Expanding access to surgery on a global scale

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Universal health is a top priority at the Weill Cornell Brain and Spine Centre in New York, USA. Their global neurosurgery programme, a collaborative project designed to improve access to surgery and surgical care across the world, has been running for the past 10 years. Spinal News International reached out to Roger Härtl and Babacar Cisse, both instrumental in the programme’s delivery, who here discuss the importance, achievements and future of this project.

Roger Härtl performs surgery in Tanzania (courtesy Weill Cornell Medicine Neurosurgery)

A recent study in The Lancet showed that five bil­lion people do not have access to emergency or essential surgical care. According to Härtl, there is a worldwide shortfall of 23 million neurosurgeons and 14 million neurosurgical procedures. This problem is especially apparent in a country such as Tanzania which, in 2008, had just nine neurosurgeons for a population of 50 million. Ten years on, there are now 12 neurosur­geons in the country, though all save one are clustered in Dar es Salaam, and the growing population is burdening the healthcare service.

2008: Tanzania
In 2008, Roger Härtl and a small team from Weill Cornell set out to Tanzania. This inaugural trip marked the beginning of a global health project that a decade on has changed and expanded from an annual trip to include daily communication, a “self-sustaining” model that represents far more than the sum of its parts, as Härtl describes it to Spinal News International.

Tanzania was a natural starting point for Härtl, who had spent time there as a medical student and was eager to return once fully qualified. Coincidentally, he treated the President of Tanzania at the time, Jakaya Kikwete, during his residency. The following year, the president invited Härtl to Dar es Salaam. While there he visited MOI, the largest hospital in Dar es Salaam, and where the need for a neurosurgeon was “very clear”.

Härtl and his team recognised two main problems: there was a lack of infrastructure to be able to carry out the volume of surgery needed, and where surgical care was available, it was very difficult to access. Equipment was not maintained and the lack of an insurance system meant patients generally had to pay for surgery upfront.

Over the past 10 years, Härtl has been travelling back and forth to Tanzania. “Through trial and error,” he and his team are working towards building a sustainable programme between their facilities in New York and those in Tanzania.

In terms of funding, there has been an “overwhelming” response from patients and companies, some donating tens of thousands of dollars to the global health programme. It was recognised that a week-long annual visit was not the best way to reach the project’s potential, but the question remained—what was the best way to put a large amount of funding to use in a way that would maximise their impact? The solution, they realised, would revolve around education and training.

Härtl describes the project now as “self-sustaining”. The Tanzanian doctors he has trained are now organising an international meeting every year. The volume of spine cases has significantly increased over the years, but Härtl makes it clear that the number of surgeries per se is not necessarily an indicator of success. Who to operate on and what surgery to do is far more important.

2018: Senegal
In September 2018, Babacar Cisse took the programme to his native Senegal, representing the most recent addition to a project that aims to improve surgical care on a global scale.

Cisse told Spinal News International how the recent trip he made to Senegal centred around finding out what the surgical reality is there, what is lacking, and what can be done to help. He mentions how he encountered a number of “pleasant and unpleasant surprises”. Specifically, he found that “the neurosurgery programme was very well structured, the hospital he visited had a specific clinic dedicated to neurosurgery, and the surgeons were incredibly talented.” He adds that the surgeons he worked with in Senegal “taught the Cornell team what you can do with limited resources.” On the other hand, he notes how there was only a six-bed Intensive Care Unit and that the equipment and supplies available were old. “We take a lot for granted here in the USA,” he says.

On the differences between surgery in New York and Senegal’s capital, Dakar, Cisse comments that when you have limited resources “you become a different surgeon. There are things that you can do as a surgeon in New York that you cannot do in Dakar and you would end up harming a patient if you tried.”

Cisse notes how the new Senegal mission will commence on a yearly basis. As his family lives in Senegal, however, he will also perform surgery whenever he goes back to visit. He wants young neurosurgeons from Senegal to come to New York to do some training and also intends to conduct weekly meetings over Skype, both elements which have been so successful in Tanzania.

Building on the Tanzania model and an assessment of access to surgery in Senegal, Cisse aims to make Dakar a “centre of excellence.” He makes it clear, however, that this project is about far more than individual projects in Tanzania and Senegal. “This is about training the next generation of neurosurgeons,” he says. What they aim to do beyond teaching neurosurgical skills is to teach how to run a functional neurosurgical programme and how to run a neurosurgical hospital. This will take time. “Rome was not built overnight,” Cisse quotes.

Cisse emphasises that for him the project represents a two-way exchange of ideas. It was not his intention to go to Dakar and say “this is the American way” or “this is the Cornell way”. He suggests that the best way to make changes is to recognise and combine the best of the knowledge and resources both countries can offer in order to make the most meaningful impact. What matters most to him is not what either party wants to do, but what is best for the patient.

Collaboration and communication
Central to the whole project is a two-way collaboration between the surgeons at Cornell and those in the counties they visit, a partnership which Härtl believes must be based above all else on understanding. “You cannot transfer expectations and backgrounds to a system that is completely different to the one that you are used to,” he says. The doctors in Tanzania “work in a totally different system and have completely different priorities. They are underpaid and overworked.” Härtl told Spinal News International how some of his colleagues from New York would get quite frustrated at the lack of organisation, but for the most part any problems arose from a lack of communication. “That is the most important thing I learnt,” he says. “Rather than judging, let us find out what is going on.”

Both Härtl and Cisse stress the central role of communication going forward. Once a week Härtl has a 6am Skype call with his colleagues in Tanzania. Instead of going over once a year and taking with them a lot of equipment they now have a “more meaningful interaction.” This weekly call, along with multiple texts and Whatsapp messages with attendees, means they work together on a nearly daily basis now.

On a personal level, Härtl mentions the good relationships he has with surgeons in Tanzania as the most rewarding aspect of the initiative so far. He stresses the importance of trust and how valuable these relationships can be in effecting change. “It is difficult to understand the reasons behind hesitancy to adopt new methods and this process of building trust and creating partnerships is not easy,” he remarks, “but certainly worthwhile.”

Härtl tells the paper about two surgeons who have made the time he has spent in Tanzania particularly memorable. One, Isidor Ngayomela, works in Bugando hospital and the second, Nicephorus Rutabasibwa, is a spine surgeon at MOI. Härtl describes him as a “talented spine surgeon” interested in minimally invasive spine surgery—Härtl’s specialism in New York. “He picks up techniques quickly and is able to translate those into action in the limited resource setting in which he works,” Härtl praises.

Looking to the future
Härtl and his team have clear goals for the future of the project in Tanzania. Going forward they aim to help doctors they have met to train people locally and to document the current status of care.

There are at present no protocols in place, and he mentions how the limited resources available “are not always being used on patients who could really benefit”. Härtl and his team would like information like this to be documented, leading to evidence-based protocols to try to influence the decision-making process.

In addition, Härtl would like to accurately document severe traumatic brain injury, for which the current mortality rate is around 60%. He aims to implement protocols and train people to improve that figure. This will take time but they are making progress, including publishing papers and involving politicians and decision-makers in healthcare. Back in October 2018, Härtl had a “very promising” meeting with the new president of Tanzania, John Magufuli. Whether or not this connection will make a difference though, Härtl is uncertain. He believes that training and teaching at the local levels and publishing data to show the reality of the situation will be the way to make changes.

Going forward, Härtl describes tangible collaboration as the “core component” of the project. Six years ago, there was a neurotrauma meeting in Dar es Salaam involving participants across all of East Africa. The event involved two days of lectures and practical courses, followed by three days of operating together. In January 2019, Weill Cornell organised a global neurosurgery course in New York.

Another important component will be continuing to fund one trained neurosurgeon from North America or Europe to spend a year in Tanzania teaching and training. To date, two neurosurgeons, Maria Santos from Portugal and Andreas Leidinger from Spain, have each spent a year in Tanzania. Some of the donations also go towards funding surgeons and nurses from Tanzania to spend three months at a time in New York. They form an important bridge between the two facilities and act as “ambassadors and champion surgeons” of the initiative.

Talking finally about the wider significance of the project, Cisse remarks that “as a society, we have to think about what we are doing and not wait until the problem is acute and, for this to happen, priorities need to be shifted”. In his opinion, a public health campaign is important, and this has to start now at the level of the medical school.

He finds it “heart-breaking” that while we are talking about the same human beings, the only difference is on which side of the Atlantic you happen to be. “Health problems are not a reality until they hit you or a close family member,” he remarks, and “only then do you realise what the hospital does and does not have, and also how the system works.”

Cisse strongly believes that “we have a duty to make things better for future generations”. That will be the legacy that we will leave behind, he says, “and after all, a legacy is a second life”.

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