Taking Action

What did Global Surgery Amsterdam teach us on the challenges of foreign surgical interventions in Africa?

Oct 5, 2018
Taking Action

Dear Diary,

I have been struggling with an eating disorder for the past few years. I am afraid to eat and afraid I will gain weight. The fear is unjustified as I was never overweight. I have weighed the same since I was 12 years old, and I am currently nearing my 25th birthday. Yet, when I see my reflection, I see somebody who is much larger than reality.

I told my therapist that I thought I was fat. She said it was 'body dysmorphia'.
She explained this as a mental health condition where a person is apprehensive about their appearance and suggested I visit a nutritionist. She also told me that this condition was associated with other anxiety disorders and eating disorders. I did not understand what she was saying as I was in denial; I had a problem, to begin with. I wanted a solution without having to address my issues.

Upon visiting my nutritionist, he conducted an in-body scan and told me my body weight was dangerously low.

I disagreed with him.

I felt he was speaking about a different person than the person I saw in the mirror. I felt like the elephant in the room- both literally and figuratively. He then made the simple but revolutionary suggestion to keep a food diary to track what I was eating.

This was a clever way for my nutritionist and me to be on the same page. By recording all my meals, drinks, and snacks, I was able to see what I was eating versus what I was supposed to be eating. Keeping a meal diary was a powerful and non-invasive way for my nutritionist to walk in my shoes for a specific time and understand my eating (and thinking) habits.

No other methodology would have allowed my nutritionist to capture so much contextual and behavioural information on my eating patterns other than a daily detailed food diary.
However, by using a paper and pen, I often forgot (or intentionally did not enter my food entries) as I felt guilty reading what I had eaten or that I had eaten at all.

I also did not have the visual flexibility to express myself through using photos, videos, voice recordings, and screen recordings. The usage of multiple media sources would have allowed my nutritionist to observe my behaviour in real-time and gain a holistic view of my physical and emotional needs.

I confessed to my therapist my deliberate dishonesty in completing the physical food diary and why I had been reluctant to participate in the exercise. My therapist then suggested to my nutritionist and me to transition to a mobile diary study.

Whilst I used a physical diary (paper and pen), a mobile diary study app would have helped my nutritionist and me reach a common ground (and to be on the same page) sooner rather than later.

As a millennial, I wanted to feel like journaling was as easy as Tweeting or posting a picture on Instagram. But at the same time, I wanted to know that the information I  provided in a digital diary would be as safe and private as it would have been as my handwritten diary locked in my bedroom cabinet.

Further, a digital food diary study platform with push notifications would have served as a constant reminder to log in my food entries as I constantly check my phone. It would have also made the task of writing a food diary less momentous by transforming my journaling into micro-journaling by allowing me to enter one bite at a time rather than the whole day's worth of meals at once.

Mainly, the digital food diary could help collect the evidence that I was not the elephant in the room, but rather that the elephant in the room was my denied eating disorder.

Sincerely,
The elephant in the room

Western healthcare workers only really contribute to LMIC healthcare if they stay abroad for several years.

This statement by Tom Gresnigt, a medical superintendent at Masanga Hospital in Sierra Leone stuck with me through the entirety of the Global Surgery Amsterdam symposium. An afternoon was dedicated to sharing stories, giving advice, and discussing on and off-the-job training strategies to achieve the vision of: “One world, One Standard of Care – Improving Skills in Global Surgery.” The focus, however, lay on short and long-term foreign surgical interventions in low- and middle-income countries (LMIC), particularly in Africa.  Truth be told, a topic that I, as an aspiring med student, had a lot to learn about.

Surgical need

At the start of the symposium, we were reminded that the poorest third of the world’s population receive only 3.5% of the 235 million surgeries that take place over the world (Ologunde, 2014). Of these 8 million surgeries, only a fraction are recorded, and statistics gathered, leading to significant lack of knowledge about the burden and distribution of surgical conditions, the unmet surgical need, the missing resources (human, clinical, financial.), and the impact that foreign surgical intervention might have. (WHO, 2008).

While truly little is known about the burden of surgery in Africa, the limited data have shown that cleft lip, appendicitis, obstructed labor, clubfoot, cataracts, hernia, and trauma, such as burns are some of the direst unmet surgical necessities (Bickler et al., 2015). Most of these problems have rare long-lasting effects in the western world, for example in the Netherlands where the density of specialist surgical workforce is 47,1 per 100,000 people (Gawande, 2015). However in a place such as Sierra Leone,  with a population of 7.557 million people, a specialist surgical workforce of 0.2 per 100,000 people (Gawande, 2015) is shocking.

The ever-increasing number of international healthcare workers that travel to LMIC’s to volunteer their surgical skills and expertise reflects the acknowledgment and understanding of the challenges to the health system and the discrepancies between continents and countries (Ahmed, 2017). With this increase, however, comes the necessity for adequate training, ethical coherence, and cultural fluency, as due to the lacking evidence and outcomes of such foreign surgical intervention, the exact impact of these missions is difficult to quantify (Casey, 2007).

The impact

The impact of foreign surgical intervention is so complex you must weigh the individual benefit of the surgeries, the detrimental effects of potential complications, the training, and advice that is given to these communities and local doctors against the ethical dilemma of surgical trips to vulnerable communities (Ahmed et al., 2017) These problems are not solved by merely staying an extended period of time. The greatest challenge lies in measuring the outcome of these missions and the accompanying accountability of the surgeons, pediatricians, anesthesiologists, and the other healthcare workers. The benefits therefore of combining these trips with proper data collection and management is increasingly showing its value on validating practices and providing information on areas needing improvement (Sykes, 2014).

If appropriately used in the 21st century, data could save us from lots of failed interventions and enable us to provide evidence-based solutions towards tackling malaria globally. This is also part of what makes the ALMA scorecard generated by the African Leaders Malaria Alliance an essential tool for tracking malaria intervention globally.

If we are able to know the financial resources deployed to fight malaria in an endemic country and equate it to the coverage and impact, it would be easier to strengthen accountability for malaria control and also track progress in malaria elimination across the continent of Africa and beyond.

Odinaka Kingsley Obeta

West African Lead, ALMA Youth Advisory Council/Zero Malaria Champion

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Looking back at the statement of Dr. Gesnigt, I now understand why it stood out against the rest. He mentions this idea of contribution, of successful help in a small area, a district hospital, yet it does not encompass the importance of also contributing to a global database on the outcome of the surgical interventions. The desperate need for empirical evidence of activities done there needs to be of sufficient and reliable quality. The surgical disparities, even within countries can be reduced by being able to quantify the burden of surgery through information on the need for, access to, and outcomes of surgical care. Furthermore, a greater understanding of the iatrogenesis expenditure related to surgical care, the availability and use of surgery-related resources, such as human resources, equipment and supplies can lead to more cost-effective solutions. So lastly, the coverage, quality, and effectiveness of interventions are beyond valuable to effective long-term help for their improvement (Luboga et al., 2009).

Making data actionable

At the conference, Sister Avelina Temba from Korogwe Hospital in Tanzania shared her experiences as the only surgeon in her district. She talked about the struggles she has not having another doctor to talk to you, to discuss possible cases, advice, or future complications. She is one of the only female surgeons in her country! This extreme pressure and the massive influx of patients she treats daily is further evidence of the necessity for simple secure and reliable data collection. The management of such will allow her to monitor her patients better, assign thresholds for various conditions to alert her or other personnel, and will enable her to predict how the patient will react or develop to surgery or a specific treatment. The benefits continue, through access to a database of millions of recorded surgeries, Sister Avelina will no longer need another specialist to talk to, she can consult previous data on such surgeries, the necessary personnel, materials, and skills. These outcomes are measured and help research and studies into these surgical discrepancies, allocating foreign interventions better and promoting training in necessary surgeries where such conditions occur more frequently.

Tom Gresnigt finished his presentation with a last strong statement, ‘surgery is not a luxury, it is basic care.’ If this care can be better quantified, better recorded and managed, the need and current lacking mechanisms will be a thing of the past.

References

  1. Ahmed, F., Grade, M., Malm, C., Michelen, S., & Ahmed, N. E. (2017). Surgical volunteerism or voluntourism–Are we doing more harm than good?
  2. Bickler, S. W., Weiser, T. G., Kassebaum, N., Higashi, H., Chang, D. C., Barendregt, J. J., ... & Vos, T. (2015). Global burden of surgical conditions. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN. Disease control priorities in developing countries, 1, 19-40.
  3. Casey, K. (2007). The global impact of surgical volunteerism. The Surgical Clinics of North America, 87(4), 949-60.
  4. Gawande, A. (2015). Global surgery. The Lancet, 386(9993), 523-525.
    Luboga, S., Macfarlane, S., Von, S., Kruk, M., Cherian, M., Bergström, S., . . . Bellagio Essential Surgery Group (BESG). (2009). Increasing access to surgical services in sub-Saharan Africa: Priorities for national and international agencies recommended by the bellagio essential surgery group. Plos Medicine, 6(12), 1000200. doi:10.1371/journal.pmed.1000200
  5. Ologunde, Rele, Mahiben Maruthappu, Kumaran Shanmugarajah, and Joseph Shalhoub. "Surgical care in low and middle-income countries: burden and barriers." International Journal of Surgery 12, no. 8 (2014): 858-863.
  6. Sykes, K. J. (2014). Short-term medical service trips: a systematic review of the evidence. American journal of public health, 104(7), e38-e48.

Image source: Staff Sgt. Shejal Pulivarti (CC BY 2.0)

Dear Digital Diary,

I realized that there is an unquestionable comfort in being misunderstood. For to be understood, one must peel off all the emotional layers and be exposed.

This requires both vulnerability and strength. I guess by using a physical diary (a paper and a pen), I never felt like what I was saying was analyzed or judged. But I also never thought I was understood.

Paper does not talk back.Using a daily digital diary has required emotional strength. It has required the need to trust and the need to provide information to be helped and understood.

Using a daily diary has needed less time and effort than a physical diary as I am prompted to interact through mobile notifications. I also no longer relay information from memory, but rather the medical or personal insights I enter are real-time behaviours and experiences.

The interaction is more organic. I also must confess this technology has allowed me to see patterns in my behaviour that I would have otherwise never noticed. I trust that the data I enter is safe as it is password protected. I also trust that I am safe because my doctor and nutritionist can view my records in real-time.

Also, with the data entered being more objective and diverse through pictures and voice recordings, my treatment plan has been better suited to my needs.

Sincerely,
No more elephants in this room

Tiago Beck's profile picture

Tiago Beck

As long as I can remember medicine, and in particular neuroscience has been my fascination. I am currently a Research Master of Neuroscience student at the Erasmus Medical University in Rotterdam. I have been exploring countries and medical fields my whole life and it has ultimately lead me to the Netherlands where next to uni, I work as an student researcher at the Erasmus Medical Center and write blogs here and there. And this is just the beginning...

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