The Neglected Stepchild and the Future of Global Health

by David Shirk, E.D. Friends of Kijabe


Fact 1: Lack of access to surgery kills more people than HIV, Malaria, and TB combined.*

Really, it’s true. I shared this statistic with a doctor who had been working internationally for more than a decade. His jaw hung open.

“You have to share the article with me,” he said.

Honestly, my jaw dropped too the first time I saw the statistic. How is this possible? Had I been duped? I went to the WHO website, pulled out a calculator and the claim is true.

Fact 2: 5 billion people lack access to safe surgery and anesthesia.**

This is simple math — figure out by the numbers of surgeons and anesthetists in a country and measure against the population.

But this doesn’t mean that all 5 billion are queuing in line at a health facility.

Around 2.5% of any global population needs a surgical procedure at a given time. Which means some 130 million people around the globe need surgery today due for trauma, obstetrics, oncology, etc.

The problem is that most these 130 million can’t access a facility where they can queue for surgery.

The UN is aiming at a target of Universal Health Coverage by the year 2030. But there are huge gaps between the goal and funding aims of philanthropic organizations.

A conversation is needed about the “neglected stepchild of global health,” the complex health systems that go along with it, and the people who will lead the changes.

*UCSF Center for Global Surgical Studies

**Lancet Commision on Global Surgery 2030


Changing an Old Narrative


What do you picture when you hear the words Africa and Health?

Mosquito nets? Malnourished babies with distended bellies? A community dancing in front of a well pumping clean water? HIV?

Do you visualize something like the rural health clinic in the picture above?

What do the doctors and nurses in your head look like? What language do they speak?

If you want a snapshot of the old narrative on global health, Bill & Melinda Gates wrote a deliciously clever letter to Warren Buffet on how they used his $40 million donation: https://www.gatesnotes.com/2017-Annual-Letter

The Gates Foundation is finishing what it started. Eradicating polio, beating HIV into submission, realizing the vital connection between women’s literacy/rights and health, seeking to influence goverment policy.

My problem, I suppose is that funders are human, and humans tend to fall in line with the most successful people on the planet. So the majority follows Gates Foundation endeavors rather than searching out and investing in emerging needs.

I believe the future of global health is Both/And, not Either/Or.

Both community health and surgical access.

Both tackling TB and training oncologists.

Both infectious disease and intensive care.

All healthcare systems must address community health needs. We should care deeply about maternal-child health. Immunizations, education, and WASH projects are the most cost-effective health measures. Depending on surgical care to gather the broken pieces after poor treatment at the primary care level is not viable or ethical (i.e. orthopaedic surgery for an improperly set bone or a shunt due to untreated meningitis).

Hans Rosling believes the entire world could move out of extreme poverty by the year 2030 and shares compelling data and brilliant stories to back up this claim in his book Factfulness.

One passage details a haunting conversation with the president of the African union.

“Oh, yes, you talked about eradicating extreme poverty, which is a beginning, but you stopped there. Do you think Africans will settle with getting rid of extreme poverty and be happy living in only ordinary poverty?” – Nkosanza Dlamini-Zuma

If Rosling is correct — and I think he is — what happens in 2031, the year after extreme poverty ends?

In the year after, I think African must healthcare include both robust primary care and networks and specialization of medical and surgical services.

I think health in 2031 Africa is much more robust than mere universal basic coverage. I think it will look remarkably like 2031 in your neighborhood.

Free-flap surgery, procedure in which the tibia is removed from the leg and to replaces a jaw-bone excised due to a tumor. Dr. Chege Macharia and Dr. David Nolen from Kijabe and Dr. Bob Sinard from Vanderbilt work together on this case.


Seeing Global Surgery


Excellent surgical care involves a complex multidisciplinary web of local, regional, national, and international stakeholders and necessitates long-term commitment involving:

  • Training of not only of surgeons, but also nurses, scrub techs, anesthetists, emergency & critical care doctors and nurses.
  • Anesthesia machines, theater lights, intensive care beds, and ward space.
  • Electrical supply, clean water, medical gases, waste processing.
  • Medical equipment suppliers, service contracts, and bio-med repair capability.
  • Laboratory and diagnostic services, blood bank access.
  • Low-tax equipment imports and locally manufactured supplies.
  • Insurance schemes, with a goal of Universal Health Coverage.

Imagine your local hospital two decades ago. Or visit a rural American facility today. You would have a pretty good picture of what is possible at a Kenyan referral hospital.

Then add a waiting room with 400 patients, half on crutches or in wheelchairs.

The infrastructure is in place, but the needs are great.

How do 5 billion people have access to these resources?


Moving Beyond Zero


I recently purchased an Inside Philanthropy database of the 8,000 major foundations and individual philanthropists in the United States.

I searched the list for funders of global surgery initiatives.

Zero listed.

The usual options are there. WASH (Water & Sanitation for Health), maternal-child health, Malaria, TB, HIV, HIV, HIV, HIV, HIV.

I know that zero is not completely true. Tim Tebow built a hospital for CURE International in the Phillipines. USAID funded an opthalmology center at Tenewek, another mission hospital in Kenya. The GE Foundation is doing meaningful, often under-the-radar projects in medical education, including the IMPACT4Africa anesthesia project.

But the fact remains that surgery, let alone global surgery, is not even on the searchable list shows a tremendous bias toward the old narrative, not to the future.


Considering Equality


A revised narrative on African health care should be based on equality.

Do we believe that all humans have the right to life, liberty, and happiness?

Do we believe that healthcare is a fundamental human right?

The World Health Organization drafted a constitution seventy years ago, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human. . .”

The highest attainable standard of health in Kenya and many other African nations is now remarkably close to that of America.

The needle has moved, and our thinking should move with it.


Thinking About Real Stories


I receive a phone call from the orthopaedic surgery resident.

“There is a patient in Naivasha. If he stays at the district hospital, his leg will be amputated. If he comes to Kijabe, we can save his leg. . .but we need funding. His friends brought him, but they have no money.”

I visit the patient. Same age as me, shares my name.

David.

Later, I ride my mountain bike into the hills above Kijabe.

I imagine my leg is amputated.

I attempt to turn the pedal with a phantom foot, nothing happens, and my momentum halts.

I roll backwards, out of control down the steep mountain road.

David is a neglected persona when funders look at the continent: a 20–50 year old male in need of a surgical procedure.

If David is healthy and mobile, he can work and provide for his family. He can pay for his children’s food, healthcare, and school fees.

If he loses his leg, he loses employment, income, and the ability to provide for his family. If the surgery costs $700 and restores thirty years of health to a young man, he will make 20–30x that amount over his working lifetime.

How do we provide access and affordability for people in this neglected category?

Proportion of population without access to surgery — Lancet Global Surgery 2030 Report


Deciding Our Role


I am executive director of Friends of Kijabe, a US-based nonprofit doing fundraising work for needy patients in Kijabe.

What is my obligation when I get the phone call that David needs help?

I must be very sensitive to the fact that despite the fact that despite my job description, the burden is not solely on me.

Maybe the most important question to ask in all international resource mobilization work:

What would happen if I were not here?

The burden is first on the society and the systems in place at a local and national level.

I call my all-Kenyan team and ask their input. We speak with the surgeons. We discuss options of debridement and delay so that David might be placed on national health insurance — a plan without restrictions for pre-existing conditions. Is there no possibility for help at a government facility where costs are lower? How could the family and community be involved? Who brought him to the hospital?

We make a decision together.

It turns out that good debridement is all that David needs, not the complex surgery. The best outcome we could have hoped for.


Ending the Government Corruption Myth


The government is the largest provider of specialized health care in Kenya. NHIF — national health insurance available for Kenyan citizens — funds close to 50% of patient care at Kijabe Hospital, a private non-profit facility. Government funding assistance is much higher for national hospitals.

The Kenyan Medical Practitioners board also pays the salaries for 20+ medical officer and clinical officer interns each year for training, a huge boost to Kijabe’s clinical capacity, and a tremendous benefit to the country as they graduate and go on to serve in county postings.

While the old narrative of the corrupt African government may not be fallacy, it is not absolute truth.

Any advances toward specialized surgical care will need either government involvement, or at minimum government permission.

At least in Kenya, the government is seeking to help.


The Role of NGOs


The Kenyan government will not meet the healthcare needs of the nation alone. Neither will the American government for that matter.

Non-profit and educational/philanthropic institutional partnerships are vital to the advancement of priorities in virtually every health system in the world.

To highlight one organization doing great work on our continent, PAACS, the Pan African Academy of Christian Surgeons has trained 100 surgeons across the continent in the decade after its inception.

Funding for the trainees is subsidized jointly through PAACS and the sponsoring African mission hospital.

After training is complete, the surgeon will serve at a mission hospital in his or her home country for a bond-period equal to the amount of training, usually 5 years.

The PAACS model is turning out significant numbers of highly-qualified surgeons, making a serious effort to place them in rural hospitals proximate to the greatest need.

Is this this a perfect model for sustainability? Probably not.

Training is costly for the sponsoring hospital, and the willingness to stay in remote areas is a challenge for surgeons seeking employment opportunities for a spouse and quality education for children. Hospital infrastructure and funding for vulnerable patients are hurdles to overcome.

But if we wait to have all the answers, we will never start to address the problems.

I predict PAACS will make a lot of progress in the next twenty years before the world wakes up.

Dr. Beryl Akinyi, PAACS graduate, teaching a Medical Officer intern the correct positioning for suturing.


Dreaming Together


There are fifty four African countries. What would it mean to dream with these already-existing countries themselves? What would it mean to dream with Mozambique, Sudan, Togo, or Libya, and think about their politics in all their hectic complexities? What would it look like to use that as a narrative frame? Teju Cole from the Blackness of the Panther

I speak with surgery and anesthesia residents as they arrive at Kijabe from Sierra Leone, the Democratic Republic of Congo, Mozambique, Madagascar, Ethiopia.

They are brilliant, they are talented, they will be tremendous leaders.

But a two-theatre expansion of the operating complex at Kijabe hospital would cost $140,000 USD. $30,000 for theatre lights. $20,000 for operating tables. $60,000 for building materials. $30,000 for anesthesia machines and other equipment.

How do we fund the beautiful dream with African doctors: to provide world-class surgical services in their own communities?

The investments is not astronomical, but it is a real commitment and needs myriad partners locally, nationally and internationally.


Choosing New Heroes


Do you remember the Time magazine cover back in 2005, when Bono was sandwiched between Bill and Melinda Gates under the label “persons of the year?”

That year, thanks to action of the persons of the year, president W. Bush and the U.S. congress took substantial action on providing antiretroviral drugs to sub-Saharan Africa through a program called PEPFAR that is still providing essential medicines for patients in Africa today. A massive success.

I was a huge U2 fan and I credited Bono as the hero.

I recently met a very different looking hero, Dr. Philippa Musoke, pictured above with my wife.

In the mid-1990s, Dr. Musoke discovered that an oral dose of Nevirapine given to both mother and child could reduce the transmission rate of HIV by 50%.

Officially she is listed as a co-principal investigator on the clinical trial partnership between Makerere University in Uganda and John’s Hopkins.

Unofficially, she is superwoman.

Later, Dr. Musoke worked on a defense of the research methods used in the FEAST trial, a remarkable study that measured the effects of fluid bolus on East-African children in shock.

The trial was conducted in rural settings, but the results have held true on hundreds of patients at Kijabe by the Pediatric Emergency Medicine and Critical Care teams and the guidelines are standard of care in Kenya.

We all know Bono and Gates, but how many have heard of Musoke?

The new narrative must include true stories of African heroes, not only rock-stars on magazine covers.


Finding a Way Forward


How do we expand the narrative on global health from the past of community health/infectious disease to include a future of specialized surgical and ancillary health care?

How do we move beyond zero among major U.S. philanthropists for global surgery, anesthesia, oncology, and critical care programs?

I recently challenged a group of international surgeons: The most significant challenge you have is to make your work and your mission known to people outside of this room.

The Lancet Commission on Global Surgery published ground-breaking research in 2015 about the need for global surgery.

The G-4 alliance was subsequently formed to advocate for investment in global surgery and anesthesia.

Both should be remarkable, but neither has made significant inroads into broader public discourse.

They need to reach hearts.


Action Steps


What can you do to change the narrative on African health care?

  • Spend time in Africa. Change does not happen over email, it takes years of partnership, hard work, and trust. Go to Kenya, Nigeria, or Cameroon. Do homework on a facility that would be good fit for your skills and spend two weeks on a vision trip, getting the feel for a hospital with the goal of developing a long-term relationship with the providers.
  • Dream with Africa, not for it. What are the doctors seeing? What are their challenges? Where are they making advances? Do not fall in the trap of planning change in Africa from a board-room in America.
  • Invest for the long-term. Creating training program will take a minimum of 7 years assuming necessary infrastructure is already in place. A tipping point of success may take a decade or more.
  • Focus on training leaders. The massive benefit of the five-year PAACS surgery training program at Kijabe is the focus on surgeon-leaders. Look to invest in programs that focus on both medical skill and leadership development.
  • Share your discoveries. Read, travel, learn, grow, and share. Keeping the discourse on the most urgent needs in the developing world confined to academic medical journals is shortsighted. Post an op-ed at your local newspaper. Give a talk to your medical institution on the realities of global health. Tell about African heroes.
  • Give. Find an organization doing good work and support them regularly. Friends of Kijabe provides support for specialized training programs and subsidizes surgeries for vulnerable patients — this funding all comes from individual donors. Similar organizations exist to support the work of countless African mission hospitals. Until philanthropic funders start to see the future, the needs will only be met with the involvement of generous individuals.
  • Study. The latest WHO information on global surgery is from 2012, studies on global surgery access are desperately needed.
  • Ask others to invest. Host a fundraising event for a charity supporting surgery/anesthesia/crital care. Petition your H.R. director to offer an employer match for global health contributions. Ask a charity you support to offer support for medical training or needy patient funding.
  • Remember storytelling. If you win a research grant, devote 1% of the budget to hiring a photographer and writer. Who are the doctors involved? What great work are they doing? Go beyond publishing in a health journal. Share true stories with the wider world. Change the narrative.

Additional Reading

WHO HIV Information — 36.7 million infected, 1 million deaths in 2016

WHO TB Information — 10.7 million cases, 1.7 million deaths in 2016

CDC Malaria Information — 216 million cases, 450,000 deaths in 2016

Lancet Global Surgery 2030 Report — 2010 statistics: 16.9 million deaths due to lack of access to surgery, 1.46 HIV/AIDS, 1.2 TB, 1.7 Malaria.

WHO Size and Distribution of the Volume of Global Surgery in 2012 — last available surgical data. Useful comparison is number of surgeries per 100,000 population.

Global Surgery and Anesthesia, The Importance of Data Collection — G4 Alliance report on need for global surgery statistics and recommendations on a way forward.

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