Friday, March 17, 2017

Global Surgery Outreach: retraining the one trick pony

Med mission communication (sort of farewell speech after 25 years in the front lines)

Global Surgery Outreach: retraining the one trick pony
Bona Lotha
Gen Surg, Aesthetic Med and Plastic Surgeon
(N Del,Singapore,Taipei,Miami,Plastic@ Smile Train NYC)
Former Founder/Head of Yemen Smile Intl Plastic Missions UK in Yemen 
Introduction: As health care costs continue to soar in developing nations, the mostly defunct two tier system of health care in most states is unable to deliver much needed primary medical care, let alone surgery, to their underprivileged rural masses.Most patients either have no health insurance or are too poor to see a specialist doctor.The majority of low cost or free government clinics are in deplorable conditions and even very poor patients avoid those places.As some of us had envisioned during our earlier years in medical missions outreach, the system can only get worse, with increasing segregation and disparity between the haves and the have- nots. It is not a pleasant experience to be forgotten and without hope. Revisiting rural medical missions twenty years later, I have noticed that the plight of poor patients has only been further aggravated by higher medical costs across the region. The cost of specialist medical care is much higher and generally unaffordable for most.
The poor in developing countries are even less likely than the better off to receive effective health care. There is an urgent need to establish mechanisms that can increase the availability and improve the quality of health care in the developing world” 1
Over the last decade the role of surgery in the public health agenda has increased in prominence and attempts to quantify surgical capacity suggest that it is a significant public health issue, with a great disparity between high-income, and low- and middle-income countries (LMICs) surgery as a global health priority and possible solutions to improving surgical care globally.2

On a more positive note however, is the shifting trend in the medical referral system, where well trained doctors ,especially in family medicine are able to make referrals based only on real needs of a patient. Years ago, most cases of DM,HT and CAD were seen only by tertiary level specialists in the field, (over 90% approx.) whereas today a PCP treats over 80 % of such patients ,referring only about 10% of cases seen to more advanced centres, without any untoward consequences for the patient.
The same is true for surgical disciplines, where a well-trained surgeon is able to confidently perform many routine surgeries from other disciplines and specialities. To sound a note of caution however, this metamorphosis of a surgeon requires countless hours of serious study, observation combined with hands on trainings at select tertiary level centres and other centres where other techniques can be learnt. Later on, the same surgeon is able to perform standardized procedures more confidently and also pass on the skills to others.

Materials and Methods:
From 1992- 2015, over a 25 year period, some important observations and conclusions were made in medical mission outreach to underprivileged patient groups across several nations. A flexible, informal protocol was designed during the earlier years to assess the relevance and efficacy of a global surgical outreach programme.
IDENTIFY:   The first step was to identify the commonly encountered surgical problems in the region.
For instance, having worked across Asia and the Middle east, I find the types of surgeries in India and ME Yemen/incl E Africa and Arabia very similar and one who has worked in either nation finds it easier to understand the patterns of presentation in the other.
During the time, one is also able to know which areas of training are needed to meet the needs of the region. For instance, a surgeon may find himself in a region where there are many cleft and plastic surgery deformities, and so training in the particular subspecialty often leads to good outcomes for subsequent specialist programmes. Similarly, one does well to learn other surgical disciplines esp OB Gynae,ortho and trauma treatments. The learning curve is going to be long and challenging, but it is worth the time and effort if one is to help many patients during the time in outreach missions to underprivileged patients. The time spent in mastering newer and more sophisticated standardized procedures not only adds to one’s repertoire but also helps many others who may not have the opportunity to get such trainings in their region or country.

Trainings in commonly encountered surgical interventions for different surgical disciplines would mean wider health coverage for rural populations in need. “More comprehensive and sustainable solutions include the development of local training programs, better retention of trainees with adequate incentives particularly in rural areas”3

A very important role played by tertiary level units would include:
1.       Short term clinical attachments and trainings
2.       Visiting scholar programmes in subspecialties
3.       Regular yearly updates @ advanced centres
4.       Continued training support a few weeks to a few months every year


The GSO training programmes are aimed at converting the one trick pony into a multi trick pony who can manage services in the region where specialist services are not found. The safest approach is to use well standardized procedures.This avoids iatrogenic deformities in mission outreach by ensuring that the referral unit has reasonable expertise to deal with common problems. The number of iatrogenic deformities is usually alarmingly high when inexperienced expat missions enter underprivileged areas and practice on rural patients.


After several years of hi tech trainings across different hospitals, we used the standardized methods for large patient numbers with some impressive results. The work improved in a stepwise manner over the years, with more advanced techniques in anaesthesia, surgery and nursing care being added to the repertoire over a period. There needs to be a major shift in the way we think about global surgery perspectives.
"Until recently, surgery was a neglected health issue in developing countries because it was assumed to be too expensive and sophisticated."4
 The future success of any GSO programme in those who have learnt useful techniques, depends on large patient numbers. Our numbers were large as a result of initial successes and strategic planning, using only standardized techniques and making it a policy to refer all complicated cases. As a result, the post op outcomes were generally satisfactory and patients were happy with the services provided.


Developing a strategy includes:
1.       Identifying the catchment areas
2.       Identifying common surgeries done in the area
3.       Implementing treatment packages eg. varicose vein, piles treatment and other surgeries
4.       Establishing a unit with supporting infrastructure(OR/ICU) with reasonable backup


Target areas: mission outreach hospitals
Countries: India, China, Nepal, ME Yemen Arabia, incl UNHCR refugee camps, Indian Ocean Socotra Island
Period: 25 years, 1992- 2015
Number helped: approx. > 10,000
Infrastructure: primary unit with all relevant OR facilities and trained staff for surgery, anesthesia, nursing, ICU, OR tech
Common interventions:
1.       Surgical
2.       Trauma and burns recon
3.       OB and Gynae all surgical interventions
4.       ortho – fractures,sprains,dislocations
5.       common plastic – clefts, congenital anomalies, deformities
6.       day care minor procedures
7.       primary and some specialist care for expats in the region
Limitations:  Doing mostly uncomplicated procedures and maintaining a safety protocol
Most units in rural hospitals may not have proper blood bank facilities or CT, MRI services. There may not be nearby referral facilities available for complicated referrals like head injuries or major trauma. The mission hospital acts as a first response unit for many complicated cases.
Cost factor is also important for running a sustainable unit. No one is turned away for financial reasons. Thankfully, because of a strong sense of community among rural populations, most are able to afford some basic costs. Those who are unable to do so are often sponsored by the unit or well-wishers.


Over a 25 year period, certain important observations were made across rural populations in India, China, Yemen, Indian Ocean islands and African UNHCR refugee camps.
Patient needs are similar in these countries, where rural medical facilities are often woefully inadequate and require both non-medical (corporate sector/NGO) and medical support. The non-medical donor groups play a huge role in medical missions in such regions, enabling the units to provide better infrastructure and support for a large number of patients.
Medical personnel in these mission outreach units need support in more advanced care and equipment.
GSO programmes are generally welcome by the local populace who are thankful for services rendered. As a result of Google medicine, even rural populations know the difference between those who practice on them and the well informed and skilled team at the mission unit.
GSO programmes meet the immediate and long term needs of most patients in these regions; the services are run on a modest budget with encouraging outcomes.
In our 25 year experience across nations, our GSO programmes have helped thousands of patients who might not have had the opportunity for specialist care. Many medical personnel have also been trained as a result of medical outreach programmes.
In most rural areas, patients live with their deformities for life unless help comes along. 

One striking example is the US Smile Train mission where over one million patients across the world benefited from free cleft surgeries over ten years. The work was done by local medical teams with expat support.

“Give a man a fish, feed him for a day. Teach a man to fish, and you feed him for a lifetime.” -Chinese Proverb5  

A sustainable legacy is usually left behind by passing on the mantle to local medical units in the region.
Some useful lessons were learnt during this medical outreach effort:
1.       using the KISS principle-keeping it simple and straightforward
2.       safety protocol – using only safe standardized techniques for patient safety and better outcomes
3.       Team work and networking with senior specialists in the area of need
4.       Always learning from others, and not working in isolation
5.       Always do your best- “work hard, read regularly,: update regularly and stay positive
6.       Keep a low profile, even if you are now a multi trick pony!


GSO is one of the innovative concepts of global health for all; it is mostly a community outreach programme identifying and helping those who are in need of some specialised services. Most pioneers in this field will tell you that that the initial years were difficult and many had to retrain in other specialties because the doctors did not feel they could do a good enough job without further training. It is better not to do a bad job on a patient, than to attempt a procedure without experience in that particular field and cause an iatrogenic deformity worse than the initial problem.
I have had the privilege of meeting and training under some great world pioneers in my chosen sub speciality of aesthetic medicine and plastic surgery .Many of them owed their expertise to studying under other specialists, mission teamwork and perseverance in their subspecialised fields. As one of the leaders advised me, numbers do make the expert and later, vice versa.
Some of the world’s greatest experts in plastic surgery learnt their skills in mission settings-the bread that was cast upon the waters returns in many blessed ways. 

special acknowledgment: Her Majesty's Smilemakers et al @
 pic: early years..HMA Frances Guy UK Res Sana(presently Head of Christian Aid M East, London)
with ,HMA Mike and Trish Gifford UK Res, Colin Kramer Norwegian Oil DNO Yemen A and S and Andre Lamy of Total France E&P

thanks  and  dont forget to rock on.... :-) 

Suggested Reading :

1. Access to health care in developing countries – Owen O’Donnell Department of Balkan, Slavic and Oriental Studies, University of Macedonia, Thessaloniki, Greece

2. Surgical care in low and middle income countries: burdens and barriers
Rele Ologunde ,Mahiben Maruthappu ,Intl Journal Surgery , Aug2014Volume 12, Issue 8, Pages 858–863

3.Challenges of meeting surgical needs in the developing world ,Richard AG ,WJ urgery 2011: 35,258-261

4.Basic surgery training to save lives and prevent disability ; Daniela Bagozi Communications Officer ,WHO

5.Teaching a man to fish : a sustainable model for helping cleft children          Technology, training, and the mission to repair cleft in the developing world.
well..all said and the last dance for the speciality you love most! ciao bello..  i am a smilemaker at heart

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