Accepted Manuscript Surgical Education and Global Health: Call to Action Mary Ann Hopkins, MD, MPhil PII:
S0002-9610(14)00575-3
DOI:
10.1016/j.amjsurg.2014.10.007
Reference:
AJS 11344
To appear in:
The American Journal of Surgery
Received Date: 28 October 2014 Accepted Date: 30 October 2014
Please cite this article as: Hopkins MA, Surgical Education and Global Health: Call to Action, The American Journal of Surgery (2014), doi: 10.1016/j.amjsurg.2014.10.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Abstract: As this is a presidential address, I don’t believe an abstract is necessary as there have been none in the prior years
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Surgical Education and Global Health: Call to Action Mary Ann Hopkins, MD, MPhil NYU School of Medicine 530 1st Avenue, Suite 6C
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New York, NY 10016 212-263-7302 [email protected]
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Keywords: global health, surgical education, surgical burden of disease, humanitarian
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surgery
In planning this presidential address, it was clear from the start that it would revolve around global health and surgical education. These are the themes that have guided my career. To me, surgical education and global health are intimately intertwined and are the imperatives for which I live my professional and personal life. The deep needs and unnecessary suffering that I have seen during my life have driven me to work for the
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past 18 years with Doctors without Borders and to create online, easily scalable and accessible educational materials for surgical education. This focus has given me the deepest satisfaction I have gotten from my career in medicine.
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In 2008, Dr Paul Farmer, a noted figure in humanitarian medicine and one of the founders of Partners in Health, wrote in the World Journal of Surgery1 that one of the
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reasons that surgery in global health has been neglected is “that only now are significant numbers of surgeons involving themselves in such matters. We need the support and attention of surgeons if progress is to be made.”
I am a surgeon who has been involved global health for almost twenty years, and I agree with Farmer in this: we do need to galvanize and to push for the recognition of surgery 1
Farmer P and Kim J. Surgery and Global Health: A View from Beyond the OR. World J Surg. Apr 2008; 32(4): 533–536.
1
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as a critical component of global health. And we, members of the Association of Surgical Education, are uniquely poised to make an even bigger impact with our expertise in the education of surgery, which, in my mind, is the most pressing need and where the most
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wide reaching impact can be made.
The world has changed so much in the last 20 years. The rapid development of
information technology and the Internet has been revolutionary in how we are able to communicate, transmit information and, yes, teach. Right now, we are experiencing one
SC
of the few eras of true democratization of knowledge, similar to the explosions of
knowledge that occurred after the developments of the first simple alphabet, Ancient
M AN U
Greek, and the printing press which allowed wide spread dissemination of texts.
At the same time, natural and manmade disasters due to climate change; food scarcity; the constant onslaught of natural disasters; and armed conflicts and civil unrest have escalated to an alarming degree and permeate every aspect of our lives. Traditionally, global health in low and middle-income countries has focused primarily on
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communicable diseases such as HIV, malaria and tuberculosis, which are the three diseases that profoundly affect global mortality. The dominant funding sources such as the President’s Emergency Plan for AIDS Relief (PEPFAR), the Gates Foundation, the Global Fund, and the Clinton Foundation among many others spend billions per year. By
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far the majority of funds focus on the prevention and treatment of these communicable diseases, and there is very little emphasis either on surgery or education in the
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humanitarian aid world. A notable exception is the Clinton Foundation, which includes as part of its vision the importance of expanding the capacity of national human resources.
What motivated me to become a surgeon in the first place? I believe that what motivated me to go to medical school is what motivated all of us. I wanted to help people and fix the injustice of the world! This is where I was going to insert a quote from my medical school application essay, but since that was too difficult to find, I asked my
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medical students to share some of theirs. I think we will all see our younger selves in these quotes.
One of my fourth year advisees, Molly Anderson, now an internal medicine intern at the
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University of Washington, Seattle, Washington, wrote "when I was young, I wanted to cure a disease. But, now I realize that, for me, being a doctor is about more than curing a disease; it’s about healing a community. In a few days I am returning to Africa as a
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volunteer, but I hope one day to return as a doctor."
Polina Krass, a second year student, hopes that: “my commitment to creative,
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transformative solutions will allow me to make a meaningful impact on the lives of my patients and on the way that healthcare is delivered across the globe.”
Finally Andrew Hallet, a first year medical student, described his perception of humanitarian medicine in this way. “For practitioners who feel compelled to work among the poor and underserved, medicine transcends this already noble pursuit to
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become something even more profound. In such hands it becomes an enacted belief in human equality and health care as a fundamental human right.”
My own path to medicine is pretty roundabout. I was a Latin major as an undergraduate
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and then went on to get a Masters Degree in the History and Philosophy of Medicine. I had read about head injuries in the Edwin Smith Papyrus and I read the Hippocratic
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Corpus in the original so knew all about the essential four humors--you know, blood, yellow bile, black bile and who could forget phlegm. I figured not much ever changes in medicine--it was a logical step from old school to new school medicine. Oh wait a minute isn't medicine that discipline where 90% of what we know today is obsolete in 10 years?
Actually, what had really motivated me to go into medicine was not so much the fact that there were few jobs in ancient medicine, but what I had done during my summers in college. My younger sister and I volunteered, through an organization called “Families for Children,” in a remote orphanage in India in 1982 and 1983 and in a refugee center in 3
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Somalia in 1984. Although neither country was dangerous at that time, it seems a little crazy, given that my sister and I were 16 and 19 respectively that first year.. But it was a stroke of genius on the part of my parents who had encouraged us to go. My sister and I learn so much about human suffering and social injustice. Our eyes were irreversibly
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opened to the striking disparities between our life in the United States and the realities of poverty and life in low-income countries. It was also there where I had my first true experiences with illness and health care.
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During the second summer in India my sister and I lived in the special needs house with children who had physical and mental disabilities. I would hold and soothe a young girl,
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whose name I no longer remember in my arms. She had a massively distended abdomen, spindly legs and arms, and was as fragile as a porcelain cup. I'm sure she did not survive long after we left that fall. But holding her in my arms, feeling her head on my shoulder, and seeing her smile even briefly made me realize that any kind of care I could give people was so much more important and gratifying than anything I'd ever experienced before. On another occasion, I took a deathly ill girl on my lap in the back of an auto
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rickshaw to the hospital. I sat holding her hand though she was barely conscious as the doctors made a cut with a scalpel in her ankle. There was no blood, the cut and the tissues underneath were pure white. In retrospect I can guess she must have been in septic shock and the physicians were trying to do a cut down to get venous access to
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resuscitate her. But I knew none of that then. She died later that night, and we carried her body back to the orphanage in our arms for its proper burial. It was experiences like
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these that made me realize that I had to go become a physician.
During my fourth year of residency I picked up a brochure from Doctors Without Borders, gave them a call, and after a short interview I was accepted. This was in 1996 and they were just beginning to have a presence in the United States and to develop their now formidable reputation. It would be three years until they won the Nobel Peace Prize in 1999, which happened during my second mission with MSF in Burundi. I had to convince my department chairman, Dr. John Daly, that it was a reasonable and sensible plan to do an elective in Sri Lanka. Sri Lanka was in the middle of a long and drawn out 4
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civil war that left close to 100,000 dead over 27 years and the town I was in, Batticaloa, was in the middle of the action. The experience was transforming. I have spoken in the past here, at the American College of Surgeons clinical congress as well as at medical schools, colleges and high schools throughout the US about my experience there. Some
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of you may have heard me speak about what a life altering experience it is to be working in a remote part of the world in a conflict zone with minimal support and technology. It fundamentally changed how I approached medicine and what I saw for myself in the future. Since then I have worked with MSF in Burundi in 1999, twice in the Democratic
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Republic of Congo, in Chad, and then later in Haiti after the earthquake. Some of the brutality I saw included children mutilated by machetes as they tried to flee to the safety
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of UN protected camps and infants shot at point blank range such as a 2 year old girl who died 12 hours later of multiple intra-abdominal injuries all because her mother tried to resist her rapists and murderers.
Although the horrors of war and the brutality of some of the injuries that I saw were truly mind blowing, what struck me the most in each and every one of the missions that
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I've done, is the destruction to the educational system and its profound effect on local physicians and surgeons still in the process of their education. In Sri Lanka I was considered the teaching attending for the house officers training there, even though I was myself a fourth year resident. It sometimes felt like the blind leading the blind. In
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Burundi I was one of two physicians. The other was the medical director of the hospital, Jean Baptiste, had only finished his medical training as a general practitioner two years
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earlier. He asked to scrub on every major case so that he could learn as much as he could. Later, in the Congo, when the possibility of an emergency evacuation was likely, I made sure the nurses, already comfortable with routine C-sections, became proficient in more complex cases. Out of necessity, I would go into “clerkship director overdrive mode” and start intensively teaching suturing, minor and occasionally major surgeries including bowel resections, skin grafts and C-sections and the like to any and all health professionals. During the earthquake in Haiti in 2010, the local school of nursing was completely decimated, killing virtually all of the students who were in class inside. Everyone in Port-au-Prince was affected by the quake. The health care workers who did 5
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survive and were not injured themselves, had to deal not only with the overwhelming numbers of casualties, but with their own post-traumatic stress from having so many of their families and friends killed and their homes destroyed. The memories of these learners whose lives were lost, or who lived in volatile environments with no
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educational structure still haunt me.
Whenever I start to worry about our Liaison Committee on Medical Education (LCME) or Residency Review Committee (RRC) site visits and all the minutiae of work they require,
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makes our medical educational system so strong.
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I realize how lucky we are to have such structure, on top of personal safety. It’s what
Data from the World Bank shows the not surprising parallels between national per capita income (Figure 1), per capita health care expenditure, mortality from road traffic accidents, and the number of physicians per 100,000 people (Figure 2). The similarities of these maps highlight the difficulties of medical care in Africa and to a somewhat lesser extent Asia. Data From the United Nations Development Program published in 2007
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showed that of the 30 countries with the lowest ratio of physicians to the population, all but four were in Africa (Table 1).
This type of data from the World Bank is easily accessible in a quick Google search.
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However, getting a grasp on the prevalence of surgically treatable diseases is much harder to quantify. I don’t need to convince anyone of the importance of surgical
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interventions in low-income countries. Surgery has the potential to cure many and prevent loss of productivity due to disability or death. It is also clear that when these statistics talk about physicians per 100,000, what that means is general practitioners such as Jean Baptiste, and NOT specialists like surgeons. In his presidential address to the American Association of Thoracic Surgery in 20012, James Cox cited research by Professor Felix Unger, from Austria. Unger published the results of a remarkable worldwide survey that clearly defined the magnitude of the differences in cardiac care in 2
Cox JL. Presidential address: changing boundaries. J Thorac Cardiovasc Surg. 2001 Sep;122(3):413-8. 6
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developed versus underdeveloped countries. Cox noted, “each cardiac surgery center in North America serves approximately 120,000 people which is approximately the size of Durham, North Carolina. In Europe and Australia, each center serves a population of approximately one million people, or a larger city roughly the size of Columbus, Ohio. In
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Asia, there is one center for every 16 million people equivalent to the size of Los Angeles and the surrounding counties. In Africa, each cardiac surgery center serves approximately 33 million people.”
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It turns out that defining a surgical disease is very complicated. In 2006, a task force commissioned by the World Bank published a manuscript called Disease Control
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Priorities in Developing Countries3 Chapter 67 was entitled Surgery and was co authored by Haile Debas, et al. They defined surgical diseases as any condition that “requires suture, incision, excision, manipulation, or other invasive procedure that usually, but not always, requires local, regional, or general anesthesia.”
Gathering statistics is always a daunting task in the best of circumstances. Data,
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especially from developing countries, is often sparse and inconsistent. The reports put out by the World Bank and the World Health Organization, or WHO, sometimes must rely on sophisticated statistical modeling and not actual hard data. Local institutions such as the Ministry of Health and other nongovernmental organizations may not have
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the money, skills or human resources to compile accurate health statistics.
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Obvious surgical diseases, such as traumatic injuries and hernias are pretty straightforward to identify, but other surgical diseases such as peritonitis or cancers may not be recognized or classified as such. Without ancillary studies, diagnosis is difficult, and without routine autopsies, confirmation can be close to impossible. Even meeting those very simple criteria for classification is not straightforward. A fascinating study by Reinou Groen et al entitled “Untreated surgical conditions in Sierra Leone: a 3
Debas H, et al. Surgery. In: Jamison D, ed. Disease Control Priorities in Developing Countries, 2nd ed. Oxford University Press and The World Bank, 2006. p 1245-1280.
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cluster randomized, cross-sectional, countrywide survey” was published in the Lancet in 2012.4 The authors used cluster sampling to try to quantify number deaths that surgery would have been potentially cured and the number of patients with illnesses where a surgical consultation may have been warranted. They asked subjects to identify
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household members who had died over the previous year and whether they had
experienced any of the following in the week before their death: abdominal distension or pain; bleeding or illness during childbirth; injury; (a mass, growth, or swelling); an
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acquired deformity; or a wound not due to injury or congenital deformity.
The top ten causes of death in low-income countries were published in 2007 by the
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WHO.5 Although 50% of the list comprised of infectious diseases, the top killer, not surprisingly, was “coronary heart disease.” Perinatal conditions, cerebrovascular disease and road traffic accidents were, 4th, 5th and 10th respectively. Surgery plays a crucial role in all these conditions. The need to develop robust surgical programs including in surgical specialty programs is clear. And for roughly every traumatic death there are 50 times that number who are injured or permanently disabled. Data from the
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World Bank and WHO found that the poorest 35% of the world population receive only 3.5% of all surgery undertaken worldwide. 6
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Another compounding factor is the so-called “brain drain” caused by the diaspora of physicians from developing countries which has placed a huge burden not just on the
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health care system but on the medical education system as well. The irony is that lowincome countries often cover the cost of medical education, only to have those doctors 4
Groen RS, Samai M, Stewart K, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet 2012 Sep 22;380 (9847): 1082-7. 5 WHO Fact sheet N° 310 / February 2007, http://www.who.int/mediacentre/factsheets/en/ Fact sheet N° 310 / February 2007, http://www.who.int/mediacentre/factsheets/en/ 6
Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet 2008: Jul 12;372(9633): 139-44.
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pilfered by much richer countries due to shortages of healthcare workers in their own countries. The financial loss from training these physicians is compounded by the loss of highly intelligent human capital. Estimates show that more that 25% of all African countries had at least 50% of the doctors born in that country living abroad in the year
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2000. Physicians in low-income countries are rarely paid commensurately compared to their counterparts in developed countries. Many physicians working in publicly run hospitals and universities must supplement their income by seeing private patients. This strain on their time leads to the erosion of both patient care and teaching. And we all
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know, teaching alone doesn’t pay as well as clinical activities anywhere. These tensions are often untenable in low and middle-income countries. But the brain drain is not
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purely economic. Additional factors include the lack of opportunities for professional development and the lack of access to new and advanced medical techniques and technologies. Each and every one of us wants to give our patients the most advanced care. The situations I personally found most anguishing were when I lost patients I
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would have easily saved at NYU.
Article 25 of the Universal Declaration of Human Rights, created in 1948 after World War II7, states that everyone has the right to medical care, just as they do to food, clothing and shelter, and that should include surgical care. The problem is daunting but I
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now.
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feel we are up to the task, and must start making inroads in tackling this great need right
The ASE is an organization that I am immensely proud to be a member of. We truly represent cutting edge surgical education at all levels and our members are the world leaders in education. Our expertise lies in creating curricula, designing novel often low cost or easily replicable teaching tools, and validating teaching methodologies. Every year, I hear of some new innovative app or low cost simulator that would cost nominal amounts if we made them available to low-income countries. Each one of these areas of 7
The Universal Declaration of Human Rights: www.un.org/en/documents/udhr/index.shtml 9
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expertise can be used to both improve and expand surgical education in low and middleincome countries. I suggest that we make the ASE resource section on our webpage more robust and complete. We must become the repository for educational materials in surgery. Moreover, we should offer whatever we can to low-income countries free of
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charge and consider reduce fees for middle-income countries.
Currently, the clerkship and curriculum committees are collaborating to create the
definitive clerkship curriculum and standards. The ASE-ACS Core Curriculum in Surgery
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is in its final planning stages. We have also collaborated with the ACS, to create the ASEACS Skills Based Simulation Curriculum, and with the college and the Association of
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Program Directors in Surgery (APDS) to create the Resident Prep Curriculum for forth year students, among other curricular initiatives. Other educational tools that ASE members have created include the PowerPoint modules8 and WISE-MD9 both of which are innovative tools to supplement traditional educational activities.
The WHO does have some surgical educational modules out there for which they charge
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a scaled fee, but when you compare them to what our members have created, they pale in comparison. We should advocate to have educational materials made available to universities in developing countries. But we need to go further. I think we should actively “push” these tools to medical schools and training programs in low-income
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settings by reaching out in a more systematic fashion. As our on line presence grows, we can also use our Facebook page and twitter accounts to reach out and distribute
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educational materials.
Some of your home institutions have become leaders in massive open online courses (MOOCs). Medicine is gaining visibility in these endeavors. We, as individuals and as a group, can look at how we can add content and courses ourselves. When I skimmed through two of the most popular MOOCs, Coursera and EdX, their medical catalogues were pretty minimal– a couple of basic science and global health courses. If your 8 9
ASE PowerPoint Teaching Modules: www.surgicaleducation.com/teaching-modules WISE-MD.med.nyu.edu 10
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university is actively working in this arena, I urge you to push your fellow program and clerkship directors to have clinical courses represented as well. Creating content for clinical education is a very new and exciting field, and will have the added benefit of
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allowing your creativity and knowledge to feel no bounds.
As individuals, truthfully, we can do significantly more without much extra effort or time commitment. We can ensure that global health is taught not just at the medical student level as the LCME requires, but at a resident level as well and that this curriculum
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includes the importance of surgery in global public health.
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Attending global health conferences regionally, nationally or even internationally is something that I would urge you all to do. Many of your schools, or schools in your area, hold conferences on global health. Although surgery may not be on the agenda, you will not only learn a great deal, but you will show that surgeons support of global health efforts by your very presence. You may even meet future colleagues or collaborators for
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new projects.
If you are someone, who in hearing my talk today, decides to take that leap and spend a week, a couple of months, or a year working in a low income country, I guarantee it will change how you view the world and how you view yourself as a surgeon. A good place
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to begin searching for opportunities is Operation Giving Back10. This is one of the more impressive initiatives of the American College of Surgeons. It was started in 2004 under
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the incredible leadership of Dr. Kathleen Casey. Operation Giving Back was set up in response to a study done by Drs. Andrew Warshaw and Robert Stephens that looked at the interest in volunteerism among residents and practicing surgeons11. The response was overwhelming. Operation Giving Back has developed into a robust search engine and tool for medical students, residents, and physicians planning on doing humanitarian
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www.operationgivingback.facs.org/
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www.facs.org/about/governors/phase3givingback.pdf 11
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work. I urge you all to visit this site if you haven’t already, and to steer medical students and residents who are interested to it as well.
If you go on a surgical mission, think of bringing a resident with you. They will be able to
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count the cases that they do in their resident case log! In a remarkable turn of events the RRC and Accreditation Council for Graduate Medical Education (ACGME) finally
approved international rotations for credit for residents in 2011. I will never forget Dr. John Tarpley during Surgical Education Week in Toronto in 2007 when he was the
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president of the APDS. During the “alphabet soup panel”, he got up and relentlessly demanded why the RRC, the American Board of Surgery and the ACGME would not
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validate international rotations for residents. We owe a great deal to those educators like Dr. Tarpley for their relentless efforts and insistence on seeing this important initiative become a reality.
One of the most important things that we can do as individuals is to help our medical students and residents to do some type of international work and validate these
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educational experiences. Doing so not only imparts the importance of global public health but also will show them the value of education and training of local doctors. Two weeks ago I taught a seminar on road traffic accidents in a third year global health elective. At the end of the session I asked them what message they wanted me to bring to
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this august body of leaders in education. All of them had participated in international programs with NYU’s International Health Program and citied it as one of the most
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pivotal learning experiences in their medical education. They wanted me to ask you all to look on their experiences as serious-minded and legitimate work the way you would look on a summer spent doing bench research which they feel is looked on as almost a right of passage. The “publish or perish” environment in which we live has already trickled down to them, so early in their careers. It is the rare surgeon who can incorporate the basic science work that he did during medical school into his professional career. However insight into humanity and into your own culture, a deeper understanding of all cultures, customs and religions, and the importance of humanism and humanitarian outreach can be instantly incorporated. 12
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Many of you, if you haven’t already, are going to move into positions of prominence. Yes, I'm looking at all you current and future chairmen and deans! I urge you to consider the validity and importance of international experiences and educational outreach and work
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to support education in medical schools and departments of surgery throughout the developing world however you can. Please support your residents and faculty who do desire to go abroad, even if it is not an easy sacrifice for the department. Support them academically as well as financially. I cannot stress the importance of this enough. I hope
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my talk today and my passion for global health and surgical education has inspired you in some way to change even if it’s just a little bit. The time is now for academic surgeons
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to take lead in Surgical Education and Global Health!
I want to close now by thanking my family and especially my father, Dr. Robert West Hopkins, who is also a surgeon and educator, who retired from Brown where he taught for almost 40 years. He turned 90 this year and has taught me so much in terms of integrity, honesty, and commitment to patient care and education that I only hope I can
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impart to my students in the years to come. Thank you.
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Figure 1: Country Income Groups World Bank, 2011
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Figure 2: Number of Physicians per 100,000 WHO, 2008
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Mary Ann Hopkins, M.D.
S0002-9610(14)00575-3
DOI:
10.1016/j.amjsurg.2014.10.007
Reference:
AJS 11344
To appear in:
The American Journal of Surgery
Received Date: 28 October 2014 Accepted Date: 30 October 2014
Please cite this article as: Hopkins MA, Surgical Education and Global Health: Call to Action, The American Journal of Surgery (2014), doi: 10.1016/j.amjsurg.2014.10.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Abstract: As this is a presidential address, I don’t believe an abstract is necessary as there have been none in the prior years
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Surgical Education and Global Health: Call to Action Mary Ann Hopkins, MD, MPhil NYU School of Medicine 530 1st Avenue, Suite 6C
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New York, NY 10016 212-263-7302 [email protected]
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Keywords: global health, surgical education, surgical burden of disease, humanitarian
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surgery
In planning this presidential address, it was clear from the start that it would revolve around global health and surgical education. These are the themes that have guided my career. To me, surgical education and global health are intimately intertwined and are the imperatives for which I live my professional and personal life. The deep needs and unnecessary suffering that I have seen during my life have driven me to work for the
TE D
past 18 years with Doctors without Borders and to create online, easily scalable and accessible educational materials for surgical education. This focus has given me the deepest satisfaction I have gotten from my career in medicine.
EP
In 2008, Dr Paul Farmer, a noted figure in humanitarian medicine and one of the founders of Partners in Health, wrote in the World Journal of Surgery1 that one of the
AC C
reasons that surgery in global health has been neglected is “that only now are significant numbers of surgeons involving themselves in such matters. We need the support and attention of surgeons if progress is to be made.”
I am a surgeon who has been involved global health for almost twenty years, and I agree with Farmer in this: we do need to galvanize and to push for the recognition of surgery 1
Farmer P and Kim J. Surgery and Global Health: A View from Beyond the OR. World J Surg. Apr 2008; 32(4): 533–536.
1
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as a critical component of global health. And we, members of the Association of Surgical Education, are uniquely poised to make an even bigger impact with our expertise in the education of surgery, which, in my mind, is the most pressing need and where the most
RI PT
wide reaching impact can be made.
The world has changed so much in the last 20 years. The rapid development of
information technology and the Internet has been revolutionary in how we are able to communicate, transmit information and, yes, teach. Right now, we are experiencing one
SC
of the few eras of true democratization of knowledge, similar to the explosions of
knowledge that occurred after the developments of the first simple alphabet, Ancient
M AN U
Greek, and the printing press which allowed wide spread dissemination of texts.
At the same time, natural and manmade disasters due to climate change; food scarcity; the constant onslaught of natural disasters; and armed conflicts and civil unrest have escalated to an alarming degree and permeate every aspect of our lives. Traditionally, global health in low and middle-income countries has focused primarily on
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communicable diseases such as HIV, malaria and tuberculosis, which are the three diseases that profoundly affect global mortality. The dominant funding sources such as the President’s Emergency Plan for AIDS Relief (PEPFAR), the Gates Foundation, the Global Fund, and the Clinton Foundation among many others spend billions per year. By
EP
far the majority of funds focus on the prevention and treatment of these communicable diseases, and there is very little emphasis either on surgery or education in the
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humanitarian aid world. A notable exception is the Clinton Foundation, which includes as part of its vision the importance of expanding the capacity of national human resources.
What motivated me to become a surgeon in the first place? I believe that what motivated me to go to medical school is what motivated all of us. I wanted to help people and fix the injustice of the world! This is where I was going to insert a quote from my medical school application essay, but since that was too difficult to find, I asked my
2
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medical students to share some of theirs. I think we will all see our younger selves in these quotes.
One of my fourth year advisees, Molly Anderson, now an internal medicine intern at the
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University of Washington, Seattle, Washington, wrote "when I was young, I wanted to cure a disease. But, now I realize that, for me, being a doctor is about more than curing a disease; it’s about healing a community. In a few days I am returning to Africa as a
SC
volunteer, but I hope one day to return as a doctor."
Polina Krass, a second year student, hopes that: “my commitment to creative,
M AN U
transformative solutions will allow me to make a meaningful impact on the lives of my patients and on the way that healthcare is delivered across the globe.”
Finally Andrew Hallet, a first year medical student, described his perception of humanitarian medicine in this way. “For practitioners who feel compelled to work among the poor and underserved, medicine transcends this already noble pursuit to
TE D
become something even more profound. In such hands it becomes an enacted belief in human equality and health care as a fundamental human right.”
My own path to medicine is pretty roundabout. I was a Latin major as an undergraduate
EP
and then went on to get a Masters Degree in the History and Philosophy of Medicine. I had read about head injuries in the Edwin Smith Papyrus and I read the Hippocratic
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Corpus in the original so knew all about the essential four humors--you know, blood, yellow bile, black bile and who could forget phlegm. I figured not much ever changes in medicine--it was a logical step from old school to new school medicine. Oh wait a minute isn't medicine that discipline where 90% of what we know today is obsolete in 10 years?
Actually, what had really motivated me to go into medicine was not so much the fact that there were few jobs in ancient medicine, but what I had done during my summers in college. My younger sister and I volunteered, through an organization called “Families for Children,” in a remote orphanage in India in 1982 and 1983 and in a refugee center in 3
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Somalia in 1984. Although neither country was dangerous at that time, it seems a little crazy, given that my sister and I were 16 and 19 respectively that first year.. But it was a stroke of genius on the part of my parents who had encouraged us to go. My sister and I learn so much about human suffering and social injustice. Our eyes were irreversibly
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opened to the striking disparities between our life in the United States and the realities of poverty and life in low-income countries. It was also there where I had my first true experiences with illness and health care.
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During the second summer in India my sister and I lived in the special needs house with children who had physical and mental disabilities. I would hold and soothe a young girl,
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whose name I no longer remember in my arms. She had a massively distended abdomen, spindly legs and arms, and was as fragile as a porcelain cup. I'm sure she did not survive long after we left that fall. But holding her in my arms, feeling her head on my shoulder, and seeing her smile even briefly made me realize that any kind of care I could give people was so much more important and gratifying than anything I'd ever experienced before. On another occasion, I took a deathly ill girl on my lap in the back of an auto
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rickshaw to the hospital. I sat holding her hand though she was barely conscious as the doctors made a cut with a scalpel in her ankle. There was no blood, the cut and the tissues underneath were pure white. In retrospect I can guess she must have been in septic shock and the physicians were trying to do a cut down to get venous access to
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resuscitate her. But I knew none of that then. She died later that night, and we carried her body back to the orphanage in our arms for its proper burial. It was experiences like
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these that made me realize that I had to go become a physician.
During my fourth year of residency I picked up a brochure from Doctors Without Borders, gave them a call, and after a short interview I was accepted. This was in 1996 and they were just beginning to have a presence in the United States and to develop their now formidable reputation. It would be three years until they won the Nobel Peace Prize in 1999, which happened during my second mission with MSF in Burundi. I had to convince my department chairman, Dr. John Daly, that it was a reasonable and sensible plan to do an elective in Sri Lanka. Sri Lanka was in the middle of a long and drawn out 4
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civil war that left close to 100,000 dead over 27 years and the town I was in, Batticaloa, was in the middle of the action. The experience was transforming. I have spoken in the past here, at the American College of Surgeons clinical congress as well as at medical schools, colleges and high schools throughout the US about my experience there. Some
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of you may have heard me speak about what a life altering experience it is to be working in a remote part of the world in a conflict zone with minimal support and technology. It fundamentally changed how I approached medicine and what I saw for myself in the future. Since then I have worked with MSF in Burundi in 1999, twice in the Democratic
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Republic of Congo, in Chad, and then later in Haiti after the earthquake. Some of the brutality I saw included children mutilated by machetes as they tried to flee to the safety
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of UN protected camps and infants shot at point blank range such as a 2 year old girl who died 12 hours later of multiple intra-abdominal injuries all because her mother tried to resist her rapists and murderers.
Although the horrors of war and the brutality of some of the injuries that I saw were truly mind blowing, what struck me the most in each and every one of the missions that
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I've done, is the destruction to the educational system and its profound effect on local physicians and surgeons still in the process of their education. In Sri Lanka I was considered the teaching attending for the house officers training there, even though I was myself a fourth year resident. It sometimes felt like the blind leading the blind. In
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Burundi I was one of two physicians. The other was the medical director of the hospital, Jean Baptiste, had only finished his medical training as a general practitioner two years
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earlier. He asked to scrub on every major case so that he could learn as much as he could. Later, in the Congo, when the possibility of an emergency evacuation was likely, I made sure the nurses, already comfortable with routine C-sections, became proficient in more complex cases. Out of necessity, I would go into “clerkship director overdrive mode” and start intensively teaching suturing, minor and occasionally major surgeries including bowel resections, skin grafts and C-sections and the like to any and all health professionals. During the earthquake in Haiti in 2010, the local school of nursing was completely decimated, killing virtually all of the students who were in class inside. Everyone in Port-au-Prince was affected by the quake. The health care workers who did 5
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survive and were not injured themselves, had to deal not only with the overwhelming numbers of casualties, but with their own post-traumatic stress from having so many of their families and friends killed and their homes destroyed. The memories of these learners whose lives were lost, or who lived in volatile environments with no
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educational structure still haunt me.
Whenever I start to worry about our Liaison Committee on Medical Education (LCME) or Residency Review Committee (RRC) site visits and all the minutiae of work they require,
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makes our medical educational system so strong.
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I realize how lucky we are to have such structure, on top of personal safety. It’s what
Data from the World Bank shows the not surprising parallels between national per capita income (Figure 1), per capita health care expenditure, mortality from road traffic accidents, and the number of physicians per 100,000 people (Figure 2). The similarities of these maps highlight the difficulties of medical care in Africa and to a somewhat lesser extent Asia. Data From the United Nations Development Program published in 2007
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showed that of the 30 countries with the lowest ratio of physicians to the population, all but four were in Africa (Table 1).
This type of data from the World Bank is easily accessible in a quick Google search.
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However, getting a grasp on the prevalence of surgically treatable diseases is much harder to quantify. I don’t need to convince anyone of the importance of surgical
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interventions in low-income countries. Surgery has the potential to cure many and prevent loss of productivity due to disability or death. It is also clear that when these statistics talk about physicians per 100,000, what that means is general practitioners such as Jean Baptiste, and NOT specialists like surgeons. In his presidential address to the American Association of Thoracic Surgery in 20012, James Cox cited research by Professor Felix Unger, from Austria. Unger published the results of a remarkable worldwide survey that clearly defined the magnitude of the differences in cardiac care in 2
Cox JL. Presidential address: changing boundaries. J Thorac Cardiovasc Surg. 2001 Sep;122(3):413-8. 6
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developed versus underdeveloped countries. Cox noted, “each cardiac surgery center in North America serves approximately 120,000 people which is approximately the size of Durham, North Carolina. In Europe and Australia, each center serves a population of approximately one million people, or a larger city roughly the size of Columbus, Ohio. In
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Asia, there is one center for every 16 million people equivalent to the size of Los Angeles and the surrounding counties. In Africa, each cardiac surgery center serves approximately 33 million people.”
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It turns out that defining a surgical disease is very complicated. In 2006, a task force commissioned by the World Bank published a manuscript called Disease Control
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Priorities in Developing Countries3 Chapter 67 was entitled Surgery and was co authored by Haile Debas, et al. They defined surgical diseases as any condition that “requires suture, incision, excision, manipulation, or other invasive procedure that usually, but not always, requires local, regional, or general anesthesia.”
Gathering statistics is always a daunting task in the best of circumstances. Data,
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especially from developing countries, is often sparse and inconsistent. The reports put out by the World Bank and the World Health Organization, or WHO, sometimes must rely on sophisticated statistical modeling and not actual hard data. Local institutions such as the Ministry of Health and other nongovernmental organizations may not have
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the money, skills or human resources to compile accurate health statistics.
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Obvious surgical diseases, such as traumatic injuries and hernias are pretty straightforward to identify, but other surgical diseases such as peritonitis or cancers may not be recognized or classified as such. Without ancillary studies, diagnosis is difficult, and without routine autopsies, confirmation can be close to impossible. Even meeting those very simple criteria for classification is not straightforward. A fascinating study by Reinou Groen et al entitled “Untreated surgical conditions in Sierra Leone: a 3
Debas H, et al. Surgery. In: Jamison D, ed. Disease Control Priorities in Developing Countries, 2nd ed. Oxford University Press and The World Bank, 2006. p 1245-1280.
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cluster randomized, cross-sectional, countrywide survey” was published in the Lancet in 2012.4 The authors used cluster sampling to try to quantify number deaths that surgery would have been potentially cured and the number of patients with illnesses where a surgical consultation may have been warranted. They asked subjects to identify
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household members who had died over the previous year and whether they had
experienced any of the following in the week before their death: abdominal distension or pain; bleeding or illness during childbirth; injury; (a mass, growth, or swelling); an
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acquired deformity; or a wound not due to injury or congenital deformity.
The top ten causes of death in low-income countries were published in 2007 by the
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WHO.5 Although 50% of the list comprised of infectious diseases, the top killer, not surprisingly, was “coronary heart disease.” Perinatal conditions, cerebrovascular disease and road traffic accidents were, 4th, 5th and 10th respectively. Surgery plays a crucial role in all these conditions. The need to develop robust surgical programs including in surgical specialty programs is clear. And for roughly every traumatic death there are 50 times that number who are injured or permanently disabled. Data from the
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World Bank and WHO found that the poorest 35% of the world population receive only 3.5% of all surgery undertaken worldwide. 6
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Another compounding factor is the so-called “brain drain” caused by the diaspora of physicians from developing countries which has placed a huge burden not just on the
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health care system but on the medical education system as well. The irony is that lowincome countries often cover the cost of medical education, only to have those doctors 4
Groen RS, Samai M, Stewart K, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet 2012 Sep 22;380 (9847): 1082-7. 5 WHO Fact sheet N° 310 / February 2007, http://www.who.int/mediacentre/factsheets/en/ Fact sheet N° 310 / February 2007, http://www.who.int/mediacentre/factsheets/en/ 6
Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet 2008: Jul 12;372(9633): 139-44.
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pilfered by much richer countries due to shortages of healthcare workers in their own countries. The financial loss from training these physicians is compounded by the loss of highly intelligent human capital. Estimates show that more that 25% of all African countries had at least 50% of the doctors born in that country living abroad in the year
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2000. Physicians in low-income countries are rarely paid commensurately compared to their counterparts in developed countries. Many physicians working in publicly run hospitals and universities must supplement their income by seeing private patients. This strain on their time leads to the erosion of both patient care and teaching. And we all
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know, teaching alone doesn’t pay as well as clinical activities anywhere. These tensions are often untenable in low and middle-income countries. But the brain drain is not
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purely economic. Additional factors include the lack of opportunities for professional development and the lack of access to new and advanced medical techniques and technologies. Each and every one of us wants to give our patients the most advanced care. The situations I personally found most anguishing were when I lost patients I
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would have easily saved at NYU.
Article 25 of the Universal Declaration of Human Rights, created in 1948 after World War II7, states that everyone has the right to medical care, just as they do to food, clothing and shelter, and that should include surgical care. The problem is daunting but I
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now.
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feel we are up to the task, and must start making inroads in tackling this great need right
The ASE is an organization that I am immensely proud to be a member of. We truly represent cutting edge surgical education at all levels and our members are the world leaders in education. Our expertise lies in creating curricula, designing novel often low cost or easily replicable teaching tools, and validating teaching methodologies. Every year, I hear of some new innovative app or low cost simulator that would cost nominal amounts if we made them available to low-income countries. Each one of these areas of 7
The Universal Declaration of Human Rights: www.un.org/en/documents/udhr/index.shtml 9
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expertise can be used to both improve and expand surgical education in low and middleincome countries. I suggest that we make the ASE resource section on our webpage more robust and complete. We must become the repository for educational materials in surgery. Moreover, we should offer whatever we can to low-income countries free of
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charge and consider reduce fees for middle-income countries.
Currently, the clerkship and curriculum committees are collaborating to create the
definitive clerkship curriculum and standards. The ASE-ACS Core Curriculum in Surgery
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is in its final planning stages. We have also collaborated with the ACS, to create the ASEACS Skills Based Simulation Curriculum, and with the college and the Association of
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Program Directors in Surgery (APDS) to create the Resident Prep Curriculum for forth year students, among other curricular initiatives. Other educational tools that ASE members have created include the PowerPoint modules8 and WISE-MD9 both of which are innovative tools to supplement traditional educational activities.
The WHO does have some surgical educational modules out there for which they charge
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a scaled fee, but when you compare them to what our members have created, they pale in comparison. We should advocate to have educational materials made available to universities in developing countries. But we need to go further. I think we should actively “push” these tools to medical schools and training programs in low-income
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settings by reaching out in a more systematic fashion. As our on line presence grows, we can also use our Facebook page and twitter accounts to reach out and distribute
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educational materials.
Some of your home institutions have become leaders in massive open online courses (MOOCs). Medicine is gaining visibility in these endeavors. We, as individuals and as a group, can look at how we can add content and courses ourselves. When I skimmed through two of the most popular MOOCs, Coursera and EdX, their medical catalogues were pretty minimal– a couple of basic science and global health courses. If your 8 9
ASE PowerPoint Teaching Modules: www.surgicaleducation.com/teaching-modules WISE-MD.med.nyu.edu 10
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university is actively working in this arena, I urge you to push your fellow program and clerkship directors to have clinical courses represented as well. Creating content for clinical education is a very new and exciting field, and will have the added benefit of
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allowing your creativity and knowledge to feel no bounds.
As individuals, truthfully, we can do significantly more without much extra effort or time commitment. We can ensure that global health is taught not just at the medical student level as the LCME requires, but at a resident level as well and that this curriculum
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includes the importance of surgery in global public health.
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Attending global health conferences regionally, nationally or even internationally is something that I would urge you all to do. Many of your schools, or schools in your area, hold conferences on global health. Although surgery may not be on the agenda, you will not only learn a great deal, but you will show that surgeons support of global health efforts by your very presence. You may even meet future colleagues or collaborators for
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new projects.
If you are someone, who in hearing my talk today, decides to take that leap and spend a week, a couple of months, or a year working in a low income country, I guarantee it will change how you view the world and how you view yourself as a surgeon. A good place
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to begin searching for opportunities is Operation Giving Back10. This is one of the more impressive initiatives of the American College of Surgeons. It was started in 2004 under
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the incredible leadership of Dr. Kathleen Casey. Operation Giving Back was set up in response to a study done by Drs. Andrew Warshaw and Robert Stephens that looked at the interest in volunteerism among residents and practicing surgeons11. The response was overwhelming. Operation Giving Back has developed into a robust search engine and tool for medical students, residents, and physicians planning on doing humanitarian
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www.operationgivingback.facs.org/
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www.facs.org/about/governors/phase3givingback.pdf 11
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work. I urge you all to visit this site if you haven’t already, and to steer medical students and residents who are interested to it as well.
If you go on a surgical mission, think of bringing a resident with you. They will be able to
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count the cases that they do in their resident case log! In a remarkable turn of events the RRC and Accreditation Council for Graduate Medical Education (ACGME) finally
approved international rotations for credit for residents in 2011. I will never forget Dr. John Tarpley during Surgical Education Week in Toronto in 2007 when he was the
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president of the APDS. During the “alphabet soup panel”, he got up and relentlessly demanded why the RRC, the American Board of Surgery and the ACGME would not
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validate international rotations for residents. We owe a great deal to those educators like Dr. Tarpley for their relentless efforts and insistence on seeing this important initiative become a reality.
One of the most important things that we can do as individuals is to help our medical students and residents to do some type of international work and validate these
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educational experiences. Doing so not only imparts the importance of global public health but also will show them the value of education and training of local doctors. Two weeks ago I taught a seminar on road traffic accidents in a third year global health elective. At the end of the session I asked them what message they wanted me to bring to
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this august body of leaders in education. All of them had participated in international programs with NYU’s International Health Program and citied it as one of the most
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pivotal learning experiences in their medical education. They wanted me to ask you all to look on their experiences as serious-minded and legitimate work the way you would look on a summer spent doing bench research which they feel is looked on as almost a right of passage. The “publish or perish” environment in which we live has already trickled down to them, so early in their careers. It is the rare surgeon who can incorporate the basic science work that he did during medical school into his professional career. However insight into humanity and into your own culture, a deeper understanding of all cultures, customs and religions, and the importance of humanism and humanitarian outreach can be instantly incorporated. 12
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Many of you, if you haven’t already, are going to move into positions of prominence. Yes, I'm looking at all you current and future chairmen and deans! I urge you to consider the validity and importance of international experiences and educational outreach and work
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to support education in medical schools and departments of surgery throughout the developing world however you can. Please support your residents and faculty who do desire to go abroad, even if it is not an easy sacrifice for the department. Support them academically as well as financially. I cannot stress the importance of this enough. I hope
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my talk today and my passion for global health and surgical education has inspired you in some way to change even if it’s just a little bit. The time is now for academic surgeons
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to take lead in Surgical Education and Global Health!
I want to close now by thanking my family and especially my father, Dr. Robert West Hopkins, who is also a surgeon and educator, who retired from Brown where he taught for almost 40 years. He turned 90 this year and has taught me so much in terms of integrity, honesty, and commitment to patient care and education that I only hope I can
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impart to my students in the years to come. Thank you.
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Figure 1: Country Income Groups World Bank, 2011
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Figure 2: Number of Physicians per 100,000 WHO, 2008
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Mary Ann Hopkins, M.D.
