August 8, 2012, 7:00 AM
Late one June afternoon, Angela Chibwe was heading home on a bus on this city’s main road when she noticed an elephant on the side of the road. This would not have normally been cause for alarm, as elephants are a common sight here. This one, however, behaved unusually: it charged at the bus and caused it to flip upside down.
Several hours later, Angela woke up in Livingstone General Hospital. She was the only passenger who had been badly injured. Both of her legs were broken, and a piece of metal had cut through her forehead and left eye. The hospital’s surgeon had been able to restore sight in her eye, though it would unfortunately remain disfigured. When I met her, three weeks after the accident, she seemed to be in pain but grateful to be alive.
Angela was perhaps luckier than she realized. If the accident had occurred in a distant rural area instead of the city of Livingstone, which has more than 130,000 people and a relatively sophisticated medical system, she may not have woken up in a hospital. She may not have gotten the surgery required to restore vision in her left eye. She may have been permanently disabled, or worse.
Across Africa, countless people die or become disabled because they cannot obtain necessary surgeries. It is conservatively estimated that 56 million people in sub-Saharan Africa — over twice the number living with H.I.V./AIDS — need a surgery today. Some need cesarean sections or hernia repairs, while others require cataract surgery or treatment for physical trauma.
With high-quality surgery available in the world’s developed countries (for those who can afford the coverage or the price tag), it is easy to forget how crucial that option can be for a patient. “With surgery, people can survive who otherwise would not have,” said Mzaza Nthele, a general surgeon in Livingstone General Hospital. “Just imagine how many lives are lost if we can’t do C-sections.” The World Health Organization estimates that surgery can treat 11 percent of the global disease burden.
A country road outside the village of Siachitema, in the Southern Province of Zambia. Many patients in need of surgery must travel long distances.
Yet across the developing world, surgical care often does not reach those who need it. Surgical facilities are sometimes prohibitively far or expensive to reach, which can be fatal in emergency cases. “It’s not obvious until you visit the hospital in person,” said Kendra Bowman, a researcher and surgery resident at Brigham & Women’s Hospital. “The Western province [of Zambia] is under water for seven months of the year — there’s no running water, no electricity, no phones, they’re cut off from the world. There’s no way they’re going to go to [capital city] Lusaka to get a laparotomy. It’s a death sentence to refer those patients.”
Unfortunately, smaller health facilities often have no choice but to refer patients to larger cities. Surgical equipment is sometimes nonexistent, especially in remote areas, and supplies are a challenge to maintain. More critical, though, is the human resource gap. Zambia has only 44 fully licensed surgeons to serve its population of 13 million, who are spread over an area slightly larger than Texas.
Bowman spent a year in Zambia, during which time she visited almost all of the country’s health care facilities and spoke to nearly 500 healthcare providers about gaps in surgical care. Despite the country’s many infrastructural shortcomings, 70 percent of respondents said that skills were the biggest challenge to performing quality surgery. “[Surgical skills were] the hard stop,” she said. “The soft stops” — meaning the more surmountable obstacles — “were that they didn’t have the right equipment or lighting, that they have to use a cellphone to light the surgical field. But they can improvise that. You can’t improvise opening an abdomen.”
Filling the “hard stops” with fully licensed surgeons is not easy. Not only is the absolute number of surgeons low, but the distribution is also very uneven. Only 6 of Zambia’s 44 surgeons live in rural areas, and all of them are expatriate missionaries. “Most doctors that are trained in Zambia don’t want to work in the rural areas, though they’re needed there more than anywhere else,” said Emmanuel Makasa, the deputy director of emergency health services at the Ministry of Health.
Fully licensed doctors are also in high demand in other lines of work. Some leave public sector clinical practice to pursue careers in administration, private clinical practice and international NGO work — all of which can be more lucrative. “People will pay me more to speak about H.I.V. than to save dying surgical patients,” said Nthele, the surgeon in Livingstone. Other doctors leave Zambia altogether for higher pay in more industrialized countries.
Many African countries, including Zambia, Tanzania, Malawi, Mozambique and Ethiopia, have recognized the need for a more creative solution. Instead of finding ways to lure surgeons to rural areas, these countries have started experimenting with “task shifting” — that is, training non-physicians to do the basic work of surgeons.
Task shifting is becoming an increasingly popular method to address the human resource gap in African health care. Three weeks ago, a Fixes co-author, Tina Rosenberg, discussed task shifting in mental health. Some countries have tried it with H.I.V. treatment and counseling. Task shifting in surgery is a little trickier. Considering the precision required in surgery and the immediately dire consequences of a surgery gone awry, programs have needed to be designed with an exceptional degree of care.
In Zambia, surgical task shifting began in 2002 with the medical licentiate program, which trains clinical officers in basic surgeries like hernia repairs, bowel obstruction surgery, hysterectomies and more. “The real reason the program evolved was to take care of emergency surgical conditions,” said James Munthali, head of surgery at University of Zambia’s School of Medicine. The Surgical Society of Zambia and the Ministry of Health jointly determined the procedures in which licentiates should be trained. For instance, the program emphasizes training in cesarean sections, which constitute 45 percent of major surgeries in the country.
A two-year-old girl with a third degree burn at Kalomo District Hospital in the Southern Province of Zambia; she would have to travel more than 25 miles for her surgery.
The philosophy behind the program is that many surgical procedures can be broken down and taught to people with lower levels of medical education. “To do most of the procedures, you don’t need to be a medical doctor,” said Uwe Graf, an ob-gyn consultant who works with the licentiate training program at Chainama College in Lusaka. “As long as you’re reasonably good with your hands, you can do it.”
That may be a bit of a simplification. The three-year licentiate program is quite competitive — only 20 percent of this year’s applicants were accepted — and candidates must have five to six years of clinical training and experience before applying. The Ministry of Health then posts them to rural areas or small towns with high surgical need, where they earn good salaries and are required to remain for three years (most stay much longer). Licentiates earn over twice as much as they did in their previous roles and, if posted to a rural area, are given a substantial hardship allowance.
To date, the program has produced 117 medical licentiates, 116 of whom are currently practicing in public-sector facilities throughout Zambia.
One of the biggest advantages of the program is the stability licentiates can bring to a rural health facility. “At least for now, the medical licentiates do not run away for greener pastures,” said Hinson Siabwanta, coordinator of the training program. Unlike young doctors, they do not enter rural areas hoping for a transfer to a larger town. They are also not likely to leave the country, as their training is not recognized elsewhere. Josphat Simutowe, a medical licentiate in Zambia’s Central Province, emphasized to me how happy he was with his salary, the respect he receives from nurses and clinical officers, and the amenities his location offers.
There are not yet any peer-reviewed articles on Zambia’s medical licentiate program, but medical professionals across the country seem to hold them in high regard. Makasa, an orthopedic surgeon, described how “amazed” he was the first time he witnessed a licentiate perform an operation. “It was fascinating to see somebody who’s apparently less trained than I am handling C-sections,” he said. “And they do it very well.” Bowman said that in most rural facilities, they are referred to as the “most valuable players.”
The feedback in Zambia fits with evidence on surgical task shifting from around the continent. Post-operative results of licentiates in Malawi are considered “comparable” to medical officers, as areoperative mortality rates in Somalia.
As with any effort at task shifting, there are some important limitations to the licentiate program. For instance, there are some concerns that medical licentiates, both in Zambia and elsewhere in Africa, do not have defined career tracks or formal methods of continued education. The training program is also quite small, because of the limited number of teachers and mentors.
Some surgeons have ethical questions about the program. Medical licentiates are not trained in specialized procedures, including surgical oncology and thoracic surgery. This means that patients technically still have to be referred to fully trained surgeons for those cases. However, what if there is an emergency and no surgeon to whom to refer the case? “People are given skills and sent out to places where there is no alternative,” said Adam Kushner, a surgeon who has worked or taught surgery in 16 African countries. “If they go beyond their means, are they doing more harm than good?”
To date, however, there is little evidence suggesting that the program has caused patients significant harm. “From 2002, we haven’t had any clinical audits that have indicated that the safety of patients has been compromised because of medical licentiates,” said Siabwanta, the coordinator of the licentiate training program. He also stressed that licentiates are strictly taught their limits as technicians and the steps to take in case of an emergency.
The presence of medical licentiates does not, needless to say, obviate the need for fully licensed surgeons. There will always be surgical cases that licentiates are not equipped to handle. To that end, some Zambian surgeons are experimenting with ways to make surgeons more mobile. Munthali, who teaches surgery to medical students, is a member of the donor-funded FlySpec(Flying Specialist) program, which charters planes to conduct orthopedic surgeries in remote parts of the country. He operates on up to 16 people a day on his visits. Nthele, the surgeon in Livingstone, is creating a mobile surgery program in the Southern province.
For researchers like Bowman, the licentiate program and FlySpec are part of a larger push to make surgery more prominent on the global health map. She believes that the international community has largely ignored surgery because there is no global advocate for the cause, because data have not existed and, perhaps most important, because many perceive surgery to be expensive.
“What people don’t understand about surgical care,” Bowman said, “is that it might cost 200 dollars to fix a ruptured appendix, but it’s a one-time intervention. You save them for the rest of their life.” Research by the Disease Control Priorities Project has foundsurgery to be a cost-effective way to avert disability and death, especially if delivered locally and with low-cost technologies.
“I see the state of global surgery today similar to the state of H.I.V. 30 years ago,” said Bowman. “Today, surgery needs to be recognized as a fundamental component of global health. It should be right there with infectious disease.”