Many experts would argue that trauma is not just a one-time incident; it is a lifelong burden, affecting physical, psychosocial and emotional aspects of health. I have been interested in the subject of gender-based violence since childhood. As a child, I remember accompanying my mother to the domestic violence shelter where she volunteered on weekday evenings. Our conversation on the car ride home was peppered with discussion and questions that have continued to linger with me over the years: why does violence against women occur? How can we prevent it as a society? What is the impact of such violence on women’s physical, mental and emotional health?

As a medical student, I became interested in how such gender-based violence presents to the hospital – how it is identified (or not) by clinical providers, how healthcare professionals and social workers can assist and aid people who come into the hospital as a result of gender-based violence. Women and men who have experienced such violence may be coming into health care settings scared, fearful, and ashamed to share what has happened. As clinicians, I believe it is our duty to identify and support them as much as we can.

We know the majority of traumatic injuries that present to the hospital setting occur among males, in both higher and lower income countries. Differences in mechanisms of injury have also been explored along gender lines – for example, men are usually more likely to be injured in motor vehicle collisions than women. But what are the gender differences in outcomes for non-accidental trauma, such as assault and violence? Little has been explored in this area, largely due to lack of data, especially in lower–middle income countries. Comparing different countries can help shed light on the various ways in which women are being injured in different settings to help guide policies and practices.  For example, violent injuries against women via burns are more common in southeast Asia than other parts of the world. We were interested in knowing whether people fare differently based on their gender and how severely they were injured depending on the country in which they lived – for example, comparing the United States and India.

There is a large need for hospital-based assessment and resource provision in hospitals that take care of patients who are victims of gender-based violence. I have been involved in a study which seeks to fill this knowledge gap. Though not entirely conclusive, it is the first of its kind to show an association between gender and post-trauma outcomes based on intentionality of the injury – i.e. whether someone incurred an accidental or intentional (assault) injury. Most trauma data systems do not collect information on intentionality, but this is a crucial piece of data to add to the socio-demographic profile of a trauma patient.

In our study we found “Indian females had over 7 times the odds of dying after falls, 5 times the odds of dying after motor vehicle collisions and 40 times the odds of dying after assaults when compared with US females”. It is difficult to pinpoint exactly why this is happening but the study is an important first step to understanding why there may exist differences in gender outcomes in different countries. Possible answers generated by this study include differences in hospital access for men and women, differences in social norms, and differences in intensity of injury. Our study opens the door to future investigation into this important topic. Ultimately, targeted improvement within health care systems to provide trauma-informed care and prevention programs to reduce violence may help ensure that such gender-based differences in outcomes after injury are addressed.

About the author: Mohini Dasari is a first-year general surgery resident at the University of Washington in Seattle, Washington, USA. She spent one year during medical school studying clinical outcomes in trauma in India and the United States, as well as electronic trauma registry implementation in Latin America. Her interests lie in the intersection of gender-based violence, trauma care and global public health.

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and confirm I have no conflicts of interests to declare.

Dr. A works as a surgeon in a small town of India. Like any other small town doctor he has settled for a practice here because of affinity and close proximity to his home. Building up from the scratch, Dr. A has slowly set-up an infrastructure that provides the best possible quality and affordable healthcare to patients from surrounding rural areas who can’t afford highly expensive private hospitals or far-off government hospitals.

Dr. A juggles between multiple roles of surgeon, physician, administrator, treasurer and public health expert, often operating as a one-person medical team. While he still enjoys his profession, the lack of a ‘team’, as many doctors would agree, makes the job a daily-struggle and gruesome. Most of the support-staff hired in these clinics and hospitals are highly untrained and unskilled. For the lack of any better alternatives, doctors have to be content with this unfortunate setting. Often, this results in a team that lacks skills, discipline, experience and attitude to perform even regular procedures, leave alone highly complex surgeries. When one of the imaging machines malfunctioned in the middle of an operation, he had to wait almost a week for a technician to arrive from the state capital, and the surgery had to be continued blindly with archaic methods. In another instance, he had to use a manual orthopedic drill, when the automatic drill stopped functioning in the middle of another crucial operation. Lack of technical support, unskilled staff and frequent power-cuts makes this a usual occurrence. Inevitably quality of care and clinical outcomes are sub-optimal.

An anesthetist is the captain of the surgical ship, especially when things goes wrong. With only two anesthetists in town, there is a fierce scramble for his dates by orthopaedists, surgeons and obstetrician’s alike. Such issue gives add up to stress of doctors like Dr. A! Timely, affordable access to screened blood products is essential to delivery of quality surgical care. Most of the time blood products are scarce and even if available the improper and neglected maintenance of blood banks is a major cause of worry.

The challenges of chronic poverty limits access to surgical care. Out-of-pocket payment of hospital fees, supplies and medications demands the surgical care to be extremely affordable, often adequately provided by doctors. Culture belief and general mistrust of healthcare only adds to the challenges face by healthcare providers in small towns.

The seemingly disinterested Dr. A is also a part of a larger problem of burnout among doctors. Without any recreational facilities and dearth of whatsoever social life, numerous surgeons from smaller towns are a victim of burnout-associated symptoms such as emotional exhaustion, dissatisfaction and physical weariness. This has led to depersonalization, decline of empathy and reduced personal and professional satisfaction. The cause can be traced to widely varying factors such as overwhelming workload, poor specialists-patient’s ratio, deficiency of recreational facilities and insufficient support from medical organizations such as Indian Medical Association (IMA). IMA facilities in small towns have no provisions for recreational opportunities and CMEs and workshops are rare.

Medicine is a tough job no matter where you live, but it’s even more complicated when there is no formidable support system. Specialists like Dr. A continue to provide essential and specialized surgical care in rural areas and small towns without getting much recognition. While global health surgery has shed the tag of  the ‘neglected stepchild’ of global health, and is now  being recognized as an ‘indivisible, indispensable part of healthcare’ and  several transnational initiatives such as The Lancet Commission on Global Surgery (LCoGS) and The WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) has been initiated . Timely and affordable access to essential surgical care is the key to equitable healthcare delivery in underdeveloped regions of the world. Yet, the challenges faced by surgical care providers in low resource settings and how they overcome these challenges to provide care to impoverished patients have hardly been understood. It is time that we recognize and value surgeons like Dr A, and also build up our health systems in a manner that they can function optimally. Universal health coverage includes essential and safer surgery and anesthesia and it is time that investments are made in this direction.

About the author: Ankit Raj is a final year medical student from Kasturba Medical College, Manipal, India and is a member of The International Student Surgical Network (InciSioN).

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare I have no conflicts of interests to declare.

Chelsea Clinton and Devi Sridhar set out five tasks for the newly elected DG of the WHO

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The adoption of Sustainable Development Goals (SDG’s) in 2015 marked a shift in the global development agenda from the earlier Millennium Development Goals (MDGs) era. SDGs are particularly important for the health sector, since they reaffirm the premise of the Alma Ata declaration that health cannot exist in isolation. SDG’s intrinsically link health with actions in several sectors outside healthcare. As a country which missed several of its MDG targets, the SDGs reflect a new set of challenges for India.

At the 2015 United Nations summit, India’s Prime Minister Narendra Modi said that the “Sustainable development of one-sixth of humanity will be of great consequence to the world and our beautiful planet,” while reiterating his confidence that they will be reached. But how well does India’s latest National Health Policy (NHP 2017) released last month, align with the health related SDG’s?

To its credit, the policy, at the outset, recognises the SDG’s to be of “pivotal importance” and has identified seven priority areas outside the health sector which can have an impact on preventing and promoting health. In the section on urban health policy, the NHP calls for “achieving convergence among the wider determinants of health.” The NHP has identified the following determinants specifically: “air pollution, better solid waste management, water quality, occupational safety, road safety, housing, vector control, and reduction of violence and urban stress.” The policy links this with the government’s focus on “smart cities,” seemingly in tandem with SDG 11. This is commendable. But the omission of other traditional determinants of health that are intrinsically linked to other SDG goals of reducing poverty, hunger, promoting quality education, gender equality, and reducing inequalities (SDG 1,2,4-6,10) is surprising.

In its national programmes on maternal and child health, the policy “seeks to address the social determinants through developmental action in all sectors.” It further says that “research on social determinants of health” will be promoted, combining this with “neglected health issues such as disability and transgender health.” It touches on Panchayati raj institutions “to play an enhanced role at different levels for health governance, including the social determinants of health.” In highlighting the need for “an empowered public health cadre,” the NHP explains they need to “to address social determinants of health effectively, by enforcing regulatory provisions.” And while this is not explicitly mentioned as a determinant in the NHP the insertion of gender based violence in national programs, and the call for increased sensitization of health systems to provide care “free and with dignity in the public and private sector,” is another welcome sign. But in its entirety, these issues that are outside of the healthcare sector are reduced to mere mentions, with very little clarity on policy direction or funding. This merits some concern, considering that the NHP in itself, even outside the realm of SDGs, has outlined equity as a key principle.

In transitioning from MDGs to SDGs, the mention of health was reduced from three goals to only one, seemingly in recognition of the need for concerted policies in tandem with related fields in order for them to have a lasting impact on population health. It would have been refreshing if India’s NHP had categorically specified frameworks for integrated action in non-health related SDG’s such as those focused on poverty, hunger, education, gender equality, clean water, and sanitation. Meaningfully executing any multi-sectoral mechanism means building successful partnerships within diverse ministries and with communities. Given all that has been said about the NHP 2017 repeating many of its targets from previous versions, a succinctly articulated vision for governance and financing for inter-ministerial work to address health would have been refreshing.

Soumyadeep Bhaumik is an associate editor for BMJ Global Health and an analysis advisor for The BMJ. He is a medical doctor working in the field of evidence syntheses and program evaluation in India.  Twitter: @DrSoumyadeepB 

Pritha Chatterjee is an MPH candidate at the Harvard T.H. Chan School of Public Health and an Aga Khan International Development Scholar. She is a health journalist from India, formerly with The Indian Express Ltd.  Twitter: @pritha88

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no other relevant conflicts of interests to declare.

Disclaimer: Views expressed are those of the authors and are personal in nature.

As a paediatric surgeon in Nigeria, my experience is that child survival following emergency surgery is lower compared to children in more developed countries. This is especially the case in the neonatal period. Studies in countries with a low to middle Human Development Index (HDI) have documented several challenges associated with this issue—delays in presentation to health facilities and in surgical intervention after patients present to the hospital, sepsis, and a lack of availability of parenteral nutrition and neonatal intensive care units. However, although globally many agree that effective provision of emergency essential surgery is a key priority for the global child health agenda, in practice nothing has been done. more…