By Isaac Jarratt Barnham, 2nd Year Graduate Entry Medicine, Oxford University
There exists enormous global inequality in access to surgery. Only 6% of surgical procedures occur in low-income countries, and 5 billion people around the globe lack access to basic surgical care (Meara et al., 2015; Ng-Kamstra et al., 2016). An estimated 143 million additional procedures are required annually to meet this unmet surgical demand (Meara et al., 2015).
Whilst this challenge is receiving growing international recognition following the publication of the 2015 Lancet Report on Global Surgery, improving surgical access is still allocated less than 2% of international global health spending – around $0.78 billion (Reddy et al., 2020). Given this absence of large-scale international intervention, a significant proportion of the aid supplied by High-Income Countries (HICs) to address untreated surgical pathology in Low and Middle-Income Countries (LMICs) is currently provided through Short Surgical Missions (‘SSMs’).
Short Surgical Missions
SSMs are brief trips lasting 2-3 weeks made to an LMIC healthcare centre by a small group of HIC surgical staff. They often focus on performing a large number of procedures addressing a single pathology (e.g. Cleft Palate reconstruction), with some also offering assistance in managing the centre’s emergency workload (Gosselin et al., 2011).
These missions are incredibly popular among HIC surgeons and trainees, with up to 98% of practitioners expressing interest in involvement (Powell et al., 2007). Participants report both benefits to their surgical skills and increased exposure to relevant pathology (Leow et al., 2010). Perhaps unsurprisingly, therefore, well in excess of $250 million is spent on such missions each year (Punchak & Lazareff, 2017; Sykes, 2014).
Controversy exists, however, surrounding the suitability of SSMs for addressing global inequality in surgical access, with a number of concerns being raised (Grant et al., 2020).
Rates of complication
Firstly, rates of postoperative complication occurring during SSMs are consistently found to be high (Hendriks et al., 2019), with some procedures incurring rates of complication up to 20 times greater when performed during a surgical mission than when undertaken by the same surgical team in an HIC setting (Maine et al., 2012). Crucially, SSMs often also produce a significantly higher rate of complication than those experienced by local surgeons (Daniels et al., 2018).
There are a number of reasons to believe this lower quality of care results specifically from the short duration of SSMs. Firstly, the time constraints intrinsic to a ‘Short’ Surgical Mission often prompt visiting surgeons to rush cases to increase overall output, thus compromising quality (Nthumba, 2010). Secondly, in order to increase output, SSMs often see surgical trainees perform procedures they would be considered underqualified for in a high-income setting (Nthumba, 2010; Yeow et al., 2002), with unsurprising implications for complication rates.
Thirdly, the brevity of SSMs prevents visiting surgeons from participating in patient follow-up, as staff return to their home nation soon after a patient’s surgery. Overburdened LMIC surgeons are thus left to follow up both SSM patients as well as their own, compromising postoperative care.
Short Surgical Missions, therefore, often provide substandard patient care and thus may be a poor intervention for addressing unmet surgical needs in LMICs.
Complex implementation
Secondly, SSMs are typically provided through the collaboration of several stakeholders, including funders, healthcare providers, NGOs and LMIC organisations. They are, therefore, complex to implement and are vulnerable to collapse should any party withdraw (Nthumba, 2010). SSMs are also dependent on international travel and have therefore almost entirely ceased during the Coronavirus pandemic (Joos et al., 2021). The instability of SSMs, therefore, makes them unreliable providers of support for LMICs.
Poor educational provision
Most importantly, however, SSMs fail to address the root cause of LMICs’ need for surgical assistance – low LMIC surgical capacity. Missions primarily act to address untreated pathology. In doing so, they treat only the symptoms of insufficient surgical provision and not the cause, perpetuating LMICs’ dependence on HIC assistance for providing surgical care.
Whilst some SSMs do incorporate an educational component, missions often fail to coordinate their teaching with local programmes, and thus both fail to address topics relevant to LMIC practice and frequently displace more appropriate, locally provided, teaching (Ginwalla & Rickard, 2015). More concerningly, however, SSMs may actively deprive local surgeons of educational opportunities by prioritising the provision of learning experiences for visiting HIC trainees at the expense of locals (Grant et al., 2020; Hendriks et al., 2019).
SSMs are, therefore an ineffective method of addressing the lack of staffing underpinning low access to surgical care in LMICs.
The way forward?
More effective methods of supporting surgical teams in LMICs are needed. There is good evidence that by extending LMICs visits to last many months low rates of post-operative complications comparable to those found in HICs can be achieved (Shrime et al., 2017). However, clinical commitments in their home nations make participation in such a long mission unfeasible for most HIC staff wishing to play a part in addressing global surgical inequality.
A modern and increasingly attractive alternative intervention open to such staff may be the provision of E-learning and Telementoring. This would involve offering online teaching and classes on topics relevant to LMIC practice. Recent technological developments, however, now also allow surgical mentors to support staff in theatre using live video feeds streamed from wearable technology, allowing real-time teaching of surgical techniques (Datta et al., 2015; Karim et al., 2020).
Challenges for this form of intervention still exist, including restricted internet access in LMICs high set-up costs, and the difficulty of arranging teaching times over different time zones (Erridge et al., 2019; Joos et al., 2021). Despite this, however, recent advances raise distanced teaching as a cost-effective and sustainable opportunity to address a key cause of poor provision of surgical care in LMICs - the lack of adequately trained surgical staff.
Conclusion
SSMs, therefore, often provide poor care to LMIC residents, are logistically challenging to perform and prone to collapse, and are an ineffective means of providing educational support to LMIC surgeons. HICs must look for other methods of supporting those nations lacking surgical provision. Distanced teaching utilising emergent technology offers such an opportunity. HICs should harness the enormous uptake of online training methods driven by the Coronavirus pandemic to springboard efforts to extend such teaching to LMICs.
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