Addressing the global burden of surgical diseases

mapofhaitiWhile medical care in poor countries, like Haiti, has increased over the last 20 years, surgical care has largely been ignored and has even been labeled “the neglected stepchild of global public health.” Here, Stephen Sullivan, one of Children’s Global Surgery Fellows, discusses his experience delivering surgical care in Haiti.

By Stephen R. Sullivan, MD, MPH

Each morning Sara*, a 63 year-old woman from a rural village in central Haiti, wakes to the call of roosters. On one such morning, she woke in darkness and, like usual, leaned over in her small hut to light her kerosene lamp. Tragically, the lamp had accidentally been filled with gasoline instead of kerosene. It exploded, and Sara suffered severe burns to her face and upper body. She was eight hours away from the nearest clinic, suffering from life-threatening burns. Had it not been for the incredible care delivered by an American nurse in a small remote outpost rescue unit (a single room for emergency care), she likely would have died.

For months, Sara teetered back and forth on the line of survival. She was slowly and literally nursed back to health. But the deep burns created massive wounds with raw, open flesh extending across her upper body. She desperately needed surgical care with skin grafting but unfortunately those services weren’t available near her village. Several hours away in the capital city of Port-au-Prince, surgeons were available, but the cost was more than Sara and her husband, poor farmers who had raised 10 children, could afford.

In the United States, burns such as those Sara suffered would be skin grafted within seven days and pain control would be paramount. Most of us are familiar with the unpleasant experience of a small hand burn from the stove top. The pain of Sara’s burns covering her entire upper body is almost incomprehensible. Such was Sara’s life for the next 18 months, when she lived as a patient receiving wound care in the small rescue unit. Unable to work or care for herself or family, meaningful life seemed uncertain.

I met Sara in the October 2009. As a plastic surgeon from Children’s, I was spending a year in Cange, Haiti as a Global Surgery Fellow. In 2008, Children’s, along with several Harvard-affiliated surgeons and Partners in Health (PIH), a Boston-based nonprofit corporation, created a Global Surgery Fellowship for surgeons who wanted to provide surgical care in a developing country. I, like an increasing number of surgeons, had recognized the need for surgical care in poor countries, and was eager to experience and address these global needs. While medical specialties have developed many formal training programs in Global Health, educational opportunities in global surgery are quite limited.

As a trained plastic surgeon and global surgery fellow, I delivered surgical care in rural Haiti during the 2008-9 academic year. I performed a wide range of operations—from general surgical procedures to obstetric care for women to cleft lip and palate repairs, I worked closely with Haitian surgeons and, together, we had an exchange in surgical education. My Haitian colleagues were very skilled and well trained in a broad general surgical practice, but plastic surgery was a new field for them and the number of patients in need was great. In addition to operating together, we further developed the surgical care infrastructure within the existing medical care system of PIH and Zanmi Lasante (ZL or “Partners In Health” in Haitian Kreyol), PIH’s sister organization in Haiti.

PIH/ZL has long had a relationship with Haiti, the poorest country in the Western Hemisphere. In 1985, Dr. Paul Farmer and Ophelia Dahl worked with others to form ZL and mobilized around basic health needs in the Central Plateau of Haiti. ZL opened a free medical care clinic in Cange, Haiti, called Clinique Bon Sauveur, and in 1986 documented the first known case of AIDS in Haiti’s Central Plateau. Voluntary counseling and testing were offered free of charge as ZL focused its efforts on HIV prevention and education during the early years of the epidemic. But over time, the Clinique evolved into a hospital complex offering comprehensive in-patient and out-patient medical care. More than 250,000 patient visits to the Cange hospital complex occur per year, and it is linked to a network of hospitals and clinics serving 1.2 million people in the Central Plateau and Lower Artibonite districts.

operating room
The Central Plateau's first surgical procedure was performed in this operating room.

While medical care in resource-poor countries like Haiti has increased over the last 20 years, surgical care has been largely ignored. PIH, however, recognized the surgical care needs of Haitians and in 1996, built an operating room at the Clinique, where the Central Plateau’s first surgical procedure was performed.

Since then, compassionate surgeons from around the world have been donating time, skills and equipment while working closely with Haitian surgeons to develop a surgical care system. Most of the patients have overcome living conditions and adversity unimaginable by Americans.

Despite these efforts, the surgical needs of the population are not currently met. Surgeons, with leadership from Drs. Mike Steer, Harvard Professor emeritus and Surgical Director of PIH, and John Meara, MD, chief of the Department of Plastic and Oral Surgery at Children’s, are working with PIH/ZL to piggyback on their   medical care partnership for treatable surgical diseases. In September 2008,  I arrived in Cange to initiate the Global Surgery Fellowship – the same month Haiti was devastated by hurricanes. Not to be deterred, Harvard-affiliated surgeons and visiting surgeons have since provided surgical care in Haiti for approximately two to three weeks out of each month. Since the partnership started, the average number of operations in Cange has increased from around 800 to over 1,900 each year. Last year, 53 surgeons and residents operated in Haiti. Visiting surgical subspecialists work closely with Haitian surgeons to teach and perform oncologic, pediatric, plastic, burn, obstetric, ophthalmologic, orthopaedic, urologic and general surgery. Visiting surgeons also work closely with Haitian medical students and residents training to be surgeons, offering them experience and knowledge to broaden their training.

As the surgical volume grows in Cange, patients with increasingly complex problems have appeared. To ensure safety and the best possible outcomes, some patients require care beyond the capabilities offered in Haiti. Last year, Children’s provided care for Haitian children with complex congenital anomalies of the face (read this story and watch a video about a Haitian boy born with a rare facial anomaly). Children’s surgeons are also performing open-heart surgery in the West African nation of Ghana.

As for Sara, over the course of the last year, I helped teach my Haitian surgeon colleagues how to care for patients with burns and patients in need of plastic surgery. We operated twice on Sara’s burns. Using skin grafts, we treated her open burns and scars, and restored movement of her neck. For the first time in almost two years, Sara is now free of dressings, wound care and excruciating pain. She can now independently care for herself and hopefully has a long and bright future as a member of her family and Haitian community.

Sara serves as just one example of the burden of untreated surgical disease in Haiti and other resource poor countries. The partnership with PIH and the Global Surgery Fellowship provided me with an opportunity to become involved in the global health movement. Our colleagues in medicine and infectious disease have blazed the trails, and now surgeons must follow.

* Name has been changed to protect confidentiality.

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    Not to be deterred, Harvard-affiliated surgeons and visiting surgeons have since provided surgical care in Haiti for approximately two to three weeks out of each month.