Opinion
EDITORIAL
SURGICAL DELIVERY IN UNDER-RESOURCED SETTINGS
Surgical Delivery in Under-resourced Settings Building Systems and Capacity Around the Corner and Far Away Meera Kotagal, MD, MPH; Karen Horvath, MD
Service to patient and community has always been the sacred vow of every physician. Certainly for those marginalized in society—by poverty, plague, isolation, or disaster—our obligation takes on renewed importance. As the physician Francis Weld Peabody wrote in his classic essay “The Care of the Patient,” “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”1 During the past decade, this focus on communities in need has been reinforced in the surgical disciplines by the growing interest in global surgery. Global surgery is the practice of surgery—and the development of systems for surgical care—in resource-limited settings. We now see a new generation of trainees pursuing careers in global surgery and an explosion of fellowships, training tracks, and clerkship opportunities focused on global surgery.2 Additionally, there have been a number of collaborative, multi-institution, multinational efforts to incorporate surgical care into global public health discourse. Some recent examples include the publication of a volume on surgery in the third edition of Disease Control Priorities3 as well as the development of a Lancet commission on global surgery.4 Global surgery as a discipline has, to date, focused on the provision of surgical care in resource-limited settings— largely in impoverished countries around the world—by trainees and practicing surgeons from the United States and other resource-rich settings. It is equally important, though, to recognize that resource-limited settings do not exist solely in lowand middle-income countries; they are also abundant as “deserts of care” in high-income countries such as the United States.5 As the field of global surgery further develops, a number of key issues are crucial to consider and emphasize, including a need to focus on systems development and capacity building, locally driven care, public health challenges and solutions, and the ethics of global surgical work.
Systems Development and Capacity Building Global health initiatives have historically vacillated between supporting primary care efforts and focusing on a single disease or pathogen to the exclusion of others.6 These programs have become known in public health parlance as horizontal and vertical programs, respectively. Unlike horizontal programs that focus more on health system strengthening, vertical programs often operate as silos, investing money in the diagnosis and management of the chosen disease, with far less health 100
system development. Julio Frenk, MD, MPH, PhD, Dean of the Faculty at the Harvard School of Public Health, and Jaime Sepulveda, MD, MPH, MSc, DrSc, Executive Director of Global Health Sciences at the University of California, San Francisco, proposed that horizontal and vertical approaches could be integrated to create diagonal programs, using health aid or interest in a single disease as a mechanism to help strengthen the health system as a whole.7 Global surgical initiatives must be seen as crucial tools to help achieve this diagonal objective. Health care systems must be able to provide preoperative, intraoperative, and postoperative care involving multiple components such as skilled surgical, anesthesia, and nursing professionals; a functioning supply chain; and the capacity to identify, support, and care for patients outside the formal health system, often through broader networks of community health workers. One crucial aspect of systems development in underresourced settings is building local capacity. Much of the early work in global surgery occurred in the form of mission trips, bringing skilled health care professionals to communities in need for short, episodic provision of surgical care.8 However, as global surgery has developed, there has been an increasing emphasis on longer-term initiatives focused on building local capacity to provide care: developing skilled professionals in communities in need rather than bringing them in from outside. Mentorship is needed in this area. Success of capacitybuilding initiatives depends on trained mentors who are culturally aware and emotionally intelligent and who have an interest in investing in local health care professionals.
Locally Driven Care and Research A corollary to capacity building is the primacy of local priority. Both clinical care initiatives and research projects are more likely to focus on areas of need and to answer questions of importance if they stem from local health care professionals and the communities they serve. Creating locally driven initiatives, however, is not a simple task. Doing so requires investment in communities and long-term engagement with local health care professionals—efforts we believe are key to the success of global surgical programs. This focus also requires subjugating the interests and goals of health care professionals and trainees from the United States and other resource-rich countries to the broader goals of the community being served and its health care professionals. It
JAMA Surgery February 2015 Volume 150, Number 2 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/07/2015
jamasurgery.com
Editorial Opinion
may be a worthy endeavor to provide opportunities for US trainees to grapple with and learn from provision of surgical care in under-resourced settings; however, the focus of these electives must be carefully examined. These experiences may inspire future interest in providing care long term in underresourced settings, but doing so must not come at the expense of the communities being served and the local health care professionals.
Public Health Issues Surgery and public health are partners; public health efforts are key to reducing the surgical disease burden and improving outcomes in under-resourced settings of all types. Trauma prevention and systems development—including road safety initiatives and the training of lay first responders—as well as the development of cancer collaboratives focused on research and care provision are key public health initiatives to reduce surgical burden of disease that have been implemented in a variety of under-resourced settings.9,10 Another key public health partner is the community health worker, instrumental in helping to treat diseases such as human immunodeficiency virus and tuberculosis and equally critical to the management of surgical disease.11 Community health workers can identify cases, provide education regarding surgical disease and management, and follow up with patients postoperatively. Surgeons must be as eager to engage with and help educate the public health community as they are to operate on patients with surgical disease to truly make an impact in under-resourced settings.
Ethics While there is great personal value to the global surgeon from engagement in the provision of surgical care in underresourced areas, the local community’s needs and priorities must predominate. In particular, there are 3 ethical imperatives for the field of global surgery. First, although electives for surgical trainees from high-income countries present a tremendous opportunity and should be supported by the Accreditation Council for Graduate Medical Education, the needs of visiting trainees should never supersede the training needs of local trainees or health care professionals, and systems should be developed to keep this in check. Additionally, current observorships in high-income settings for health care professionals from low- and middle-income countries fall far short of reciprocating this educational
experience, lacking the ability for health care professionals from low- and middle-income countries to participate meaningfully in care, and this should be addressed moving forward in global surgery. Second, it is important to remember that every effort should be made to provide surgical treatment in keeping with the standard of care acceptable in resource-rich settings. Lastly, accepted research ethics must be considered in global surgical initiatives. Ideally, research ideas would be locally driven with support and engagement from local health care professionals, and research and publications should be conducted in that fashion. In addition, research approvals must be obtained from both host (local) and partner (foreign) institutions.
Deserts of Care Much of the work in the field of global surgery has focused on under-resourced settings in low- and middle-income countries. However, under-resourced settings exist throughout the world in many contexts, including in high-income countries such as the United States. These deserts of care often occur in communities of poverty and isolation, and while their surroundings are arguably over-resourced, these communities do not reap those benefits. Included are those in both rural and impoverished urban communities as well as minority communities that lack access to care similar to the lack of access faced by individuals in low- and middle-income countries.6,12,13 Rural patients, for example, are often isolated from highlevel trauma care; as a result, they have been found to have increased mortality compared with their urban counterparts.14 Additionally, there are marked discrepancies in the surgical workforce between rural and urban areas.15 As we seek to improve access, capacity, and ultimately care in underresourced settings, we must realize that these settings exist in all corners of the globe, often right next door to settings with ample resources.
Conclusions Surgical delivery in under-resourced settings, the theme for the coming year at JAMA Surgery, is complex and of vital importance to communities around the world with limited access to high-quality surgical care. As we kick off this yearlong theme, we welcome articles that focus on strategies for understanding gaps in surgical care delivery and outcomes and on methods for expanding capacity, improving delivery, and reducing surgical burden of disease.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Surgery, University of Washington, Seattle.
1. Peabody F. The care of the patient. JAMA. 1927; 88(12):877-882.
4. Meara JG, Hagander L, Leather AJ. Surgery and global health: a Lancet Commission. Lancet. 2014; 383(9911):12-13.
Corresponding Author: Karen Horvath, MD, Department of Surgery, University of Washington, 1959 NE Pacific St, PO Box 356410, Seattle, WA 98195 ([email protected]).
2. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective global surgery rotations for residents: a call for cooperation and consortium. World J Surg. 2011;35(12):2617-2624.
5. Crandall M, Sharp D, Unger E, et al. Trauma deserts: distance from a trauma center, transport times, and mortality from gunshot wounds in Chicago. Am J Public Health. 2013;103(6):1103-1109.
Published Online: January 7, 2015. doi:10.1001/jamasurg.2014.3496.
3. Disease Control Priorities Network. Disease Control Priorities 3 (DCP3). http://www.dcp-3.org /volume/1/disease-control-priorities. Accessed August 27, 2014.
6. Mills A. Mass campaigns versus general health services: what have we learnt in 40 years about vertical versus horizontal approaches? Bull World Health Organ. 2005;83(4):315-316.
Conflict of Interest Disclosures: None reported.
7. Frenk J. Bridging the divide: comprehensive reform to improve health in Mexico. http://www jamasurgery.com
(Reprinted) JAMA Surgery February 2015 Volume 150, Number 2
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/07/2015
101
Opinion Editorial
.who.int/social_determinants/resources/frenk.pdf. Accessed August 27, 2014. 8. Magee WP Jr. Evolution of a sustainable surgical delivery model. J Craniofac Surg. 2010;21(5):13211326. 9. Mock CN, Tiska M, Adu-Ampofo M, Boakye G. Improvements in prehospital trauma care in an African country with no formal emergency medical services. J Trauma. 2002;53(1):90-97. 10. Jayaraman S, Mabweijano JR, Lipnick MS, et al. First things first: effectiveness and scalability of a
102
basic prehospital trauma care program for lay first-responders in Kampala, Uganda. PLoS One. 2009;4(9):e6955. 11. Farmer P, Léandre F, Mukherjee JS, et al. Community-based approaches to HIV treatment in resource-poor settings. Lancet. 2001;358(9279): 404-409. 12. Cooper GS, Yuan Z, Landefeld CS, Rimm AA. Surgery for colorectal cancer: race-related differences in rates and survival among Medicare beneficiaries. Am J Public Health. 1996;86(4):582586.
13. Finlayson SRG. Surgery in rural America. Surg Innov. 2005;12(4):299-305. 14. Grossman DC, Kim A, Macdonald SC, Klein P, Copass MK, Maier RV. Urban-rural differences in prehospital care of major trauma. J Trauma. 1997;42 (4):723-729. 15. Lynge DC, Larson EH. Workforce issues in rural surgery. Surg Clin North Am. 2009;89(6):1285-1291, vii.
JAMA Surgery February 2015 Volume 150, Number 2 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/07/2015
jamasurgery.com
EDITORIAL
SURGICAL DELIVERY IN UNDER-RESOURCED SETTINGS
Surgical Delivery in Under-resourced Settings Building Systems and Capacity Around the Corner and Far Away Meera Kotagal, MD, MPH; Karen Horvath, MD
Service to patient and community has always been the sacred vow of every physician. Certainly for those marginalized in society—by poverty, plague, isolation, or disaster—our obligation takes on renewed importance. As the physician Francis Weld Peabody wrote in his classic essay “The Care of the Patient,” “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”1 During the past decade, this focus on communities in need has been reinforced in the surgical disciplines by the growing interest in global surgery. Global surgery is the practice of surgery—and the development of systems for surgical care—in resource-limited settings. We now see a new generation of trainees pursuing careers in global surgery and an explosion of fellowships, training tracks, and clerkship opportunities focused on global surgery.2 Additionally, there have been a number of collaborative, multi-institution, multinational efforts to incorporate surgical care into global public health discourse. Some recent examples include the publication of a volume on surgery in the third edition of Disease Control Priorities3 as well as the development of a Lancet commission on global surgery.4 Global surgery as a discipline has, to date, focused on the provision of surgical care in resource-limited settings— largely in impoverished countries around the world—by trainees and practicing surgeons from the United States and other resource-rich settings. It is equally important, though, to recognize that resource-limited settings do not exist solely in lowand middle-income countries; they are also abundant as “deserts of care” in high-income countries such as the United States.5 As the field of global surgery further develops, a number of key issues are crucial to consider and emphasize, including a need to focus on systems development and capacity building, locally driven care, public health challenges and solutions, and the ethics of global surgical work.
Systems Development and Capacity Building Global health initiatives have historically vacillated between supporting primary care efforts and focusing on a single disease or pathogen to the exclusion of others.6 These programs have become known in public health parlance as horizontal and vertical programs, respectively. Unlike horizontal programs that focus more on health system strengthening, vertical programs often operate as silos, investing money in the diagnosis and management of the chosen disease, with far less health 100
system development. Julio Frenk, MD, MPH, PhD, Dean of the Faculty at the Harvard School of Public Health, and Jaime Sepulveda, MD, MPH, MSc, DrSc, Executive Director of Global Health Sciences at the University of California, San Francisco, proposed that horizontal and vertical approaches could be integrated to create diagonal programs, using health aid or interest in a single disease as a mechanism to help strengthen the health system as a whole.7 Global surgical initiatives must be seen as crucial tools to help achieve this diagonal objective. Health care systems must be able to provide preoperative, intraoperative, and postoperative care involving multiple components such as skilled surgical, anesthesia, and nursing professionals; a functioning supply chain; and the capacity to identify, support, and care for patients outside the formal health system, often through broader networks of community health workers. One crucial aspect of systems development in underresourced settings is building local capacity. Much of the early work in global surgery occurred in the form of mission trips, bringing skilled health care professionals to communities in need for short, episodic provision of surgical care.8 However, as global surgery has developed, there has been an increasing emphasis on longer-term initiatives focused on building local capacity to provide care: developing skilled professionals in communities in need rather than bringing them in from outside. Mentorship is needed in this area. Success of capacitybuilding initiatives depends on trained mentors who are culturally aware and emotionally intelligent and who have an interest in investing in local health care professionals.
Locally Driven Care and Research A corollary to capacity building is the primacy of local priority. Both clinical care initiatives and research projects are more likely to focus on areas of need and to answer questions of importance if they stem from local health care professionals and the communities they serve. Creating locally driven initiatives, however, is not a simple task. Doing so requires investment in communities and long-term engagement with local health care professionals—efforts we believe are key to the success of global surgical programs. This focus also requires subjugating the interests and goals of health care professionals and trainees from the United States and other resource-rich countries to the broader goals of the community being served and its health care professionals. It
JAMA Surgery February 2015 Volume 150, Number 2 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/07/2015
jamasurgery.com
Editorial Opinion
may be a worthy endeavor to provide opportunities for US trainees to grapple with and learn from provision of surgical care in under-resourced settings; however, the focus of these electives must be carefully examined. These experiences may inspire future interest in providing care long term in underresourced settings, but doing so must not come at the expense of the communities being served and the local health care professionals.
Public Health Issues Surgery and public health are partners; public health efforts are key to reducing the surgical disease burden and improving outcomes in under-resourced settings of all types. Trauma prevention and systems development—including road safety initiatives and the training of lay first responders—as well as the development of cancer collaboratives focused on research and care provision are key public health initiatives to reduce surgical burden of disease that have been implemented in a variety of under-resourced settings.9,10 Another key public health partner is the community health worker, instrumental in helping to treat diseases such as human immunodeficiency virus and tuberculosis and equally critical to the management of surgical disease.11 Community health workers can identify cases, provide education regarding surgical disease and management, and follow up with patients postoperatively. Surgeons must be as eager to engage with and help educate the public health community as they are to operate on patients with surgical disease to truly make an impact in under-resourced settings.
Ethics While there is great personal value to the global surgeon from engagement in the provision of surgical care in underresourced areas, the local community’s needs and priorities must predominate. In particular, there are 3 ethical imperatives for the field of global surgery. First, although electives for surgical trainees from high-income countries present a tremendous opportunity and should be supported by the Accreditation Council for Graduate Medical Education, the needs of visiting trainees should never supersede the training needs of local trainees or health care professionals, and systems should be developed to keep this in check. Additionally, current observorships in high-income settings for health care professionals from low- and middle-income countries fall far short of reciprocating this educational
experience, lacking the ability for health care professionals from low- and middle-income countries to participate meaningfully in care, and this should be addressed moving forward in global surgery. Second, it is important to remember that every effort should be made to provide surgical treatment in keeping with the standard of care acceptable in resource-rich settings. Lastly, accepted research ethics must be considered in global surgical initiatives. Ideally, research ideas would be locally driven with support and engagement from local health care professionals, and research and publications should be conducted in that fashion. In addition, research approvals must be obtained from both host (local) and partner (foreign) institutions.
Deserts of Care Much of the work in the field of global surgery has focused on under-resourced settings in low- and middle-income countries. However, under-resourced settings exist throughout the world in many contexts, including in high-income countries such as the United States. These deserts of care often occur in communities of poverty and isolation, and while their surroundings are arguably over-resourced, these communities do not reap those benefits. Included are those in both rural and impoverished urban communities as well as minority communities that lack access to care similar to the lack of access faced by individuals in low- and middle-income countries.6,12,13 Rural patients, for example, are often isolated from highlevel trauma care; as a result, they have been found to have increased mortality compared with their urban counterparts.14 Additionally, there are marked discrepancies in the surgical workforce between rural and urban areas.15 As we seek to improve access, capacity, and ultimately care in underresourced settings, we must realize that these settings exist in all corners of the globe, often right next door to settings with ample resources.
Conclusions Surgical delivery in under-resourced settings, the theme for the coming year at JAMA Surgery, is complex and of vital importance to communities around the world with limited access to high-quality surgical care. As we kick off this yearlong theme, we welcome articles that focus on strategies for understanding gaps in surgical care delivery and outcomes and on methods for expanding capacity, improving delivery, and reducing surgical burden of disease.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Surgery, University of Washington, Seattle.
1. Peabody F. The care of the patient. JAMA. 1927; 88(12):877-882.
4. Meara JG, Hagander L, Leather AJ. Surgery and global health: a Lancet Commission. Lancet. 2014; 383(9911):12-13.
Corresponding Author: Karen Horvath, MD, Department of Surgery, University of Washington, 1959 NE Pacific St, PO Box 356410, Seattle, WA 98195 ([email protected]).
2. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective global surgery rotations for residents: a call for cooperation and consortium. World J Surg. 2011;35(12):2617-2624.
5. Crandall M, Sharp D, Unger E, et al. Trauma deserts: distance from a trauma center, transport times, and mortality from gunshot wounds in Chicago. Am J Public Health. 2013;103(6):1103-1109.
Published Online: January 7, 2015. doi:10.1001/jamasurg.2014.3496.
3. Disease Control Priorities Network. Disease Control Priorities 3 (DCP3). http://www.dcp-3.org /volume/1/disease-control-priorities. Accessed August 27, 2014.
6. Mills A. Mass campaigns versus general health services: what have we learnt in 40 years about vertical versus horizontal approaches? Bull World Health Organ. 2005;83(4):315-316.
Conflict of Interest Disclosures: None reported.
7. Frenk J. Bridging the divide: comprehensive reform to improve health in Mexico. http://www jamasurgery.com
(Reprinted) JAMA Surgery February 2015 Volume 150, Number 2
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/07/2015
101
Opinion Editorial
.who.int/social_determinants/resources/frenk.pdf. Accessed August 27, 2014. 8. Magee WP Jr. Evolution of a sustainable surgical delivery model. J Craniofac Surg. 2010;21(5):13211326. 9. Mock CN, Tiska M, Adu-Ampofo M, Boakye G. Improvements in prehospital trauma care in an African country with no formal emergency medical services. J Trauma. 2002;53(1):90-97. 10. Jayaraman S, Mabweijano JR, Lipnick MS, et al. First things first: effectiveness and scalability of a
102
basic prehospital trauma care program for lay first-responders in Kampala, Uganda. PLoS One. 2009;4(9):e6955. 11. Farmer P, Léandre F, Mukherjee JS, et al. Community-based approaches to HIV treatment in resource-poor settings. Lancet. 2001;358(9279): 404-409. 12. Cooper GS, Yuan Z, Landefeld CS, Rimm AA. Surgery for colorectal cancer: race-related differences in rates and survival among Medicare beneficiaries. Am J Public Health. 1996;86(4):582586.
13. Finlayson SRG. Surgery in rural America. Surg Innov. 2005;12(4):299-305. 14. Grossman DC, Kim A, Macdonald SC, Klein P, Copass MK, Maier RV. Urban-rural differences in prehospital care of major trauma. J Trauma. 1997;42 (4):723-729. 15. Lynge DC, Larson EH. Workforce issues in rural surgery. Surg Clin North Am. 2009;89(6):1285-1291, vii.
JAMA Surgery February 2015 Volume 150, Number 2 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/07/2015
jamasurgery.com
