International Surgery: Challenges and Responses

"Most people on the planet who need surgery can't get it. Changing this surprising situation is a challenge to which universities should rise - to solve the problem or to train people who can solve it. As an academic health science faculty, we cannot provide health care for Canada, much less the world. We don't build healthcare infrastructure, but what we can provide is training." - Andrew Howard

In 1999, John Wedge and Massey Beveridge founded the International Surgery Office within the Department of Surgery, and Andrew Howard joined the enterprise. He now serves as Director of the Program. Andrew has had a long interest in surgical education and surgical care in Africa. He has a mandate to study injury control in African children. In this resource constrained setting, the infrastructure required for care and research is severely limited.

There is a long and distinguished history of Canadian participation in International Surgery, dating back to Norman Bethune, a University of Toronto graduate and hero of International Surgery in Spain and China Canadian Cardiac surgeon Lee Erett won the Norman Bethune award from the Chinese Government for operative teaching and practice in China (see also http://www.surgicalspotlight.ca/Shared/PDF/Spring07.pdf ). For many years, our surgeons have been going to where they were needed and treating grateful patients, regardless of their ability to pay. Readers will be familiar with the problems of HIV, tuberculosis and malaria in Africa, but there is a less well-known problem- the severe deficiency of surgical care. 13% of Africans die from trauma and 1 in 13 women die in childbirth.

Andrew Howard with his wife, Lianne and their two daughters, Emma and Samantha

The service needs overwhelm capacity. There are only 400 surgeons in all of East Africa. Most are very busy. They do private work to support themselves and provide care in the public system, leaving little time and no financial support for teaching. The University of Toronto psychiatry program led by Clare Pain provides a very effective model. They have worked with psychiatrists at the Addis Ababa University in Ethiopia. Ten years ago, there were no residents. They now have a functioning residency and have raised the number of practitioners in the country from 3 to over 3 dozen. Based on this example, Ted Gerstle is developing a similar program in pediatric surgery, and Andrew is trying to do the same in Orthopaedic surgery.

The Office of International Surgery provides electronic access to the University of Toronto library, so surgeons and other healthcare personnel in Africa can share our textbooks, journals and other subscription- based services. The librarians who have made this possible are Sandra Kendall at Mount Sinai Hospital, and Sian Meikle and Warren Holder at the Robarts Library. The Office of International Surgery provides the services to several hundred surgeons in Africa and supports librarians in Africa to facilitate their use.

The College of Surgeons of Eastern, Central and Southern Africa (COSECSA) is a certifying body that has developed surgical training programs (see also http://www.cosecsa.org/). The College approves training by skilled surgeons at busy community hospitals as well as university sites. There is an online course with a tutorial to help candidates pass the College exams (see http://www.ptolemy.ca/members/). The entries are developed by African surgeons in combination with a Canadian author to provide an international perspective. Some of the work on this project has been published in the Canadian Journal of Surgery. The training process is somewhat like the British system. There is an early exam, analogous to the British Fellowship exam or our Principles of Surgery Exam, followed by specialty-specific training in various disciplines such as paediatric surgery, urology etc. Canadian surgeons provide examiners, but also develop curricula and travel to Africa as teachers. When I interviewed Andrew, he had just returned from giving exams in Uganda for COSECSA.

Andrew was born in Edinburgh, grew up in High Prairie Alberta, completed his undergraduate medical training and surgical residency at Queens, followed by a fellowship in Orthopaedic Surgery at the Hospital for Sick Children. His wife Lianne and two daughters Emma and Samantha accompany him on his paddling and skiing forays into the Canadian wilderness, and they are looking forward to travelling to Africa together one day.

The Office of International Surgery has brought surgeons to Toronto to study. For example Milliard Derbew spent a sabbatical year at the Wilson Centre, studying Surgical Education (see also the Surgical Spotlight, Spring 2006, page 9, or go to http://www.surgicalspotlight.ca/Shared/PDF/spring06.pdf). He subsequently became Dean of Medicine at Addis Ababa University. There is a striking need for paediatric orthopaedic surgeons in Africa, given that almost half of the population is less than 15 years old. Andrew's hope is to develop a Canadian Community of Interest in Surgery in Africa. "We are at a very early stage, but the Surgeon Scientist and Surgical Education Program grew from a small group of interested surgeons to major themes in our department."

UNIQUE APPROACHES TO THE CHALLENGE

Alex Mihailovic

Alexandra Mihailovic is a Critical Care fellow who completed our general surgery residency with a focus on trauma. Her critical care program includes 13 months of core training in various disciplines, including transplantation, medicine, surgery, and seven months of trauma training in Cape Town.

The experience in Cape Town is enlightening and intense - four to five thoracotomies or laparotomies per day, largely for gang - related injuries in the townships - "When a patient has been shot and there are 4 bullets on the chest X-ray, it's impossible to tell which are today's bullets. It's difficult to record outcomes in this population as most of the patients will never return for follow up once they've left hospital. The sanctity of life is less cherished. When a 22- year old dies in the operating room, the staff comforts the surgeon saying: 'He probably killed five people today before he was shot'. Some staff are resentful of putting multiple units of 'our blood into this killer'."

Alex worked with Neil Lazar in the medical ICU at UHN. She became very interested in ethics and social determinants of illness. "In Africa, there is little investment in prevention of trauma and therefore no reduction in the cost of patching up the surviving victims." Alex is a PhD candidate, studying the epidemiology of trauma in Uganda. Andrew Howard is on her committee. She also spent two months in Haiti, as the only surgeon at the time she was there, treating victims of the earthquake and the results of displacement post earthquake with the Canadian and German Red Cross.

One of the striking problems in Haiti was the intervention by doctors from NGOs, who performed elective operations in addition to emergency care. This was encouraged by many NGOs, because they provide the opportunity for publicity photos. However, diverting patients to a free elective surgical service deprives the local surgeons of the fees they need to buy food and maintain their lives in Haiti. "There is a danger that NGOs might eventually force the local doctors to move to Miami or elsewhere in order to make a living. I felt more like a culprit in this situation, as the local doctors said: 'I can't feed my children if you visiting surgeons do the hernias, gall bladders and cesarean sections'."

Alex found a middle ground, debriding ulcers, rotating flaps, treating burns, operating only on inpatients and emergency cases to keep her out of the elective schedule. The ethical quandary after surgery is - "where do these burned patients and paraplegic patients go? People in wheelchairs can't travel where there are no roads and often there are no rehabilitation or prosthetic services available to help them gain independence again...so after all that work to get them surgically healed you then are left with a patient you can't discharge into the streets."

Georges Azzie

HSC surgeon Georges Azzie focuses his practice of international surgery in a setting where he was initially employed by local authorities (Botswana) and where he knows and understands the environment.

Programs he has helped foster are based on local needs assessments. Georges helped develop a multi-facetted program to develop laparoscopic skills among surgeons. This included (but was not limited to) yearly workshops, a telesimulation program done in conjunction with Allan Okrainec (see also Surgical Spotlight Winter 2009) and ongoing support at multiple levels. [There is an interesting response to this important contribution to international surgical education: Some program directors from higher income countries object to teaching minimal access techniques to local surgeons. They send their residents to Africa to perform open operations as surgical tourists. "Where else can they get this experience?" - Ed]

Georges' experience leads him to minimize the destructive side - effects of "surgical tourism" in low and middle income environments. He is "the first to admit that he has more questions than answers with regard to addressing the global burden of surgical disease and to mentoring those with similar career interests."

M.M with notes from Andrew Howard, Alexandra Mihailovic and George Azzie