A mangled mess

On August 13, 2012, in surgery, by Karen Grepin

I consider myself a relatively healthy person. But when I fill in a medical history form that asks for me to list all of my previous surgeries, I start to look a little worse for wear: shave biopsy left shoulder 2012, caesarean section 2012, punch biopsies to hand and right calf 2010, caesarean section 2010, lumpectomy 2009, LEEP 2005, Bankart repair to right shoulder 2004, and finally another Bankart to right shoulder 1997. I am healthy today, but only because of the way I have been cut, stitched, and singed back together by doctors with surgical training.

Until recently there has been little attention given to the need for surgical health services in low income countries. Many people consider it “too expensive” or “unnecessary” for poor people in poor countries. I think it is more than this: it is “unknown”. We have very poor information on what the need for such services might be in these settings. Health surveys, such as the DHS, mainly collect information on the health of children and women as they pertain to the rearing of children. It is hard to understand what the burden of diseases that are amendable to surgery might be in these settings. The prevalence of such conditions is unknown.

So a couple of years ago, some folks I met via Twitter (where else?) came up with the idea of developing a survey that would help shed light on the prevalence of such conditions. Their criteria was that the survey needed to provide population based estimates of a set of common conditions amenable to surgery and must be done in such a way that it could be collected quickly and inexpensively. Working with other expert they developed SOSAS: Surgeons OverSeas Assessment of Surgical Need.

On a shoe-string budget of $35K, they set out to test their survey instrument in Sierra Leone. I can tell you $35K for any substantial survey is really cheap. With it they surveyed a nationally representative sample of roughly 2000 households. Their findings are published in this week’s Lancet.

Briefly, they found that nearly a quarter of respondents had a condition that they self-identified as something that could be treated by surgery. In addition, a quarter of the reported recent deaths among household members might have been averted had surgical services been made available. This strikes me as a lot – a true mangled mess – but of course until this survey is repeated in other settings, it is hard to make a comparison to other contexts. Regardless, it seems that expanding access to surgical health services even in one of the poorest countries in the world would likely go a long way to help improve population health. All the kings horses and all the kings men could not put Humpty Dumpty together again, but perhaps all they really needed was 1 good surgeon?

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14 Responses to “A mangled mess”

  1. Karen Grepin says:

    A mangled mess http://t.co/qd3b3wvt #globalhealth #globalsurgery

  2. Peter Singer says:

    A mangled mess http://t.co/qd3b3wvt #globalhealth #globalsurgery

  3. A mangled mess http://t.co/qd3b3wvt #globalhealth #globalsurgery

  4. A mangled mess http://t.co/qd3b3wvt #globalhealth #globalsurgery

  5. A mangled mess http://t.co/qd3b3wvt #globalhealth #globalsurgery

  6. ProfSuter says:

    A mangled mess http://t.co/qd3b3wvt #globalhealth #globalsurgery

  7. Great blog post on @theLancet paper “@KarenGrepin: A mangled mess http://t.co/fo9CthSY #globalhealth #globalsurgery”

  8. A mangled mess http://t.co/qd3b3wvt #globalhealth #globalsurgery

  9. April Harding says:

    I agree surgery is almost always overlooked when donors and other helping entities analyze and try to help developing countries wrt health. I think this mainly happens because surgery gets done in hospitals. And donors are averse to doing anything on hospitals (low cost effectiveness, and higher utilization by middle and upper income people). I think it’s a big mistake to ignore them.
    However, I think it would be just as big a mistake to try to support “access to surgical services” in a programmatic (vertical) way. If we do, we global do-gooders could do as much damage to hospitals as we have to primary care clinics.

    • Karen Grepin says:

      Totally agree! There are models of “vertical surgical” supply and I tend to think they are flawed. The right way to suppor such initiatives will be to involve everything from medical education, to training, to referral networks, to infrastructure. And not all of it has to happen in a hospital – many forms of surgery can be implemented at lower levels of care, including in the communities. What is needed and what works will depend on the context. But the data collected in the survey I cite in this post I think is an important first step to better understanding the situation for planning purposes.

  10. Brett Keller says:

    on global surgery need >> A mangled mess | by @KarenGrepin http://t.co/I65qH9LQ

  11. Obi says:

    I think access is perhaps a bigger issue than availability of such services in many countries. There are still many places where the patient has to pay a fee (a lot of the time more than they can afford) before services, and this has led to many deaths among those who have sought such care. So in such places, some people give up before even attempting to seek such care. Surgical services (both equipment and staff) are available in many places, but the poor often are unable to access them due to cost (actual cost and transportation at times).

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