Global Surgical Burden of Disease in Low and Middle Income ......2019/05/17 · programs to underserved (Poster session presented at the Pediatric Surgical and Trauma Nursing Conference)

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Global Surgical Burden of Disease in Low and Middle Income Countries

Melissa Duran, MSN, CRNP, NNP-BCDivision of General, Thoracic, and Fetal Surgery

Global Health CenterChildren’s Hospital of Philadelphia

Philadelphia, PA

Disclosure

• All of the pictures used in this presentation are of patients and their families that we cared for during our mission trips.

• All of the patients and/or their families that were photographed gave their consent for their pictures to be taken and used.

Objectives1. The learner will be able to describe the global surgical

burden of disease.2. The learner will be able to describe the role of the surgeon

and the benefits of surgeons in training participating in short-term platforms for surgical delivery in low and middle income countries.

3. The learner will be able to describe the partnerships and patient outcomes of the CHOP-led international surgical mission to Guatemala.

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Surgical Burden of Disease

• Conditions treatable with surgery account for ~11% of global burden of disease

• Burden of these diseases disproportionately falls on low and middle-income countries (LMICs)

• >67% of world’s population do not have access to safe, affordable surgical care

• 3%-6% of world’s operations are performed in LMICs


• Surgical services concentrated in cities and only available to those who can afford them

• Global Surgery 2030 tasked with proposing strategies to improve surgical services and access to surgical care around the world


• Surgical diseases too costly investment in time and money

• Scarce resources better spent addressing problems associated with infectious diseases or other public health concerns

• View has changed with new data documenting economic benefits resulting from treating surgical diseases

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• No comprehensive and reliable measurements for global burden of surgical disease

• Optimally, would know:• # of patients suffering from

each surgical condition• # presenting to health facility

where they can be treated

• # receiving treatment • Method of treatment• Outcome of treatment


• Without treatment, surgical diseases increase acute and chronic burden of disease

• Have an enormous negative impact on local micro and macro economies


• In a country like Guatemala, even minor disabilities have life long consequences

• “Salvemos nuestro futuro, salvando a nuestros niños”

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• Surgical care can be delivered in cost-effective manner in small hospitals

• Current burden of disease in LMICs not being adequately managed by patchwork of surgical services

• Relief organizations perform nearly 250,000 operations per year in LMICs

• Global need for more efficient, effective and beneficial surgical care is clear


• Only 5% of needed emergency and essential surgery performed

• US and Europe:10,000 operations are performed annually for every 100,000 persons

• In places such as Tanzania, Pakistan, and Malawi: ~300 per 100,000

Role of the Surgeon

• Many attempts to assist developing countries with management of surgical diseases

• 20th century: Inappropriate use of technology and no sustainability

• 1978 to turn of the century: Funding for international surgical initiatives limited due to lack of appreciation of role of surgical diseases in global burden of disease

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Role of the Surgeon

• Importance of investing in international surgical care

• Cost-effectiveness has begun to be studied

• Lack of economic and social barriers prevent access to these surgeries and millions of people face avoidable death and severe disability

Short-Term Platforms

• Burden borne by rapidly growing international charitable sector

• Temporary surgical platforms: Most common model of surgical delivery


• Short-term surgical trips: Send surgeons, anesthesiologists, nurses, and/or supporting staff, along with, at times, surgical instrumentation and technology, into LMIC hospitals and clinics

• Perform restricted set of surgeries

• Local physicians are only needed for immediate postoperative care

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• Uniting model: surgical teams flown into regions with high burdens of specific diseases

• Operate for short stints: Usually 1-2 weeks

• Return to same region in subsequent years

• Strive toward close partnership with local hospitals and ministries of health

Surgeons in Training

• Drs. Paul Farmer and Edward O'Neil, Jr. have been instrumental in growing area of service learning in medical education

• Articulate need for core ethical value of justice to remain forefront in global health, medical ethics and professionalism


• Farmer's work has had a particular impact on medical trainees

• “Health care is a human right, one signs onto a lifetime of work dedicated to erasing double standards for rich and poor”

• Challenges health profession as a whole while inspiring many students

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• Many institutions, regularly participate in organized international mission trips

• First to allow surgical fellows and some other programs are following suit


• Benefits: • Improved cultural

competency and sensitivity

• Increased career interest in public health and volunteerism in surgeons’ own communities

• Improved clinical and surgical skills


• Benefits:• Increased global awareness

of severity of disease• Increased and diverse

opportunities for collaborative research projects

• Improved infrastructure for future surgical collaboration in international communities visited by surgeons

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• International mission trips reawaken humanity in trainees, reminding them why they chose medicine

• Continued dedication to these populations in postgraduate physician practice



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• Personal connections play role in a volunteer’s interest

• Emotional experiences draw volunteers together creating relationships that extend beyond the trips

• Relationships and volunteer’s ability to feel valuable and useful among most important factors in motivating volunteers to return for future MSTs

Introduction• Concept of mission came from Liz

Doolin through a public health project at USC

• Dr. Doolin looked to American College of Surgeons website for possible options

• Identified a program through Partner for Surgery (PFS) that facilitated surgical missions in Guatemala

• PFS has relationship with Asociación Compañero para Cirugía (ACPC) to help identify patients in indigenous areas of Guatemala

Guatemala• The Republic of Guatemala: a country

in Central America bordered by:• Mexico

• Pacific Ocean

• Belize

• Caribbean Sea• Honduras

• El Salvador

• Population: ~16.6 million• Most populated state in Central

America

• Guatemala is a representative democracy

• Capital and largest city: Nueva Guatemala de la Asunción

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Guatemala• Official language: Spanish

• Spoken by 93% of the population as either 1st or 2nd

language• Twenty-one Mayan languages

spoken• Two non-Mayan Amerindian

languages: • Xinca:

• Indigenous to Guatemala• Garifuna:

• Arawakan language spoken on the Caribbean coast

Guatemala• Guatemala is largest economy in

Central America• Social and economic inequality is

high• ~54% of the population lives in

poverty

• Indigenous population is especially affected

• Limited access to healthcare, education and economic opportunities

Background

• Producing an annual surgical mission to Guatemala presents many challenges including:

• Financial support• Diversification of care• Governmental oversight/restrictions• Local relationship building

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Background

• Collaboration with appropriate groups allows us to deepen impact beyond surgery

• Delivering care without understanding impact or outcome of that care presents ethical challenges

Asociación Compañero para Cirugía (ACPC)

• Non-profit that provides medical and surgical care for Guatemalans with little or no access to adequate health care


• Health promoters employed through ACPC educated on various diagnoses that may require surgical intervention

• Health promoters visit indigenous areas and provide list of patients who are potential surgical candidates

• Surgical facility and housing for both patients and staff secured

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• Sustain an annual mission to Guatemala where >50 pediatric surgeries are performed yearly

• Provide educational material for triage missions and nutritional support for children with cleft lip and/or palate


“Today my boy is a normal boy. When he was born I wanted to hide him; I was scared of him. Now he is beautiful and he is complete.”

Surgical Mission

• Colleagues from multiple community partners came together to form surgical team

• Funding obtained through grassroots fundraising by surgical team members

• Funds and all monetary transactions processed through our foundation

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Surgical Mission

• Our responsibilities:• Secure Volunteers• Fundraise• Book Flights• Immunizations/Health

Surgical Mission

• Having to use independent surgical facilities, cost of missions tripled

• Facilities require a percentage of local population be served by missions decreasing number of surgeries provided to indigenous patients

Surgical Mission

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Surgical Mission

• Number of groups which we work with has decreased and become more streamlined

• Colleagues also have vested interest in Guatemala

• Partner with private hospital, Hospitalito Atitlán, to complete surgical missions

Surgical Mission• Hope relationship will stabilize our

mission by providing consistent facility and access to suppliers in Guatemala to decrease costs

• Will continue to work closely with ACPC to provide patient and logistical support

• Unable to secure local insurance to provide potential care outside of these missions, which is a requirement when using private facility

Results

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Results

Conclusions

• With globalization, significant growth in short-term MSTs from HICs to LMICs address unmet needs

• Need for more efficient, effective and beneficial surgical care is clear

• Long-term solutions, such as training local providers and pairing academic centers with counterparts in LMICs, vital to creation of sustainable programs that address root causes of problem

Conclusions

• Vital to have long term partnership with appropriate organizations, departments and staff to produce a sustainable, annual surgical mission

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Conclusions

• Global health is everyone’s responsibility

• Compassion is key • Show that interest is genuine and

that impact is meaningful and will make a difference long term

ReferencesBradke, A. J. (2009). The ethics of medical brigades in Honduras: Who are we helping? (Unpublished Master's Thesis). University of Pittsburgh, Pennsylvania.

Campbell, A., Sullivan, M., Sherman, R. & Magee, W.P. (2010). The medical mission and modern cultural competency training. Journal of the American College of Surgeons, 212, 124-129. doi: 10.1016/j.jamcollsurg.2010.08.019.

Drill, A., Gmerek, J., Klarich, M.K. & Doolin, E. J. (2017, November). Collaboration brings hope and vital programs to underserved (Poster session presented at the Pediatric Surgical and Trauma Nursing Conference). Philadelphia, PA.

Medoff, S. & Freed, J. (2017). The need for formal aurgical global health programs and improved mission trip coordination. Annals of Global Health, 82(4), 634-638.doi: 10.1016/j.aogh.2016.08.003.

Murray, J.S. (1999). Pediatric nursing health care delivery plan for humanitarian missions in developing countries. Pediatric Nursing, 25(4), 387-392.

Parsi, K., & List, J. (2008). Preparing Medical Students for the World: Service Learning and Global Health Justice. The Medscape Journal of Medicine, 10(11), 268.

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ReferencesRussell, S. (2008). A gram of hope: Medicine for the Mayans. Canadian Family Physician, 54(8), 1156-1158.

Shrime, M.G., Sleemi, A. & Ravilla, T.D. (2015). Charitable platforms in global surgery: A systematic review of their effectiveness, cost-effectiveness, sustainability, and role training. World Journal of Surgery, 39(1), 10-20. doi: 10.1007/s00268-014-2516-0.

Sykes, K.J. (2014). Short-term medical service trips: A systematic review of the evidence. American Journal of Public Health, 104(7), e38–e48.

Tannan, S.C. & Gampper, T.J. (2015). Resident participation in international surgical missions is predictive of future volunteerism in practice. Archives of Plastic Surgery, 42(2),159-63. doi: 10.5999/aps.2015.42.2.159. Epub2015 Mar 16.

Tefera, G., Wilczak, B. & Barber, D. (2016). Operation Giving Back and the ACS Archives offer opportunities for engagement. Bulletin of the American College of Surgeons, 101(12), 70-71.

Yeow, V.K., Lee, S.T., Lambrecht, T.J., Barnett, J., Gorney, M., Hardjowasito, W., Lemperle, G., McComb, H., Natsume, N., Stranc, M. & Wilson, L. (2002). International Task Force on Volunteer Cleft Missions. Journal of Craniofacial Surgery, 13(1), 18-25.

Acknowledgements

In Loving MemoryLisa Joan Haffner Dorantes

December 21, 1974-December 1, 2016

Documents

Global Surgical Burden of Disease in Low and Middle Income ......2019/05/17 · programs to underserved (Poster session presented at the Pediatric Surgical and Trauma Nursing Conference)