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Contents
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xiii
44 How to Care for Women’s Health in Low- and Middle-Income
Countries: A Quick Overview and Procedural Guide for the
Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
Reinou S. Groen, Megan Hadley,
and O. K. (Bomi) Ogedengbe
45 How to Manage Urologic Problems in Low- and
Middle-Income Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
Nicholas A. Romas
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
Introduction
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MarkA.Hardy andBethR.Hochman
The idea that some lives matter less is the root of all that is wrong with the world.
– Paul Farmer
Abbreviations
ACS American College of Surgeons
DALYs Disability-Adjusted Life Years
HICs High-Income Countries
LMICs Low- and Middle-Income Countries
NGO Non-Governmental Organization
SSA Sub-Saharan Africa
WHO World Health Organization
First, Do no Harm
Global surgery is dened by a commitment to
achieving equitable and sustainable access to surgical care in all environments. This involves two primary challenges: rst, expanding surgical capacity
in areas with low surgical volume (whether due to
M. A. Hardy (*)
Department of Surgery, Columbia University Vagelos
College of Physician and Surgeons,
New York, NY, USA
e-mail: mah1@columbia.edu
B. R. Hochman
Department of Surgery, Columbia University Vagelos
College of Physician and Surgeons,
New York, NY, USA
e-mail: brh2106@cumc.columbia.edu
1
limited population density, infrastructural resources,
or clinical expertise), and second, ensuring that
patients are readily able to access necessary surgical
care without barriers (whether physical, socioeconomic, or political). Some of these challenges have
been previously addressed by others [1–3]. In this
book we focus on components of the rst challenge,
but it is paramount to recognize the pervasive
impact of the second challenge throughout the care
continuum, and at times our own potential contribution to the problem. Exposure to surgical care delivery in differently resourced environments and in the
context of different cultures and lived experiences is
thus an invaluable starting point for all global surgeons. However, exposure alone is inadequate; an
effective global surgeon understands how one’s
own identity and the interplay with that of others
inuences both patient engagement in health care
and successful clinician teamwork. The positionality of HIC partners working in surgical and anesthesia practices in LMICs can be particularly complex.
Therefore, our initial chapter focuses on the ethical
and decolonization aspects of collaborations
between clinicians from differing cultural, medical,
and economic backgrounds while another chapter
explores preparatory considerations from a HIC
perspective when engaging in HIC-LMIC
partnership.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_1
1
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M. A. Hardy and B. R. Hochman
The principle of “Primum non nocere” (rst,
do no harm) guides all of these discussions.
Francis Moore, former chairman of the
Department of Surgery at Peter Bent Brigham
Hospital, once said, “you can’t learn to play the
piano by attending concerts” [4] (i.e., you have to
practice somewhere), but we must emphasize
another adage that, “anything is NOT usually better than nothing.” All surgical practice must be
rmly grounded on the standard ethical principles of benecence, nonmalecence, autonomy,
and justice. In all environments, surgeons and
surgical capacity-building must rely on informed
consent, graded responsibility, close supervision
for trainees, and ultimately, senior availability
and gradual transfer of skills. Understanding our
colleagues and our patients is the foundation for
success.
Know Your Patients
In reviewing our (MAH & BH) experiences with
our trainees in Ethiopia, Kenya, Vietnam, and
India, we realized that our main contacts with
patients occurred primarily on the operating
table, and, as noted by one of our colleagues, Dr.
Nishikawa, we knew little about where or how
they lived (many traveled from remote rural areas
or distant mountains). Our patients often had
very little understanding of doctors or western
medical interventions; most of their illnesses
were treated by traditional healers with practices
unfamiliar to us. Many of our patients were unfamiliar with what we considered commonplace–
owning a pair of shoes, riding in a car, and having
consistent access to electricity and running water.
Some had never previously met anyone from outside their own community, and by the same
token, we had not previously met anyone from
their community.
Learning from and contributing to highquality care both in and out of the operating room
relies on a baseline understanding of our patients.
Part of educating faculty and residents working
in new environments with patients from unfamiliar backgrounds necessarily includes an introduction to their patients’ languages, religions, living
and working conditions, cultural practices, and
beliefs about illness and medical care. As Dr.
Nishikawa suggested, it is important, if possible,
to visit patients in their own environment at least
once to better understand how different perceptions evolve based on these fundamental aspects
of our lives. Whether a patient has never interfaced with a medical establishment or visits them
frequently, a surgeon’s understanding of that
patient’s journey will enhance their ability to
deliver patient-centered care, including quelling
any fear or anxiety they may experience when
confronted by an operating room lled with
bright lights, ashing monitors, and a group of
masked strangers.
Reach Your Objectives
When engaging in academic clinical partnerships, host and visiting faculty have to be clear
about their goals, respectful of each other’s
needs, and diplomatic in their actions. The theme
of “How To” build surgical capacity in resourcelimited environments permeates the rst half of
this book. We hope this can serve as a guide for
bidirectional partnership participants who are
formulating their own targeted goals. Topics
include “How to” efciently and effectively organize new services and facilities, recruit and train
faculty, staff, trainees, and students, and organize
teams and quality improvement efforts. We also
include chapters on “How To” function ethically
in unfamiliar cultural environments with the support of the hospital and many other involved
agencies. As is emphasized in several chapters,
all activities should be done in concert with
approval of the host hospital, the regional administration, and in some instances the Ministry of
Health. We also review considerations for obtaining funding, gaining approval and support from
the local community, and building cooperation
with professional staff consisting of local doctors, nurses, technicians, and hospital administrators. We emphasize that independent and
non-approved actions are not looked upon kindly,
and frequently not forgiven; therefore, visitors
must always tread gently and wisely.
1 Introduction
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3
Learn, Teach, andServe
withtheHumility toListen, Learn,
andGrow
District (also called rst-level, rst-referral, or
rural) hospitals are charged with providing essential general medical and surgical care, whereas
higher-level hospitals offer increasingly specialized and complex services. Surgical educators in
district hospitals area are therefore primarily concerned with teaching basic surgical skills for the
treatment of common problems requiring the socalled Bellwether procedures (laparotomy, cesarean section, fracture xation, trauma resuscitation
and stabilization). This book addresses urgent and
emergent problems that a general surgeon working in a district hospital must learn to manage,
with a focus on pathologies seen more commonly
in LMICs than in HICs (e.g., typhoid bowel perforations and extrapulmonary tuberculosis). We
also highlight pathologies seen when diagnosis is
delayed or neglected (e.g., breast malignancies
and thyroid masses) and surgical approaches for
these problems when resources are limited.
Surgical faculty and trainees participating in
bidirectional partnerships have a unique opportunity to engage in a collaborative exchange of cultural beliefs, medical knowledge, and technical
skills. With this in mind, we review “How To” concepts underlying educational techniques (Chaps.
15–20 in the Education section)), and we also
describe experiences with building surgical capacity beyond the district level to regional care coordination and highly specialized care such as transplant
surgery (Chaps. 4–13 in the Systems Strengthening
section). Expansion of surgical specialty care in
LMICs has historically met resistance as a consequence of limited or absent local expertise and of
insufcient funding. We hope to inspire innovation
with approaches to surgical training and with the
recognition that investment in surgical capacity
enhances population health and prosperity.
Support andInteractions
Health care around the world has long come from
multiple sources guided both by community and
religious traditions as well as resource availability. Many LMICs perceived to be in greatest need
have been visited by missionaries and nongovernmental organizations (NGOs) which made
meaningful contributions. In 2015, the World
Health Organization (WHO) formally resolved to
strengthen essential surgical care worldwide, and
the Lancet Commission and World Bank
attempted to quantify the level of need. This
enthusiasm has been accompanied by rapidly
growing interest among professional medical
societies such as the American College of
Surgeons (ACS) and HIC academic medical centers and surgical training programs, which in
many instances have expanded relationships created by retired or senior academic surgeons. In
these instances, HIC surgeons rotate to their partner sites occasionally with trainees in tow and
then try to facilitate commensurate rotations of
partner surgeons to their home institutions for
true bidirectional benet. However, these relationships remain relatively uncoordinated and
insufciently focused and funded. Formal academic linking with LMICs remains very much in
its nascency and should be encouraged and
cultivated.
The call for closer interaction between wealthy
medical institutions and LMICs to expand surgical training becomes obvious when considering
that more than 5 billion of the world’s 7.9 billion
people live in poverty in LMICs [5], and a large
portion of the global burden of disease is concentrated in LMICs. Surgical conditions precipitate
the majority of the world’s disability-adjusted
life years (DALYs) [6, 7, 11], yet only 3.5% of
the world’s surgical procedures are performed in
LMICs, which spend less than $100 per person
on health care annually [7]. As of 2018, there
were only 0.53 surgeons per 100,000 population
in Sub-Saharan Africa [11] as compared to
5.2/100,000 surgeons in the United States in
2019 [8, 9]. According to a systematic analysis of
the 2010 global burden of disease, 21% of the
injury burden calculated in LMICs (52.3 million
DALYs) could have been averted by the presence
of basic surgical care [6]. Furthermore, according
to the Lancet Commission in 2015, approximately 30% of the global burden of disease could
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M. A. Hardy and B. R. Hochman
be treated with surgical care. This translates not
only to impaired welfare of millions of individuals, but also to stunted economic development of
entire communities if not nations [10]. These
numbers likely signicantly underestimate common curable surgical diseases that remain poorly
measured, including biliary disease, hernias,
ulcers, appendicitis, correctible congenital anomalies, and cancers. In comparison to the attention
given to communicable diseases such as HIV/
AIDS, malaria, and TB, the relative dearth of
accurate data regarding surgical needs (addressed
in Chap. 8 and others) and the errant belief that
surgery is prohibitively expensive have hindered
progress in the development of adequate surgical
care for underserved communities. As we have
learned all too well from the COVID pandemic,
disparity in access to health care is pervasive and
may be equally poorly quantied in both LMICs
and in HICs. Partnerships between HICs and
LMICs at an academic level offer a major opportunity to systematically quantify these problems
and help formulate and implement effective
global solutions.
due to Echinococcus, whereas the same lesion in
an HIC would more likely be a tumor. Abdominal
distention in an adult male in Kenya might be
more likely the result of volvulus or bezoar than
the adhesions more commonly seen in HIC
patients. Nevertheless, the diagnosis and management of all of these problems should be familiar to all general surgeons, including those in
training.
We provide tools to manage many, but not all,
urgent and emergent surgical situations in general surgery as well as in Orthopedics (Chap. 36),
Urology (Chap. 38), Obstetrics and Gynecology
(Chap. 37), and Neurosurgery (Chap. 21). We
address pathologies encountered as a consequence of delayed diagnosis, such as advanced
breast cancer (Chap. 29), and opportunities to
institute cancer surveillance methods like colonoscopy (Chap. 26). We review approaches to
standard surgical problems including abdominal
catastrophe (Chaps. 25–27), hernia (Chap. 28),
burns (Chap. 30 and 31), and wounds and soft
tissue infections (Chap. 32 and 33), all with
emphasis on conditions more common to LMICs.
Specic Surgical Interventions
In addition to its “How To” segments, this book
provides guidance on a variety of surgical pathologies and treatments with which a general surgeon should become familiar and be able to apply
when a specialist is not available. We aim to complement material that can be readily found in
standard surgical texts which largely focus on
problems encountered in HICs. The surgical
pathologies seen in LMICs often differ signicantly from those most commonly seen in HICs
as a consequence of variations in infectious disease prevalence, environmental exposures, physical access to medical care, and attitudes toward
Western medicine. These differences commonly
include presentation of signicantly advanced
disease or precipitate an entirely different set of
differential diagnoses. For example, a patient
with an untended traumatic open fracture may
present with near-fatal systemic infection. A
pediatric patient might present with a brain mass
Surgical andAnesthesia Program
Initiatives
Most of the authors of the various chapters have
been selected on the basis of their extensive experience working either as volunteers or as permanent staff in LMIC hospitals on several continents
and in many countries. Several American surgeons have helped to organize signicant initiatives in LMICs, such as Pan African Surgical
Residency Programs (Haisch, C), Neurosurgical
Pediatric Spina-Bida and Hydrocephalus
Programs (Koning, M), Renal Transplantation
Program (Punch, J), Facing Africa Program
(Lawrence & colleagues), and institutional
exchange programs (Hardy, MA). Others have
had input through national or international agencies such as WHO (Park, KB), Pan African
Congress (Oluwole, S), or American College of
Surgeons-College of Surgeons of East, Central
and Southern Africa (ACS-COSESCA) Surgical
Training Collaborative (Hochman, B).
1 Introduction
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5
Additional Challenges
Surgical knowledge and training are only small
parts of the greater mission to achieve equitable
and sustainable access to surgical care. Operating
rooms in LMICs face challenges of inconsistent
utilities (e.g., electricity and running water) and
limited critical supplies (e.g., ventilators and oxygen) in addition to personnel decits from anesthesiologists to operating room nurses to
biomedical specialists. The barriers that prevent
patients from arriving to the hospital such as roads
and transportation compound the above limitations found in many LMIC. Many potential
patients have a poor understanding of illness and
medicine, many are limited by the prohibitive
costs relative to their income, and yet others have
no means of transportation or face threats to their
own security en route. Precise quantication of
surgical burden, resource need, and barriers to
access are all processes that HIC partners might
help facilitate. Clarity with these variables is a
powerful tool in compelling local, national, and
international authorities and funding sources to
allocate support toward surgical care. Investment
in surgical infrastructure elevates all aspects of
health care systems. As Dr. Farmer previously
said, “global health need not be a competitive race
for scarce resources…we can build a coherent
movement that comes to include surgery” [11, 12].
References
1. Meara JG, McClain CD, Mooney DP, Rogers SO Jr,
editors. Global surgery and anesthesia manual: providing care in resource- limited settings. Boca RatonLondon- New York: CRC Press; 2015.
2. Swaroop M, Krishnaswami S, editors. Academic
global surgery, Series in academic surgery. Cham:
Springer; 2016.
3. Park A, Price R, editors. Global surgery: the essentials. Cham: Springer; 2017.
4. Personnal Communication- Dr. Francis Moore -1976.
5. Organisation for Economic Co-operation and
Development (OECD) 2022. https://www.investope-
dia.com/terms/o/oecd.asp
6. Higashi H, Barendregt JJ, Kassebaum NJ, Weiser
TG, Bickler SW, Vos T. Burden of injuries avertable by a basic surgical package in low- and middleincome regions: a systematic analysis from the Global
Burden of Disease 2010 Study. World J Surg. 2015;
39(1):1–9.
7. Haagsma JA, Graetz N, Bolliger I, etal. The global burden of injury: incidence, mortality, disability-adjusted
life years and time trends from the Global Burden of
Disease study 2013. Inj Prev. 2016;22(1):3–18.
8. https://familymedicine.uw.edu
9. https://bulletin.facs.org/2018
10. Meara JG, etal. Global surgery 2030: evidence and
solutions for achieving health, welfare, and economic
development. Lancet. 2015;386(9993):P569–624.
11. Farmer PE, Kim JM. Surgery and global health: a
view from beyond the OR.World J Surg. 2008;32(4):
533–6.
12. Bae JY, Groen RS, Kushner AL.Surgery as a public
health intervention: common misconceptions versus
the truth. Bull World Health Organ. 2011;89(6):394.
Part I
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System Strengthening
How toPrepare forShort- or
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Long- Term Surgical Practice
inLow- andMiddle-Income
Countries
MarkA.Hardy, BrianA.Chang, RichardM.Smiley,
RichardK.Raker, andBethR.Hochman
A teacher affects eternity. He can never tell where his inuence stops.
– Henry Adams
2
Abbreviations
Scope ofMedical Trainee or
Practitioner inGlobal Health
ABS American Board of Surgery
ACGME Accreditation Council on Graduate
Medical Education.
GME Graduate Medical Education.
LMIC Low- and Middle-Income Country.
PD Program Director.
PDT Pre-departure Training.
RCS Royal College of Surgeons.
RRC-S Residency Review Committee for
Surgery.
WACS West African College of Surgeons.
M. A. Hardy (*)
Department of Surgery, Columbia University Vagelos
College of Physician and Surgeons,
New York, NY, USA
e-mail: mah1@columbia.edu
B. A. Chang
Department of Anesthesia, Columbia Medical Center,
NY Presbyterian Hospital, New York, NY, USA
e-mail: bac9046@nyp.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_2
Involvement
Interest and participation in global health opportunities has increased among surgical residents,
medical students, and other fully-trained health
care clinicians from high-income areas. These
opportunities are primarily in “underserved”
countries, frequently referred to as low- and
middle- income countries (LMICs). As is well
known these vary signicantly by their economic
proles, health and training systems, and even by
their locations, especially urban as compared to
rural. Even in developed countries, such as the
USA, there are underserved areas, such as many
Indian reservations or in countries where some
district hospitals are well staffed and equipped
because of provincial or political support while
R. M. Smiley · R. K. Raker
Department of Anesthesia, Columbia University
Vagelos College of Physicians and Surgeons,
New York, NY, USA
e-mail: rms7@cumc.columbia.edu;
rkr1@cumc.columbia.edu
B. R. Hochman
Department of Surgery, Columbia University Vagelos
College of Physicians and Surgeons, Milstein
Hospital, New York, NY, USA
e-mail: brh2106@cumc.columbia.edu
9
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M. A. Hardy et al.
others may be given inadequate budgets by the
Ministry of Health. Numerous general surgery
residency programs have established collaborative efforts with partner institutions in LMICs.
Many clinical specialists such as anesthesiologists, plastic surgeons, otolaryngologists, or ophthalmologists provide their services in LMICs as
teams which address specic health problems.
This is best illustrated by the Team Face Africa
described in Chaps. 34–40 specializing in reconstruction of the face for Nona. There are also
other teams that specialize in cleft palate repairs,
cardiac surgery, cataract and glaucoma operations, and other interventions. An anonymous
survey of incoming interns revealed that >75%
were interested in participating in medical mission trips, and approximately two-thirds of them
were interested in incorporating global health
into their long-term careers [1]. Specically,
interest and participation in global surgical programs has increased over the past two decades, as
has their availability. The need for global surgery
has become emphasized and more obvious [2].
This increase in interest has led to a rapid rise in
the number of global health opportunities worldwide. They are now offered through numerous
medical schools and residency training programs.
Over the last two decades, the proportion of US
medical schools offering global health opportunities has tripled [3]. More than half of both medical and surgical residency training programs
offer residents the opportunities to participate
either in short mission trips or in dedicated global
health tracks which offer specic short
(4–8weeks) rotations, or some other intervals of
several months [3–6]. These may or may not be
recognized by the American Board of Surgery
(ABS) depending on the degree of direct supervision and the accreditation of the foreign institution and its surgical staff as accredited trainers by
the Residency Review Committee for Surgery
(RRC-S). Junior and recently retired surgical faculty are major volunteers who frequently participate in LMICs on rotations from 1 to 6months,
and rarely longer. There are many reasons why
individuals decide to participate in global health
experiences. These include the desire to improve
access to health care in low-resource settings, to
improve medical knowledge or language skills),
or to experience new destinations and culture
[4–7]. The types and duration of global health
experiences are just as heterogeneous as the reasons for participation. Some senior volunteers
participate in trips where they are responsible for
setting up temporary clinics and providing medical supplies. Others may engage in needs-based
assessments, or develop educational instruction
workshops that improve emergency care or other
specialties, for example, chest tube insertions in
Ethiopia, or insertion of stents for obstruction by
esophageal cancer in Malawi.
The involvement of trainee and faculty volunteers has led to a call for “pre-departure” training
and orientation programs. Opportunities for international volunteer work are widely available for
the interested practicing or retired surgeons, surgical residents or students [3]. https://www-
sciencedirect- com.ezproxy.cul.columbia.edu/
science/article/pii/S0039606012000980?via%3D
ihub- bib4. Adequate preparation for their experi-
ences and responsibilities in an unfamiliar clinical
and cultural environment prior to such educational visits is critical to achieve the greatest
effectiveness and benet for both the host institution and the visiting staff. This applies to both the
teaching and learning efforts of all the involved
individual professionals, as well as patients.
Based on our own experiences in working in
LMICs, we have prepared a practical guide for
residents and students to adequately prepare them
for such international surgical rotations [8].
Although little has been written about the need for
preparation of fully-trained clinicians and health
care staff, the need for rational and thorough preparation is not unique to medical students and resident trainees [8, 9].
Recognition of common problems due to
lack of adequate pre-departure training (PDT)
has led to a number of studies which focused on
various methods to improve PTD, mostly for
medical students or resident physicians, since
these groups are most amenable/available for
organized training [8–16]. A general consensus
on topics that should be addressed has been
2 How toPrepare forShort- or Long-Term Surgical Practice inLow- andMiddle-Income Countries
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Table 2.1 Core themes for pre-departure training/preparation
Theme Recommendation
Trainee specic
Personal health and safety • Review site-specic recommendations for vaccination and antimicrobial
prophylaxis.
• Ensure health insurance/evacuation plan.
• Identify site-specic safety risks.
• Emergency contact information.
• Plan for who to contact and where to go in case of an emergency/need for
personal medical care.
Emotional wellness • Consider risk of “culture shock” and “reverse culture shock”.
Communication • Learn (when possible) appropriate language skills (i.e., host institution’s native
language and unspoken forms of communication).
• Identify members of the host community to serve as liaisons between volunteers
and members of the community.
Personal development • Reect on personal motivations for participating in global health experience.
• Consider and clarify goals and expectations of both the volunteer and host
institution.
Cultural competency • Learn about local culture and customs, especially how it impacts the host
community’s interaction with the health care system.
• Cultural humility.
Ethical considerations • Discuss culturally appropriate communication techniques to navigate difcult
situations.
• Reect on volunteer role and level of training; only engage in appropriate tasks.
• Emphasize the importance of upholding same standards of care and ethics that
trainees maintain at home institution (the issue of “standard of care” is a complex
area that is hard to dene in one sentence).
Program- specic logistics • Identify licensure and other legal document requirements necessary for practice/
taining/teaching in programs at host country/institution.
• Encourage bidirectional communication prior to departure to ensure similar
expectation between trainee and host institution.
• Ensure appropriate supervision of trainees.
11
developed, and they should be applicable with
some modications, for any physician contemplating a global project [12–18]. In 2008, the
Association of Faculties of Medicine of Canada
published guidelines for PDT programs, which
included the following domains: personal
health, travel safety, cultural awareness, language competencies, and ethical considerations
[17]. Since then, several studies have expanded
these initial guidelines to provide a more encompassing outline of the topics that should be covered during PDT programs [5, 18–21]. These
recommendations are summarized in Table2.1.
The following which has been previously published by one of us (MAH) [8] is partially based
on a brief practical guide for visitors to prepare
for a surgical visit, elective rotation, or mission
to an underserved region.
Preparations
The rst task is to determine why, where, and
for how long one can go. This will obviously
depend on the schedule, support, level of training
and expertise and the need for visitor(s) as contributor, teacher, organizer, or administrator following an invitation by the host institution. The
other important factors to consider are the age
and obligations of the visitors and the stability of
political situation in the host country. To enjoy
and succeed in an international rotation/elective
one has to dene one’s goals and objectives.
Among many objectives is to see, examine, and
treat a variety of cases new to the visitor, depending on the region’s epidemiology. Surgical rotations tend to be more time-demanding than
others. There are many cultural and language bar-
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