GLOBAL SURGERY-A UVA SUCCESS STORYMICHAEL CURCI MD, FACS, FCOSECSA

LESLIE E. RUDOLPH MD LECTURE

OCTOBER 2, 2019

I have no disclosures

The Maine Connection

OBJECTIVES

• Why global surgery as a rotation for medical students and residents?

• Capacity building in LMIC

• Place of of western academic medicine in global surgery

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Abdullah, F. Arch Surg 2008;143:728-729.

Disparity of Global Health Resourcesa

Value of global surgery

Rickard et al JACS.2018;227:455-466

Peck et al

Value of global surgery

Value of global surgery

• Global Surgery: Effective Involvement of US Academic Surgery: Report of the American Surgical Association Working Group on Global Surgery • Mock et al. ANN SURGERY 2018:268:557-563

Mock et al Annals of Surgery Volume 268, Number 4, October 2018

Value of global surgery

Mock et al Annals of Surgery Volume 268, Number 4, October 2018

Value of global surgery

Academic Advancement in Global Surgery: Appointment, Promotion, and Tenure: Recommendations from the American Surgical Association Working Group on Global Surgery

Wren et al. ANN SURGERY 2019

Value of global surgery

MODEL FOR MENTORSHIP

MILLENNIUM DEVELOPMENTAL GOALS

• Eradicate extreme poverty and hunger

• Achieve universal primary education

• Promote gender equality and empower women

• Reduce child mortality

• Improve maternal health

• Combat HIV/AIDS, malaria and other diseases

• Ensure environmental sustainability

• Global partnership for development

Injuries and Violence: The Facts. WHO, 2010.

TRADITIONAL HEALER CARE FOR PYLORIC STENOSIS

TRANSPORTATION?

2 YEARS LATER

Tanzania’s Approach to Surgical Care for Its Rural Population

•TASK SHIFTING instead of TASK SHARING

•Assistant Medical Officers(AMOs) with 5 years of training are accredited to manage medical and limited surgical diseases

•Bloomberg Philanthropies Foundation Project, supported by the Tanzanian Ministry of Health, expanded obstetrical care to selected health care centers to bring surgical care closer to the population in need and provide additional training and infrastructure

• Clinical Officers and doctors did not differ significantly in key outcomes for caesarean sections

• Anesthesia training decreased maternal mortality(2.4% v 0.9%)

• NPCs had increased wound infections and dehiscenses

• Enhanced retention in the local health care system

• Reduced training and employment costs

REDESIGNED RURAL CLINIC

April

2015

The Lancet Commission

on Global Surgery

Lancet Commission (5 messages)

1

• 5 billion people lack access to safe, affordable surgery and anesthesia- 2030 target is 80% coverage for essential surgery and anesthesia

2

• 143 million additional surgical procedures are needed each year to save lives and prevent disability- 313 million procedures performed worldwide and only 6% in the poorest countries where >1/3 of the population live

Lancet Commission (5 messages)

TERM STILLBORN-NO AVAILABLE TREATMENT FACILITY

UNTREATED FEMUR FRACTURE

3

• 33 million individuals face catastrophic expenditures due to payment for surgery and anesthesia each year- 48 million have non medical costs for accessing care

Lancet Commission (5 messages)

4

• Investment in surgical and anesthesia services is affordable, save lives and promotes economic growth- loss of economic productivity estimated US 12.3 trillion dollars between 2015-2030

• Estimated 420 billion investment to scale up surgical services between 2015-2030

Lancet Commission (5 messages)

5

• Surgery is an essential part of health care; 16.9 million lives lost due to surgical conditions in 2010 (33% of all deaths worldwide)

• Surgery provides support for medical and pediatric diseases

• 77.2 million disability-adjusted-life-years(DALYs) could be averted each year

Lancet Commission (5 messages)

Change in surgical workforce needed per 100,000 population by 2030

Merea J. Lancet 2015;386:591

RWANDA’S HUMAN RESOURCES FOR HEALTH(HRH) PROGRAM

• 7 year program-strengthen health care training and expand workforce

• 14 US medical centers and universities partnership with MoH and University Rwanda

• US$170 million-physicians, nurses, dentists and hospital managers

• Populate district hospitals with specialists and provide Rwandan faculty for self sustaining resident training at the end of 7 years

HRH SURGERY

• Surgery and anesthesia component supported by 3 institutions-Dartmouth, Harvard and UVA

• 4 surgical residencies-general surgery, neuro surgery, urology and orthopedics

• US faculty paired with Rwandan faculty to provide didactic and clinical teaching and increase capacity as instructors and educators

FINANCIAL SUPPORT FOR THE HRH PROGRAM

• Direct contracting between the US government and Rwanda-no third party NGO

• Funds transferred to MoH and is responsible for allocation of funds and administration of the program

• Funding sources-PEPFAR

-USAID

-CDC

-Global Fund

PEDIATRIC SURGERY IN RWANDA

• 2012-no pediatric surgical care for population of 12 million people

• Year 1-twinning partner developed interest in pediatric surgery

• Year 2-began fellowship training at Kijabe in Kenya-accredited COSECSA program

• Year 5(2017)-completes training and passes oral and written exams-returns to Rwanda as the first accredited Rwandan pediatric surgeon

CHALLENGES IN PEDIATRIC SURGERY

• Delays in care-poorly connected to the health care system-financial, geographic, education-patients use traditional healers

• Limited surgical understanding for timely referrals -average newborn is frequently >1week old

• Delay in receiving care-hospital admission does not guarantee treatment

• Inequality of infrastructure distribution

FINANCING PEDIATRIC SURGICAL CARE

• Mutuelle De Sante-insurance for the majority of the population-patient pays 10% of fee

-daily ward admission fee-$1.20

-chest x-ray-$4

-plain abdomen-$4

-US abdomen-$3.70

-CT scan without contrast-$65

-CT scan with contrast-$75

• GROSS NATIONAL INCOME-$700/YR($2/day)

Twining Concept

NEONATAL INTENSIVE CARE

Kigali University Hospital King Fiasal Hospital

Pediatric surgery at CHUK-Jan 6-24,2019

• Esophageal atresia 2

• Intestinal atresias 4

• Malrotation and volvulus 1

• Imperforate anus 6

• Gastroschisis 1

• Omphalocele 1

• Wilms tumor resection 3

• Nephrectomy for hydronephrosis 1

• Hirschsprungs 3

• Laparotomy for SBO, typhoid perforation, trauma 4

• Intussusception 2

• Pyloromyotomy 3

• Orchidopexy 1

• Hypospadias repair 2

• Pyomyositis-drainage 1

•

• Total Cases 35

DR BRAD ROGERS VISITS RWANDA

PARAPAGUS DIFUS

University Teaching Hospital Kigali: The Pediatric

Surgery Team

Allain Jules, Michael Curci, Edmond Ntaganda

J.A. O’Neill Jr.JPS 53 (2018) 21-24

“There are certain values that can neither be taught nor tested for in surgical learning that only a humanitarian experience and role modeling can provide”

FINAL THOUGHTS

•START EARLY IN YOUR PROFESSIONAL CAREER AND PARTICIPATE IN A GLOBAL HEALTH CARE PROJECT

•LOOK FOR TRAINING PROGRAMS THAT HAVE PROTECTED TIME FOR STUDENTS, RESIDENTS AND FACULTY

•FIND A MENTOR

THANK YOU-ASANTE-MURAKOZE