In countries with a shortage of surgeons, other health care workers can fill in the gaps – STAT


hen my wife went into labor in 2006, I was responsible for just two things: calling our obstetrician and making the 20-minute drive to a private maternity hospital in Addis Ababa, the capital of Ethiopia.

Things were much harder for my uncle Mamo and his wife, Adanech, when she went into labor at home in their rural Ethiopian village. After she was in labor for two days with little progress, it was clear that she and the baby were in danger.

She urgently needed surgery — a caesarean section.


That meant my uncle had to:

  • sell a cow and an ox for cash;
  • buy bus tickets for a trip by gravel road for two hours to the town nearest their farm;
  • arrange for a place to stay overnight;
  • witness his wife’s misery as a hospital nurse examined her, naked, in front of the strangers who were accompanying other women laboring on benches and on the floor of the maternity ward;
  • rush out of the hospital, prescriptions in hand, to buy intravenous fluids and antibiotics at a pharmacy;
  • donate blood because the hospital blood bank was closed;
  • wait for administrative paperwork to clear;
  • and, finally, wait for the doctor to arrive.

It took 24 hours from the time they arrived at the hospital until the “emergency” caesarean was performed.

Despite uncle Mamo’s efforts, my aunt’s determination to have a healthy baby, and the best efforts of local health care workers, my cousin died 10 minutes after she was born.

A huge unmet need

More than 5 billion people — the majority of the world’s people — lack access to safe, affordable, and timely surgical and anesthesia care. It’s a big problem in Ethiopia, where I was born and raised. An average-size hospital serving a population of 100,000 anywhere in the world should have 20 specialists to perform 5,000 lifesaving surgical procedures per year. Ethiopia has fewer than one specialist per 100,000 people.

That ratio hasn’t improved much in the decade since my newborn cousin died. But now my country is in the midst of changing that. I’ve been helping health care workers who aren’t trained as surgeons perform emergency surgery.

Ethiopia is part of an emerging global movement to provide quality basic surgical care to families so women in need of caesarean sections don’t die; kids with compound fractures aren’t crippled; and men aren’t permanently debilitated by hernias. Informed by a 2015 Lancet Commission on Global Surgery report, a group of corporations, institutions of higher learning, and global health advocates have committed themselves to tackling the lack of basic surgical care. Ethiopia was the first country to embrace a radical rethinking of surgery’s conventional doctor-at-the-helm arrangement and earlier this year established a national plan for safe surgery.

In districts where there are no surgeons, we are investing in nonspecialist surgical care providers — health care workers like nurses, clinical officers, general practitioners, and midwives who are already on the job. They aren’t surgeons but can be trained to work as teams to perform certain emergency procedures in their community facilities. This would relieve the burden from the limited number of surgeons who work primarily in larger urban hospitals. The thinking is that teams in the trenches are well positioned to identify medical problems that require surgery and take the lead on delivering uniquely creative solutions.

In remote hospitals, when nonspecialist surgical care providers gain clinical skills and use checklists — and have the agency to effect change — they can ensure standardized, high-quality surgical care for those who need it.

Checklists are the key. I have to admit, I’m a list guy. Lists are important to me, my profession, and my patients. Use of the World Health Organization’s Safe Surgery Checklist has made surgery safer, globally reducing complications of surgery by 36 percent and deaths by up to 62 percent. Likewise, use of the 2016 WHO guidelines aimed at preventing surgical site infections and curbing the spread of superbugs is also saving lives.

Lists and guidelines are vital for standardizing care and ensuring quality. They can improve safety and timely referrals, preventing the life-threatening complications that result from delays in care.

Because the concept of using nonspecialist surgical care providers to improve access to surgery upends the status quo, this approach is not without skeptics. That’s why we’ve fostered relationships between health workers in rural facilities and specialists in urban hospitals, so surgeons in the latter can see for themselves that if everyone focuses on patient care rather than professional differences, nonspecialist surgical teams can save lives. Lots of them.

A case in point is a senior surgeon who declined, at first, to advise nonspecialists. After visits to two facilities where the initiative is well underway, he agreed to be on call to provide guidance about procedures and help ensure timely referrals. From his office at the Ministry of Health, he’s now the driving force behind Ethiopia’s commitment to deliver surgical care to all who need it.

Firsthand experience convinces me that this reimagined surgical ecosystem works. Emerging evidence shows how the delays and disparities that stymied my uncle and exacted a heavy toll on my aunt and baby cousin may finally begin to end.

Tigistu Adamu Ashengo, M.D., is the associate medical director at Jhpiego, an international, nonprofit health organization affiliated with Johns Hopkins University.

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