there is no surgeon available, or they need extra hands, nurses can, and do, fill the role.” So which is it? If you are fully trained and qualified to perform the surgery sometimes, then you should be fully trained to do the job full time. And if the nursing shortage is a problem, as you said, and we simply must let nurses fill physician jobs when needed, as you implied, then why not let non-nurses practice nursing when needed, like right now? Because training, knowledge, and experience are kind of important, right?
    And by the way, when the patient signs the consent form, and you perform some part of the surgery when needed, is your name on the consent form? If your mother had surgery, had a complication, and you found out the surgery was performed by a nurse because her surgeon was too busy in another case, would you be understanding? Does it really matter who does the surgery? Of course it matters, and you would likely sue the doctor, that nurse, and the hospital for malpractice based on lack of fully informed consent, not for money but to send a message, so they can’t hurt anyone else every again.
    We are no longer talking about neurosurgery in the jungle. This is right here in America, where we have no excuse: if it is wrong for an internist to perform surgery, then it is at least as wrong for a nurse, even if both spent time in the OR working with surgeons.
    And finally, if you are going to address me by name, spell it correctly.

  • Dr. Grant, you are missing the point. I said as a force multiplier, not replacing. As an OR nurse, many of us are trained as First Assistants and perform many roles during the procedure along with the surgeon. Opening, dissecting and in many instances we catch things missed by the surgeon. I am not advocating nurses becoming full time surgeons, but in situations where there is no surgeon available, or they need extra hands, nurses can, and do, fill the role. As for the nursing shortage, you are correct, it is just like the physician shortage. There are too many vacancies throughout healthcare, why not work together and abandon the adversarial methodology?

  • Nurse Scroggins, so if having RN’s licensed to performing surgery without supervision is better than no one at all, then what about our shortage of college-trained RN’s? Would you say it’s better to have high school-trained CNA’s licensed to practice as RN’s without supervision, as a force multiplier until a higher level of care is available, than to have no RN’s at all?
    And once RN’s are neurosurgeons, are you going to stop them when a “real” neurosurgeon is available?

  • MN A disruptive approach indeed. Take this a step farther, could non physician healthcare professionals perform minor procedures such as hernia repair, small mass excision or even appendectomy? I believe so. As an army combat medic, we did many advanced procedures in combat zones that would require a physician in the civilian world. Many surgical, ICU, and Emergency Nurses could perform minor, low risk procedures in developing countries or in critical incidents in first world countries. It is time to put patients first and get past legacy thought.

    • Ok, as an army medic, say you are allowed to do surgery without supervision. For you, medical school was optional and yet, you are a surgeon. And if med school becomes optional and you get the same job, privileges, and paycheck, what moron would choose to endure med school and years of residency? No one. But then, that ‘simple appendectomy’ turns out to be cancer, that you have now spread cancer cells all throughout his abdomen. Who do you call? A doctor? Nope, once med school becomes optional, then you’re it.

    • Dr. Grant,
      I fully agree, in normal situations. But in a developing country, or crisis situation, professionals that have minimal experience could do life saving procedures, or in the developing country where there was no care, something may be better than nothing. Nothing will take the place of a properly trained surgeon, but a force multiplier could relieve some suffering until the higher level of care is available. It is highly likely that an appendiceal cancer would go undetected completely if there was no one available at all.

  • Except this completely discounts the role of medical school and residency, and takes us back to the bad old days of apprenticeships. Why was that bad? Each of us as strengths and weaknesses; if I am your only teacher, you will probably not have my strengths but you will have my weaknesses. And if you have never taken pharmacology, pathology, etc like every other medical student, then do we really expect a neurosurgeon to teach all of that? I understand we need more surgeons, but this plan reminds me of an old British saying: the plan seems penny wise, but is pound foolish.

    • yeah except this isn’t talking about western systems that have sufficient training programmes. This is a low-resource setting with no capacity for increasing the number of neurosurgeons rapidly – this is a decent stop gap. Task shifting is decades old already, this is a really neat application.

    • Dr Trant, your criticisms are completely valid and this should be looked at as a stop gap measure only. The ideal is setting up medical schools and proper residency programs and we are seeing this happening in Tanzania. However until properly trained medical professionals are educated and disseminated, this is a better way than short term non-training medical missions, which have created a paralyzing dependency for the local health care workers. We do keep objective clinical outcomes databases and publish in peer reviewed journals (with our local partners) in order to keep track of quality of care. We have also taken this model of training and applied it to other medical specialties with similar results (partly funded by the US government) – wherever possible with fully trained local MDs.

  • Thanks for removing a choice insult from the English language: “It’s not brain surgery.” I just hope some aeronautical engineer doesn’t get any ideas from this article.

  • What a wonderful idea–on so many levels. Here’s hoping that it can serve as a model for training specialists in countries around the world, and that it receives widespread and generous corporate support.

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