Reflections of a Cardiac Surgeon Turned Global Health Educator

Abstract

After 35 years of cardiac surgery practice in Allentown, Pennsylvania, I was ready to work full-time in global health (GH). I was not a novice: I had studied tropical medicine in the Panama Canal Zone and worked for 2 years as an epidemiologist at the Centers for Disease Control and Prevention. In addition, before my retirement I had served five overseas missions in roles as cardiac surgeon, epidemiologist, general surgeon, and primary care physician. Early in my overseas experience, I learned that heart surgery is not a priority in low- and middle-income countries (LMICs)—formerly called “the third world”—where I wanted to work. Therefore, when I retired from cardiac surgery, I served a 1-year residency in trauma/surgical critical care to get back into “a general surgery mode.” I have since had 19 more assignments. I have served on medical school faculties in Tanzania, Sierra Leone, Malawi, Rwanda, and Liberia. My work in GH has taken me to Guatemala, St. Lucia, Haiti, Pakistan, Sri Lanka, Libya, Croatia, Jordan, and to 6 countries in Sub-Saharan Africa. I want to share what I have learned about GH. The disparity in health care between the United States (US) and LMICs is generally known. To appreciate it fully, health care professionals from high-income countries need to experience the paucity of health care services in the third world personally. Some examples begin to tell the tale. Sub-Saharan Africa accounts for 25% of the global burden of disease but has only 3% of the world’s health care workers and less than 1% of global health care expenditures [1Curci M. Task shifting overcomes the limitations of volunteerism in developing nations.Bull Am Coll Surg. 2012; 97: 9-19Google Scholar]. There are 1.1 doctors and nurses per 1,000 population compared with 12.3 per 1,000 population in the United States [2Crisp N. Chen L. Global supply of health professionals.N Engl J Med. 2014; 370: 950-957Crossref PubMed Scopus (191) Google Scholar]. Imagine developing acute appendicitis, going to a health center on foot, then to a district hospital, and eventually to a referral hospital to be seen by a surgeon. The delay can be days, and the outcome is likely to be dismal. In fact, parts of many LMICs have no referral systems or surgeons whatsoever. There is no consensus about how to address GH problems. Only 39% of US medical schools have didactic education in GH [3Kahn O.A. Guerrant R. Sanders J. et al.Global health education in US medical schools.BMC Med Educ. 2013; 13: 3Google Scholar]. GH programs, where they exist, are largely a patchwork of uncoordinated efforts. However, there is hope because two-thirds of US medical schools have GH interest groups, and students are increasingly pursuing international rotations in underserved nations [3Kahn O.A. Guerrant R. Sanders J. et al.Global health education in US medical schools.BMC Med Educ. 2013; 13: 3Google Scholar]. The effort to improve access to health care in LMICs is growing. I am encouraged that this surge of interest in GH implies a growing belief that health care is a universal right. Surgery has been “the forgotten step-child of global health” [4Bae J.Y. Groen R.S. Kushner A.L. Surgery as a public health intervention: common misconceptions versus the truth.Bull World Health Organ. 2011; 89: 395Crossref Scopus (67) Google Scholar]. The first of the many reasons for this is that there were precious little data about the burden of surgically treatable diseases until 2012 when Groen and colleagues [5Groen R.S. Samai M. Stewart K.A. et al.Untreated surgical conditions in Sierra Leone: a cluster randomized, cross-sectional, countrywide survey.Lancet. 2012; 380: 1082-1087Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar] identified and quantified the needs in Sierra Leone, a small impoverished country in West Africa. Hospitals in that nation in 2008 were worse off than US hospitals in 1864, during our Civil War. The findings were similar in Rwanda and Nepal [6Kushner A.L. Series Editor’s Foreword.in: Kushner A.L. Operation Crisis — Surgical Care in the Developing World During Conflict and Disaster. Johns Hopkins University Press, Baltimore2017: xiiGoogle Scholar]. Second, surgery was thought to be too complex and resource dependent to be cost-effective in the third world. However, it has become clear that basic surgical intervention is comparable in cost-effectiveness to public health interventions, such as vitamin A administration and measles immunization [4Bae J.Y. Groen R.S. Kushner A.L. Surgery as a public health intervention: common misconceptions versus the truth.Bull World Health Organ. 2011; 89: 395Crossref Scopus (67) Google Scholar], and that there are enormous costs when surgical diseases are untreated or inadequately treated [7Meara J.G. Leather A.J. Hagander L. et al.Global surgery 2030: evidence and solutions for achieving health, welfare and economic development.Lancet. 2015; 386: 569-624Abstract Full Text Full Text PDF PubMed Scopus (1818) Google Scholar]. The Lancet Commission on Global Surgery showed there were 5 billion people without access to safe surgery in 2015 [7Meara J.G. Leather A.J. Hagander L. et al.Global surgery 2030: evidence and solutions for achieving health, welfare and economic development.Lancet. 2015; 386: 569-624Abstract Full Text Full Text PDF PubMed Scopus (1818) Google Scholar]! The deficits in surgical health care specialists are staggering. Imagine the toll taken by the lack of care for obstructed labor, incarcerated hernias, appendicitis, and bowel obstructions! Third, increasing high-speed transportation in medically underserved nations has created an epidemic of trauma. Ninety percent of all road traffic deaths occur in parts of the world with 56% of the motor vehicles, and half of these deaths occur in “vulnerable road users”—pedestrians, bicyclists, and motorcyclists. “Surgical” problems, including injuries, cause more world-wide deaths than malaria, tuberculosis, and human immunodeficiency virus infections combined [1Curci M. Task shifting overcomes the limitations of volunteerism in developing nations.Bull Am Coll Surg. 2012; 97: 9-19Google Scholar]. Fourth, noncommunicable diseases, such as cancer, cardiovascular diseases, and diabetes, are increasingly common in LMICs, generating additional problems requiring surgical intervention [7Meara J.G. Leather A.J. Hagander L. et al.Global surgery 2030: evidence and solutions for achieving health, welfare and economic development.Lancet. 2015; 386: 569-624Abstract Full Text Full Text PDF PubMed Scopus (1818) Google Scholar]. Some international organizations have addressed the global surgery challenges. The International Committee of the Red Cross, based in Geneva, has surgical missions that treat victims of war. Médecins Sans Frontières/Doctors Without Borders provides emergency surgical interventions in situations of conflicts and natural disasters. I am proud to have worked for both of these organizations. Many institutions and faith-based organizations send surgical teams on short-term medical missions. The American College of Surgeons “Operation Giving Back” lists a plethora of opportunities in the third world. There are some exemplary programs. The Himalayan Cataract Project has made a major impact in eliminating treatable blindness by performing state-of-the-art operations in remote places using portable but modern operating microscopes and implanting artificial lenses manufactured in Kathmandu, Nepal. Operation Smile sends specialists to repair cleft lips and cleft palates. Interplast provides plastic and reconstructive surgery. For the most part, these organizations provide direct patient care, but recently, there has been more effort to build capacity in the underserved world by teaching local clinicians. Much of the ongoing GH assistance is good, but there is some fluff. How does one evaluate short-term medical missions? They are costly [8Maki J. Qualls M. White B. et al.Health impact assessment and short-term medical missions: a methods study to evaluate quality of care.BMC Health Serv Res. 2008; 8: 121Crossref PubMed Scopus (171) Google Scholar]! Do these programs have any long-term impact? Could they actually be harmful? I recall in Rwanda when a visiting pediatric surgical team so overwhelmed the operating rooms in a teaching hospital where I was working that there was little capacity to do emergency surgery. I question the value of some programs that send teams to provide open heart surgery in low-resource settings. I suggest that inserting mechanical heart valves in patients where life-long anticoagulation is not reliable violates the basic principle of primum non nocere. How can we make global surgery missions sustainable? One method is called “task shifting,” where nonphysicians are trained to do common surgical procedures—cesarean sections, laparotomies, incarcerated hernias. This approach has some advocates and has been used with some success in Mozambique, Tanzania, and Malawi [1Curci M. Task shifting overcomes the limitations of volunteerism in developing nations.Bull Am Coll Surg. 2012; 97: 9-19Google Scholar, 2Crisp N. Chen L. Global supply of health professionals.N Engl J Med. 2014; 370: 950-957Crossref PubMed Scopus (191) Google Scholar]. Another option is to bring surgeons to North America or Europe for training. This is extremely expensive, removes the trainees from the scant workforce at home, and educates them in surgery that is strikingly different from that in their own country. Surgical emergencies, such as typhoid small-bowel perforations and sigmoid volvulus, which are common in the third world, are rarely, if ever, seen in North America or Europe. Finally, some surgeons from third-world countries stay in the host nations after completing their education and contribute to the “brain-drain” [9Cancedda C. Farmer P.F. Kerry V. et al.Maximizing the impact of training initiatives for health professionals in low-income countries: frameworks, challenges, and best practices.PLoS Med. 2015; 12: e1001840Crossref PubMed Scopus (58) Google Scholar]. A new paradigm in medical aid is based on the principle of cooperation between Ministries of Health of the host nations, funding bodies (eg, US Agency for International Development), and consortiums of US medical institutions [9Cancedda C. Farmer P.F. Kerry V. et al.Maximizing the impact of training initiatives for health professionals in low-income countries: frameworks, challenges, and best practices.PLoS Med. 2015; 12: e1001840Crossref PubMed Scopus (58) Google Scholar]. The expectation is that with local “ownership,” which emphasizes local priorities, the efforts will be more fruitful. The largest of these programs is Human Resources for Health in Rwanda with a budget of $170 million and a consortium of 26 US and Canadian medical institutions committed for a period of 8 years. In 2013, I was privileged to work in this program as a general/thoracic/trauma surgeon for 4 months at the University Teaching Hospital of Kigali. I returned for 2 years (2015 to 2017) and had a similar position at the University Teaching Hospital of Butare. Despite seemingly adequate funding, the challenges of making these programs functional are formidable. For example, the American Board of Surgery’s recent decision to recognize rotations abroad as part of the residency training raises the concern that American surgical residents will “steal cases” and dilute the experience of the local residents. When I worked in Rwanda (and in a similar program in Liberia), the contracted institutions had difficulty identifying faculty members who were willing to live and work abroad for at least 1 year. The program stakeholders share the belief that continuity and longevity are needed so that the visiting faculty can “fit in.” American faculty members are concerned about the security of their academic positions at home, the professional and personal lives of their spouses, and the educational opportunities of their children abroad. I believe that it is precisely because of these recruitment problems in US-based academic institutions that the University of Virginia offered me a position in Rwanda. Most US faculty members in Rwanda (and Liberia) were at the end of their careers or had recently completed their training. Imagine an expatriate surgeon who recently completed his or her residency mentoring an African colleague who has been practicing for a decade or more. Or an old-timer like me teaching residents and giving programmatic advice. When my ideas clashed with those of my hosts, my opinion was ignored. The host country “owned the program.” Despite some tensions, Human Resources for Health in Rwanda was a mutually enriching, promising experience. One of my Rwandan residents, who had previously no experience in thoracic surgery, wrote a paper, “Thoracic Surgery in a Limited-Resource Setting— Rwanda,” which was presented at the annual meeting of the Eastern Cardiothoracic Surgery Society. Educational programs based on information technology advances, such as massive open on-line courses and the “flipped classroom,” in which the sequence of lecture and homework are reversed, show some promise [2Crisp N. Chen L. Global supply of health professionals.N Engl J Med. 2014; 370: 950-957Crossref PubMed Scopus (191) Google Scholar]. Telemedicine can provide prompt, even real-time, consultations with specialists thousands of miles away. Surgical skills laboratories may also be beneficial. All fourth-year medical students in Butare are required to participate in a 1-day supervised session that involves chest tube insertions, bowel anastomoses, and other procedures in a recently slaughtered goat. When the long day is over, the students and faculty members cook and eat the goat! What’s in it for us? Satish Gopal, an oncologist from the University of North Carolina who is working in Lilongwe, Malawi, describes a frightening experience [10Gopal S. Global health: what’s in it for us?.JAMA. 2017; 318: 1325-1326Google Scholar]. His small child developed cerebral malaria. What right did he have to subject his family to such risks? He eloquently makes the case for continued involvement, for commitment. It is, after all, a humanitarian ideal that propels us in that direction. Few, if any, stalwart individuals like Dr Gopal will become rich and famous, but their research may help future doctors and patients both at home and abroad. Work in GH is also fun, particularly if one is young and carefree or old and no longer burdened with rearing children and paying mortgages. Not all assignments require living in a mud hut in the middle of sweltering South Sudan. I have worked in surprisingly modern cities—Kigali, Lilongwe, Monrovia, and Butare. Housing is reasonable, with indoor plumbing and electricity. One does not have to survive on the local cuisine. My wife and I are fans of Indian food, and the best that we have ever had was in Kigali! One can make surprisingly gourmet meals. My wife made an amazing risotto from Rwandan grown arboreal rice—she brought dried porcini mushrooms in her suitcase. I recently had a dinner of pasta with delicious homemade pesto using locally grown basil in Liberia. In some cities one can even buy a bottle of Dom Pérignon (at inflated prices, of course) for a special occasion in Africa. One can visit the legendary Serengeti or lesser known Lake Kivu in Rwanda or Muvu Lodge in Malawi. Try it, you’ll like it! Low- and Middle-Income Countries and US Trainees Benefit From the Global Health EducatorThe Annals of Thoracic SurgeryVol. 107Issue 2PreviewIn his essay outlining his global surgical career, Dr Sinclair [1] highlights the need to transition from a cardiac surgeon back to “general surgery mode.” Although the burden of general surgical and obstetric emergencies cannot be overlooked by the global surgeon, noncommunicable diseases secondary to advancing age, Westernization of diet, and urbanization will be the leading causes of death in low- and middle-income countries (LMICs) by the year 2030 [2]. Developing and understanding LMIC-appropriate therapies for chronic health complaints must be priorities for education of practitioners in LMICs and trainees pursuing a career in global surgery. Full-Text PDF Double Burden of Disease: A Global Health ChallengeThe Annals of Thoracic SurgeryVol. 107Issue 4PreviewDr Sinclair [1] raises very pragmatic issues on the key considerations and adjustments necessary for an enriching global health experience, but more importantly, he highlights the need for coordinated, sustained engagements between and among stakeholders [1]. Getting the priorities of the host countries and institutions right, and as the saying goes, “…working yourself out of the job by building local capacity for posterity…,” should be major criteria for the assessment of any global health undertaking especially targeted at provision of surgical care. Full-Text PDF Fostering the Future of Cardiac Surgery Around the WorldThe Annals of Thoracic SurgeryVol. 108Issue 6PreviewWe are little over 10 years away until 2030, a year for which many global health targets are set. These targets include the Sustainable Development Goals, the World Health Organization targets for universal health coverage, and the Lancet Commission on Global Surgery target for access to safe surgical, obstetric, and anesthesia care for 80% of the world’s population.1 The latter, however, is still far away from being achieved, and as a result, so are the former. Full-Text PDF The Importance of Global Surgical EducationThe Annals of Thoracic SurgeryVol. 108Issue 1PreviewIt is with pleasure that I read Dr Sinclair’s account of his experience in global health throughout his distinguished career [1]. He cites many of the challenges that global surgery has faced. For many years, global surgery has been an unrecognized, unmeasured problem. Only recently have aggressive efforts been made to highlight the burden of disease represented by surgical disease. Indeed, with the increasing availability of transportation, motor vehicle crashes in particular represent a large burden of global disease. Full-Text PDF