Rej Bhumbra: Global surgery—global wellness

The Chinese phrase, “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime,” is widely used, but its principles hold true, especially if you are working in the field of global surgery. A meeting organised at the Royal College of Surgeons by Chris Lavy recently brought together a collection of doctors, medical students, journalists, and representatives from global health charities and organisations.

The thermal burns equivalent of “teaching the aforementioned man to fish” was brought to the forum by UK surgeons working in Nepal. Local techniques used to dress burns are an example of local solutions to local problems. Rather than opening a supply chain to a multinational dressings company to assist in burn healing, the application of sterilised banana skins proved to be just as effective in this context. These can be sterilised in a pressure cooker for 15 minutes.

Martin Bircher, an orthopaedic surgeon from St George’s and lead for global surgery at the Royal College of Surgeons, relayed how countries such as China had no universally accepted nationwide surgical standards. Inevitably this has led to variation in surgical quality and much work is needed to reduce this disparity in one of the fastest developing economies in the world. It was this variation in trauma care not so many years ago that triggered Advanced Trauma Life Support for particular parts of the so called “first world.”

The meeting had a relatively unique aspect for a medical conference by showcasing three minute “lightening” presentations by 20 different global care groups. This was particularly refreshing and would appeal to those with conference attention span issues.  There was also a husband and wife presentation from Rish and Kat Parmer, orthopaedic and general surgical trainees respectively. A very effective, and some would say brave, presentation modality that insightfully captured both interpersonal and interprofessional interactions. They recorded their operative numbers and case mix demonstrating quite clearly that training abroad benefits the NHS in both clinical and managerial experiences for the long term.

Working abroad is understandably attractive to medical teams as they treat patients with real needs who live in real poverty. This is potentially beneficial to the trainees, patients, and hospitals—both globally and in the NHS. However, it has to be done properly. There are well established harms that have been caused by a lack of insight and planning from western surgeons working internationally.

Specialist organisations that establish relationships between UK hospitals and low or middle income countries are promoting good practice and training events. Fellowship and academic programmes are already well established in both the US and Canada.  The UK is starting to catch-up with a fellowship programme that is being designed by Andy Leather at Kings College, London. Fergal Monsell from Bristol offers limb reconstruction for orthopaedic paediatric trainees working in Cambodia. Surgical trainee, Caris Grimes presented economic data on global surgery, and reiterated the importance of ensuring meticulous planning prior to departure as well as the establishment of a meaningful research agenda.

The practical issues of how you get clinicians out there delivering surgical care in countries with up to 85% of the population living in very rural conditions was answered by not addressing that as a problem. They have locals, not medically trained, delivering care. This is not uncommon and the variability is massive. I remember seeing many patients with “knee swellings” in South Africa, who had been treated in villages by the local witch “doctor” using circumferential knee lancing to release the “bad demons.” I can see how this could work for osteomyelitis, but it did fall down when an osteosarcoma was involved. On the other hand the story of Hamilton Naki was recounted by Michael Cotton, who spent many years working as a general surgeon in Bulawayo, Zimbabwe. Naki was a South African gardener, who left school at 14 and started in the research animal house in Cape Town. He went from gardening, to cleaning, and onto animal restraining to finally anaesthetising and dissecting the animals. Described by Christina Barnard as “one of the great researchers of all time in the field of heart transplants” he finally ended up teaching many of the trainees as well as working as a laboratory assistant to Barnard himself.

The late Jose Antio Socrates, a multi award winning leader of an anticorruption and environmental campaign in Palawan, used the phrase, “appropriate orthopaedics,” to describe that care is more than an intervention. It is also a judgement made in sensitivity to the facilities and skills mix of the local context and environment.

Maybe we should say, if you treat burns patients in an evolving economy, and you do not have an established burn dressing supplier, make sure you can get some banana skins in the steam pressure cooker and things are looking up. I find this story ironic as one of my neighbours in another evolving economy, Hackney, burnt his hand with steam from a car radiator. His hand was immediately cooled with wet towels, and I said he should pop over to the Homerton hospital for some non adherent dressings to cover the burn. He said, “Don’t be silly mate, I’ll just put a few banana skins on….”

One of the representatives from the Mercy ships programme summed up the sentiment of global surgery and its future, “For hope to be credible in the future it needs to be tangible in the present.” The people who dedicate their professional and personal lives to this make that tangibility, one step closer.

Rej Bhumbra is the editorial registrar, BMJ