Take Home Messages from the 2015 WHO – Global Initiative for Emergency and Essential Surgical Care (GIEESC) Meeting in Geneva

A Personal Account by Dr. J. Gnanaraj

BACKGROUND

The tenth meeting of the Global Initiative on Emergency and Essential Surgical care [GIEESC] had the primary objective of deciding on the roadmap for the implementation of the World Health Assembly resolution No. 68.15 of the World Health Organization [WHO]. The author was one of the representatives from the surgical workforce from the remote and rural area among the experts and dignitaries who form the GIEESC. This article gives his perspectives of the take home message from the meeting and does not in any way represent the official view of WHO or GIEESC.


  • Each year more than 234 million surgeries are carried out globally.
  • Surgically treatable diseases are among the top 15 causes of physical disability worldwide.
  • Eleven percent of world’s disease burden is from conditions that could be successfully treated through surgery.
  • The low and middle income countries are the most affected.

GIEESC pic 1

THE MAGNITUDE OF THE PROBLEM

The surgical disease burden looks like a lot especially if the data shows that a tenth of all disease burdens could be managed surgically. Our experience in working in remote areas shows that many of the surgically treatable conditions are not diagnosed. With high tech diagnostic camps in the remote and rural areas in India over the last three decades, we found that 75% of the surgical patients were diagnosed for the first time during these diagnostic camps [1]. For example unless an ultrasound examination is carried out the patients will not know that he/she has a gall stone or kidney stone that would result in a cure if appropriate treatment is given. The implication is that the actual surgical burden is much higher than what the data indicate.
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WHAT COULD BE DONE

To plan for effective care it is very important to have the exact data about the need in rural areas. With the advances in mobile phone technology and internet it might be possible to enroll the help of all the practicing physicians in the rural areas [including the non physician care givers] in the data collection of the surgical needs in rural areas. If these healthcare providers have an incentive in recording the information and if there is a common well-advertised database to which they can easily access, it would be of great help. In addition to these diagnostic camps is a great way for diagnosing surgical conditions. We have found that people are not willing to travel more than 5 kilometer to a diagnostic center while they do not mind traveling several thousand kilometers to go and have surgical treatment if necessary.

THE HISTORY OF GIEESC

The WHO is more of a community or public health organization traditionally. Until a decade ago it had no representation for surgical work. The high specialization and cost of surgical work did not allow it to be considered as part of public health. It was with great difficulty the pioneers at GIEESC established GIEESC and made sure that at present there are six indicators relating to surgery in the list of 100 core health care indicators of the World Health Organization. Now there are about 3,000 members of GIEESC from 138 countries and the limitation is very little representation from China and Russia. Almost all the members present felt that World Health Organization is the best organization to give guidelines for surgical care. WHO should be the ultimate authority although it cannot be involved in credentialing and accreditations. WHO Recommendations on the Surgical Safety Checklist, made a very significant contribution to improving the safety in rural areas.

ADVOCACY AND WHO

The WHO feels that the primary work of the organization is advocacy. The recent effort is regarding Ketamine. WHO managed to keep it on the Essential drugs list despite the calls to take it off the list due to the recreational use in some countries. Currently in the lower and middle income countries, ketamine is used in 90% of caesarian sections and 95% procedures in trauma centers. Ketamine is cost-effective and not dependant on infrastructure, water and electricity supply and is less demanding on airway precautions. Similar advocacy might be planned for other narcotics if necessary.

The importance of antimicrobial resistance to surgical care cannot be overemphasized. The WHO advocacy is directed towards rational use of antimicrobials.

Another important advocacy of the WHO is to encourage funding to research projects targeted towards meeting the surgical needs of rural areas.

COMMENT

A look at the research trends in surgery in recent time’s show that the newer products and equipment significantly add to the cost of surgical treatment. The research is funded and directed by corporate and commercial organizations who would like to profit. With respect to the minimally invasive surgeries robotic surgeries significantly increase the cost and so do the development of flimsy disposable equipment for single incision laparoscopic surgeries. If research is directed towards Gas less laparoscopic surgeries there would be great reduction in the costs for regular and single incision laparoscopic surgeries and minimally invasive surgeries could be made available to the 90% of the patients who do not benefit from laparoscopic surgeries at present [2,3]. Teaching institutions and others should include rural surgeons in their team to direct research.

DATA COLLECTION ANALYSIS AND SHARING

Data is the key component of the way forward in safe and effective health care delivery and WHO is in an ideal situation to do the collection. It was pointed out that when the users benefit from the data and view the combined data it motivates them to use the data and contribute to it. If the data of all the patients diagnosed with surgically treatable conditions is available as soon as diagnosis is made it would help to plan the treatment efficiently and in a cost effective way. Innovative and cost effective methods of providing care are then possible [4]. Such data would also benefit sharing of human and equipment resources in rural areas.

TRAINING COMPETENCE AND CREDENTIALING

Recent evidence shows that 2.2 million trained surgical and anesthesia care providers are necessary to fulfill global surgical workforce needs. Hence the WHO recommendation is to train not only surgeons but other medical, paramedical and nursing staff to provide surgical and anesthesia care. The college of surgeons of East, Central and Southern Africa [COSECSA] is already conducting such short term training programs [5]. Clinical Officers Surgical Training [COST] is another such program that is already available [6]. WHO can develop a core curriculum as a template which could be modified according to the local needs.

COMMENT

Employing qualified and well-trained staff in rural surgical facilities is an uphill task all over the World. The turnover of patients might not be sufficient to pay for them and trained staff would prefer the urban areas rather than the rural areas. This means that most of the rural surgical facilities are manned by locally trained staff and this has many legal implications despite the fact that many of the locally trained personnel are competent. Training and giving them credentials are one of the most consistent felt needs of the rural surgeons all over the World. Task specific credentialing endorsed by WHO would go a long way in meeting this felt need [7].

THE PILOT STUDY PROPOSAL

Northeast India is an interesting geographical location. Within a short area it has mountains, plains, rivers, special areas and rain forest, etc. representing many areas in the World. The people are also very different in culture and habits and the health scenario is way behind many areas compared to the rest of the country. It would form an ideal place for pilot study about rural surgical care.

The World Health Organization can endorse a pilot study where a small team does the following:

  1. Training and credentialing
    • Gasless Lift Laparoscopic surgeries
    • Minimally invasive surgery for rural surgeons
    • Urology for rural surgeons
    • Basic Life Support [BLS] training for all staff
    • Minimally invasive surgery support staff training
      • Technical staff
      • Nursing staff
    • Anesthesia training for rural surgical facilities
      • Doctors
      • Nursing staff
  2. Data collection and standardization of rural surgical facilities
    • Details of all medical practitioners diagnosing surgical conditions
    • Details of all minor and major operating rooms
    • Details of all health care providing staff
    • Details of all surgical patients
    • Preparing the standards and requirement for rural surgical facilities
  3. Owning, renting and maintaining surgical equipment
  4. Organizing diagnostic and surgical camps
  5. Accreditations and standardization of all surgical facilities in rural areas
  6. Setting up a research facility for rural surgeons
gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

References (click to show/hide)

  1. Available from: http://mdcurrent.in/primary-care/diagnostic-surgical-camps-cost-effective-way-address-surgical-needs-poor-marginalized/
  2. Gnanaraj Jesudian. Single Incision Lift Laparoscopic Surgeries [SILLS]: Taking modern surgery to the poor. J Miss 2(3):e11465 Published online 2013 October 8 [http://minsurgery.com/?page=article&article_id=11465]
  3. Jesudian G. Single Incision Gasless Laparoscopic Myomectomy. Int J Infertil Fetal Med 2015;6(2): 84-87. [DOI : 10.5005/jp-journals-10016-1106.]
  4. Gnanaraj J, Sungtiakum Jamir. Enjoy your donations while those in need benefit: The Surgical Services Initiative. mdCurrent-India April 2015 [http://mdcurrent.in/primary-care/enjoy-your-donations-while-those-in-need-benefit-the-surgical-services-initiative/ ]
  5. Available from: https://en.wikipedia.org/wiki/COSECSA
  6. Available from: https://en.wikipedia.org/wiki/Clinical_Officers_Surgical_Training
  7. Available from: http://mdcurrent.in/practice-management/task-specific-credentialing-and-training-for-the-rural-surgical-workforce-a-proposal/

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