Surgery by Non-Surgeons: An Impending Future

Co-authored by Jenny Gilberston and Rose Nanyonga

2014-11-06-jennygilbertson.jpegJenny Gilbertson received her Bachelor of Science in chemistry and French at Beloit College and her masters in scientific engineering in bioengineering innovation and design from Johns Hopkins University. She currently lives in Norway, where she works for Laerdal Global Health.

2014-11-06-rosenanyonga.pngRose Clarke Nanyonga, MSN is a Ph.D. candidate at the Yale School of Nursing. She is a Jonas Scholar for Nursing Excellence, Co-Founder of the School of Nursing at International Health Sciences University, Uganda, and is the lead activist for the Rose's Journey International Awareness Campaign to end ritualistic child sacrifice in Uganda. Rose holds a BSN degree from Arkansas Tech University and an MSN (Family Nurse Practitioner) from Baylor University.

"So on our heels a fresh perfection treads... born of us and fated to excel us." - John Keats, Hyperion Book II

Forecasting their individual futures compels young people to imagine what they intend to accomplish and how they will do it. One way to encourage this process is to ask for an article about themselves that will be published as a cover story in a major magazine 10 years in the future. I subjected my co-author to this exercise, knowing of her commitment to solving one of the overwhelming problems facing Sub-Saharan Africa today: the severe shortage of surgeons coupled with an acute and growing need for basic surgical procedures. Here is an abridged copy of the article that will be published in 2025 accompanied by expert local commentary from a future Medical School Chancellor in Uganda:

In between lectures, Jenny Gilbertson sat down with me at a campus café in Seattle to reflect on the trajectory of Kaamiir on the tenth anniversary of its founding. Although technically based in Kampala, Gilbertson is often on the road, overseeing Kaamiir implementation throughout Africa and Southeast Asia, and speaking to future global health leaders at universities around the world.

The idea for Kaamiir was born back in 2015, in a hospital in rural Uganda. Gilbertson had traveled there to study under Dr. Sam Luboga, a Ugandan surgeon. Together the two of them developed an in-house surgical training program. "When I first arrived in Uganda back then," Gilbertson explains, "there were .25 surgeons per every 100,000 people." Although that rate was pretty standard compared to many other African countries at the time, it came into stark contrast with the contemporary U.S. rate of 5.69 per 100,000 people. "There were, and are, huge disparities in basic surgical care," Gilbertson explains, "but it was really the vulnerable populations, such as mothers and children, who felt it the most."

Gilbertson helped train local Ugandan women in basic surgical techniques. "Many of these women" she explains, "had once been my patients. I had performed cesareans on them. I had repaired their fistulas." When I asked her why she trained primarily women, Gilbertson explained, "I train men too, of course, but with women I know that the impact I'm having is much larger and multi-faceted. For many of them, this job helps delay childbirth, or if they have children, helps fund their education and provides their family with a powerful role model." In addition to learning surgical skills, Gilbertson explains, participants in the program assumed leadership roles within their communities. These women, while performing surgeries in their local hospitals, would also mentor local women try to improve community level health through other vehicles. For some women, this was hosting educational events. For others, it was working with local and governmental officials to revolutionize sanitation practices in their area. "All of these women were passionate about different causes" Gilbertson explained, "and all I could do was encourage that. They knew, better than I ever could, what needed to happen in order to revolutionize the health of their nation."

Ten years later, Kaamirr (Wolof for "to be complete") has expanded across Africa and into Southern Asia. There have been tens of thousands of surgical technicians trained, and the results are incredible - deaths and disabilities from surgically treatable conditions have plummeted. In addition, the mentor programs sponsored by Kaamiir have had an incredible impact as well on many areas such as reducing the rates of childhood mortality and increasing adult literacy.

Commentary from Rose Nanyonga:

Training surgical technicians could be an answer to the problem of surgeon shortages throughout Africa if it is well-implemented and has the support of relevant stakeholders. Academic medicine has clung to the traditional hierarchical system of certifying surgeons only after many years of expensive training, but medical schools could actually lead the way to new models. Perhaps foreshadowing Jenny Gilbertson's future article, Professor Sam Luboga at Makere University in Kampala has started teaching Essential Surgical Skills training, a program which will be piloted in 25 districts. We may collaborate with Jenny and launch a training program in our medical school at IMG

For those of us who have trouble comprehending the manpower problem around Essential Surgery in Sub-Saharan Africa, I should again point out the statistics cited above - in Uganda we have only one surgeon per 400,000 people. If population forecasts hold up, there will be a need for 47 million C-sections between now and 2025. Who will do these procedures?

I think Ms. Gilbertson's vision can be accomplished with vibrant leadership, and the support of the surgical community and Ministries of Health so that in addition to sufficient trained technicians, we develop viable economic models to encourage this approach.

For those who wax pessimistically about the future of global health, let us take note, embrace, and support the collaborative vision of these two emerging leaders that it may become reality. As Thomas Edison said "Vision without execution is hallucination."